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The treatment approaches for a patient with AFib have been updated in the most recent ACC/AHA/ESC (European Society of Cardiology)/HRS Guidelines. [23] In the left-hand column of the Figure are listed the major findings regarding pharmacotherapy to achieve rate control versus rhythm control (restoration of sinus rhythm). These therapeutic approaches will be discussed in subsequent presentations, but the important point is that stroke risks were higher in rhythm control patients than the rate control patients in each of the rate versus rhythm control trials, largely because anticoagulation was stopped by physicians who believed sinus rhythm would remove the risk. [24] [25] [26] [27] [28] On the right in the Figure, the major constraints of cardioversion and ablation of the fibrillation foci are shown; here too the data suggest that risk of stroke persists, despite the restoration of sinus rhythm with cardioversion, or successful pulmonary vein isolation or surgical ablation.[23, 27-28]
Reiffel JA. Am J Med 2013; 126: 00-00.
[23] Fuster V, Rydén LE, Cannom DS, et al; American College of Cardiology/American Heart Association Task Force on Practice Guidelines; European Society of Cardiology Committee for Practice Guidelines; European Heart Rhythm Association; Heart Rhythm Society. ACC/AHA/ESC 2006 Guidelines for the Management of Patients with Atrial Fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation): developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society. Circulation. 2006;114:e257-e354.
[24] Wyse DG, Waldo AL, DiMarco JP, et al; Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) Investigators. A comparison of rate control and rhythm control in patients with atrial fibrillation. N Engl J Med. 2002;347:1825-1833.
[25] Van Gelder IC, Hagens VE, Bosker HA, et al; Rate Control versus Electrical Cardioversion for Persistent Atrial Fibrillation Study Group. A comparison of rate control and rhythm control in patients with recurrent persistent atrial fibrillation. N Engl J Med. 2002;347:1834-1840.
[26] Roy D, Talajic M, Nattel S, et al; Atrial Fibrillation and Congestive Heart Failure Investigators. Rhythm control versus rate control for atrial fibrillation and heart failure. N Engl J Med. 2008;358:2667-2677.
[27] Shah AN, Mittal S, Sichrovsky TC, et al. Long-term outcome following successful pulmonary vein isolation: pattern and prediction of very late recurrence. J Cardiovasc Electrophysiol. 2008;19:661-667.
[28] Calkins H, Brugada J, Packer DL, et al; European Heart Rhythm Association (EHRA); European Cardiac Arrhythmia Scoiety (ECAS); American College of Cardiology (ACC); American Heart Association (AHA); Society of Thoracic Surgeons (STS). HRS/EHRA/ECAS expert Consensus Statement on catheter and surgical ablation of atrial fibrillation: recommendations for personnel, policy, procedures and follow-up. A report of the Heart Rhythm Society (HRS) Task Force on catheter and surgical ablation of atrial fibrillation. Heart Rhythm. 2007;4:816-861.