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Treatment goals:

1. Control of heart rate
2. Restoration and maintenance of normal (sinus) rhythm
3. Prevention of AEE (Vascular Stroke)

1. HEART RATE CONTROL

• It is different for a patient with AF to have 160 beats/minute, in which case they have serious problems, and for another to have 70 beats/minute, in which case they are generally symptom-free.
• We aim for a heart rate of < 80 beats/minute.The following drugs are used to control the heart rate:
  • B-Blockers (Bisoprolol, Carvedilol, Metoprolol, Nebivolol)
  • Calcium Channel Blockers (Diltiazem, Verapamil)
  • Digoxin
  • Amiodarone

  B. RATE CONTROL

  In patients with recurrent AF paroxysms, the strategy of restoring and maintaining sinus rhythm is applied.

  Restoring the rhythm causes improvement in symptoms, but does not affect mortality or the occurrence of stroke.

  Main indications:

  • persistence of symptoms despite heart rate control
  • younger patients
  • “Tachycardia”
  • first episode of AF or after acute illness.

  For rhythm control, the following are used:

  1. electrical conversion
  2. antiarrhythmic drugs
  3. ablation

  Ba. ELECTRICAL  RECONSTRUCTION

  • It is a very effective technique for restoring sinus rhythm using a defibrillator.
  • It is performed in an environment with the possibility of close monitoring of patients and resuscitation, by a Cardiologist and Anesthesiologist.
  • It is combined with antiarrhythmic drugs, because the probability of AF recurrence is high.
  • If the duration of AF is less than 48 hours, it can be performed immediately.
  • If AF persists for more than 48 hours, the risk of stroke is increased (<1%).
  • To reduce it, in those who need to be reconverted immediately, we perform a Transesophageal Echocardiogram to exclude the presence of clots in the Left Atrium.
  • If the patient can wait, we administer anticoagulants for 3 weeks, and then proceed with the reversal.

  Bb. ANTIARRHYTHMIC DRUGS

  For the restoration and/or maintenance of rhythm, the following are used:

  • Flecainide
  • Propafenone
  • Amiodarone
  • Sotalol
  • Dronedarone
  • Disopyramide
  • Quinidine

  The choice is made based on the specific pharmacological characteristics of each patient, the presence or absence of underlying heart disease and/or other concomitant diseases.

  Bc. CATHETER-BASED ABLATION (Ablation)

  Firing sites in the Pulmonary Veins trigger AF attacks.

  By “isolating” the Pulmonary Veins, either by heating the tissue using “Radiofrequency” (Radiofrequencyablation), or by cooling (Cryoballoonablation), we can prevent the creation of AF paroxysms.

  The procedure is performed with special catheters, guided by a mapping system.

  AF ablation is more effective than medication in maintaining AF.

  The probability of serious complications is low (2-3%), while mortality is minimal (0.1%).

  It is mainly indicated in patients with symptomatic paroxysmal or (secondarily) symptomatic persistent AF resistant to antiarrhythmic drugs.

  With ablation we have a significant reduction in the frequency of AF attacks (80% of patients remain in sinus rhythm, without recurrence of episodes in 5 years). It remains unknown whether total mortality, stroke and Heart Failure are affected.

  C. PREVENTION OF STROKE

  • Patients with AF, especially the elderly, are at high risk (5-12%/year) of suffering a “cardioembolic” stroke.
  • The risk is the same in paroxysmal as in permanent.
  • Strokes in patients with AF are large and have increased mortality (≈ 50%/year), because the clots that cause them are large.
  • Determining the risk of stroke and its prevention is a matter of paramount importance in patients with AF.
  • Antiplatelet drugs that were administered in the past are no longer indicated.
  • Today, anticoagulant drugs are used to prevent stroke in AF.
  • The benefit of reducing the risk Stroke should be compared with the risk of bleeding.

  In order to determine the need for or not to administer anticoagulant treatment to each patient Scored schemes for calculating the risk of AEE have been developed.

  The most widely used is the CHA2DS2-VASc:

  CHA2DS2-VASc Criteria	Score
  Heart Failure- Dysfunction No. Abdominal	1
  Hypertension	1
  Age ≥75 years	2
  Diabetes mellitus	1
  Stroke, transient ischemic attack, history of thromboembolism	2
  Vascular disease: Previous myocardial infarction, peripheral arterial disease or Aortic atherosclerotic plaques	1
  Age 65-74 years	1
  Sex (female)	1

   

  Total score	Estimated incidence of stroke (% / year)
  0	0.0
  1	1.3
  2	2.2
  3	3.2
  4	4.0
  5	6.7
  6	9.8
  7	9.6
  8	6.7
  9	15.2

   

  According to the European Guidelines (2020), patients with a CHA2DS2-VASc score of:

  ≥ 2 in men and ≥ 3 in women (absolute indication)

  ≥ 1 in men and ≥ 2 in women (relative indication)

  Recommended Anticoagulants:

  • Warfarin
  • Newer Anticoagulants (NOACs)
  • Dabigatran
  • Rivaroxaban
  • Apixaban

  Warfarin

  • Reduces the risk of stroke by 64% and death by 26%.
  • Safe in patients with valvular disease, prosthetic valve, renal failure.
  • The anticoagulant effect depends on genetic and nutritional factors, the coexistence of other diseases and the co-administration of other drugs.
  • Patients must periodically monitor the “Prothrombin Time – INR” and adjust the dose of the drug, in order to maintain an INR value of 2-3.

  Dabigatran, Rivaroxaban, Apixaban

  • They reduce strokes and deaths at the same rates as warfarin.
  • The onset and attenuation of their anticoagulant effect is rapid and predictable without being affected by dietary factors.
  • There is no need to monitor the INR.
  • They are contraindicated in patients with Valvular AF and/or mechanical prosthetic valve.

  Today the newer anticoagulants are our first choice in non-valvular AF
  Useful lifestyle changes in patients with AF:

  • Stop smoking
  • Limit or stop alcohol
  • Limit consumption of coffee, tea, cola drinks
  • Obesity or overweight: reduce body weight ≥ 10%, BMI target < 27 Kgr/m2.
  • Glycemia: reduce glycated Hb ≥ 10%, HbA1c target < 6.5%
  • Hypertension: optimal BP control (target BP ≤ 130/80 mmHg)
  • Physical exercise: 30 minutes of moderate physical activity most days of the week. Avoid very intense exercise (may trigger AF paroxysm)
  • Obstructive sleep apnea: appropriate treatment (C-PAP mask).