Abstract
Résumé

- Fuster V.
- Rydén L.E.
- Cannom D.S.
- et al.

- Fuster V.
- Rydén L.E.
- Cannom D.S.
- et al.
Favours rate control | Favours rhythm control |
---|---|
Persistent AF | Paroxysmal AF |
Newly detected AF | |
Less symptomatic | More symptomatic |
Aged ≥65 years | Aged <65 years |
Hypertension | No hypertension |
No history of congestive heart failure | Congestive heart failure clearly exacerbated by AF |
Previous antiarrhythmic drug failure | No previous antiarrhythmic drug failure |
Patient preference | Patient preference |
Goals of AF Arrhythmia Management
- •Identify and treat underlying structural heart disease and other predisposing conditions
- •Relieve symptoms
- •Improve functional capacity and quality of life (QOL)
- •Reduce morbidity and mortality associated with AF and AFL, that is,
- •Prevent tachycardia-induced cardiomyopathy
- •Reduce or prevent emergency room visits or hospitalizations secondary to AF and AFL
- •Prevent stroke or systemic thromboembolism
- •
Values and preferences
Referral for Specialty Care
Rate Control of AF and AFL
Heart rate targets
- Fuster V.
- Rydén L.E.
- Cannom D.S.
- et al.
Values and preferences
Heart rate control agents

Class | Dose | Adverse effects |
---|---|---|
Beta-blockers | ||
Atenolol | 50-150 mg orally daily | Bradycardia, hypotension, fatigue, depression |
Bisoprolol | 2.5-10 mg orally daily | As per atenolol |
Metoprolol | 25-200 mg orally twice a day | As per atenolol |
Nadolol | 20-160 mg orally daily to twice a day | As per atenolol |
Propranolol | 80-240 mg orally 3 times a day | As per atenolol |
Calcium channel blockers | ||
Verapamil | 120 mg orally daily to 240 mg orally twice a day | Bradycardia, hypotension, constipation |
Diltiazem | 120-480 mg orally daily | Bradycardia, hypotension, ankle swelling |
Digoxin | 0.125-0.25 mg orally daily | Bradycardia, nausea, vomiting, visual disturbances |
Values and preferences
Rate control in specific patient populations
Values and preferences
Nonpharmacologic Treatment
Values and preferences
Rhythm Control of AF and AFL
Values and preferences
Mechanism of action of antiarrhythmic drugs
Antiarrhythmic drug therapy to maintain sinus rhythm
- Fuster V.
- Rydén L.E.
- Cannom D.S.
- et al.
- Connolly S.J.
- Crijns H.J.
- Torp-Pedersen C.
- et al.
Class | Drug | Dosage | Efficacy at 1 Year | Toxicity | Comments |
---|---|---|---|---|---|
I | Flecainide | 50-150 mg twice/d | 30%-50% |
|
|
Propafenone | 150-300 mg 3 times/d | 30%-50% |
|
| |
III | Amiodarone | 100-200 mg OD (after 10 g loading) | 60%-70% |
|
|
Dronedarone | 400 mg twice/d | 40% |
|
| |
Sotalol | 40-160 mg twice/d | 30%-50% |
|
|


- Deedwania P.C.
- Singh B.N.
- Ellenbogen K.
- et al.
Spontaneous conversion and maintenance of sinus rhythm by amiodarone in patients with heart failure and atrial fibrillation: observations from the veterans affairs congestive heart failure survival trial of antiarrhythmic therapy (CHF-STAT).
- Fuster V.
- Rydén L.E.
- Cannom D.S.
- et al.
- Fuster V.
- Rydén L.E.
- Cannom D.S.
- et al.
Values and preferences
Risks of antiarrhythmic drug therapy
Intermittent Antiarrhythmic Drug Therapy (“Pill in the Pocket”)
Values and preferences
Cardioversion as part of the rhythm-control strategy
Values and preferences
Drug conversion of AF
Need for anticoagulation
- Fuster V.
- Rydén L.E.
- Cannom D.S.
- et al.
- Fuster V.
- Rydén L.E.
- Cannom D.S.
- et al.
Nonpharmacologic therapy for rhythm control
Values and preferences
Novel therapeutic targets
Negi S, Shukrullah I, Veledar E, Bloom HL, Jones DP, Dudley SC. Statin Therapy for the Prevention of Atrial Fibrillation Trial (SToP AF trial) [published online ahead of print October 13, 2010]. J Cardiovasc Electrophysiol doi: 10.1111/j.1540-8167.2010.01925.x.
Prevention of AF in the pacemaker population
Danish 80 AAI vs VVI | CTOPP 81 | Extended 82 CTOPP | MOST 83 | Danish 87 AAI vs DDD | |
---|---|---|---|---|---|
Number | 225 | 2568 | 2568 | 2050 | 177 |
Age (y) | 71 ± 17 | 73 ± 10 | 73 ± 10 | 74 (67-80) | 74 ± 9 |
Pacing indication | SND | All pacemaker patients | All pacemaker patients | SND | SND |
Follow-up (y) | 5.5 | 3.1 | 6.4 | 2.7 | 2.9 |
Pacing modes | AAI vs VVI | AAI/R or DDD/R vs VVI/R | AAI/R or DDD/R vs VVI/R | DDDR vs VVIR | AAI vs DDDR-s vs DDDR-l |
AF occurrence (%/y) | 4.1 vs 6.6 | 5.3 vs 6.3 | 4.5 vs 5.7 | 7.9 vs 10.0 | 2.4 vs 8.3 vs 6.2 |
Risk reduction (%) | 46 | 18 | 20 | 21 | 73 |
P value | .012 | .05 | .009 | .008 | .02 |
- Sweeney M.O.
- Hellkamp A.S.
- Ellenbogen K.A.
- et al.
Adverse effect of ventricular pacing on heart failure and atrial fibrillation among patients with normal baseline QRS duration in a clinical trial of pacemaker therapy for sinus node dysfunction.
Values and preferences
Management of AF: Chronic Disease Management Principles
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Footnotes
The disclosure information of the authors and reviewers is available from the CCS on the following Web sites: www.ccs.ca and www.ccsguidelineprograms.ca.
This statement was developed following a thorough consideration of medical literature and the best available evidence and clinical experience. It represents the consensus of a Canadian panel comprised of multidisciplinary experts on this topic with a mandate to formulate disease-specific recommendations. These recommendations are aimed to provide a reasonable and practical approach to care for specialists and allied health professionals obliged with the duty of bestowing optimal care to patients and families, and can be subject to change as scientific knowledge and technology advance and as practice patterns evolve. The statement is not intended to be a substitute for physicians using their individual judgment in managing clinical care in consultation with the patient, with appropriate regard to all the individual circumstances of the patient, diagnostic and treatment options available and available resources. Adherence to these recommendations will not necessarily produce successful outcomes in every case.
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- ErratumCanadian Journal of CardiologyVol. 27Issue 3
- PreviewIn the article by Gillis et al., published in the January/February 2011 issue of the Canadian Journal of Cardiology (2011;27:47-59), in the section “Antiarrhythmic drug therapy to maintain sinus rhythm,” on page 53, the text should note, “Sotalol or dronedarone could be considered for treatment of AF in patients with a left ventricular ejection fraction <35% and in the absence of symptoms of severe heart failure, particularly if they have an implantable cardioverter defibrillator.”… “The ANDROMEDA (Antiarrhythmic Trial With Dronedarone in Moderate to Severe Congestive Heart Failure Evaluating Morbidity Decrease) trial found that dronedarone may increase the risk of mortality in recently decompensated heart failure patients (New York Heart Association classes III and IV) who were hospitalized.”
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