AF Management:

Rhythm Control
 Indication
To reduce AF-related symptoms and improve QoL

AF progression

Decrease QoL, become irreversible

or less amenable to treatment

rhythm control may be a relevant

choice
Rhythm Control Algorithm
 Immediate or Elective Cardioversion
Immediate cardioversion: performed as an emergency cardioversion
• In haemodynamically compromised:
• Synchronized direct current electrical cardioversion is the preferred choice
than the pharmacological cardioversion
• In stable patient:
• Pharmacological cardioversion or electrical cardioversion can be attempted
• Pharmacological cardioversion is less effective but does not require sedation
• Pre-treatment with AADs can improve the efficacy of elective electrical
cardioversion
• Maximum fixed-energy electrical cardioversion was more effective than an
energy-escalation strategy
 Immediate or Elective Cardioversion
Elective cardioversion
• Cardioversion did not result in improved AF-related QoL or halted AF
progression

Factor associated with increased AF reccurence:

• older age, • renal impairment,
• female sex, • structural heart disease,
• previous cardioversion, • larger LA volume index,
• COPD, • HF

Treatment of these risk factors should

be considered before cardioversion
 Immediate or Elective Cardioversion

Elective cardioversion Contraindication

• Presence of known LA thrombus

• Peri-procedural thrombo-embolic risk should be evaluated

• Long-term oral anticoagulant use should be considered irrespective of
cardioversion mode
Electrical Cardioversion

• Standard: biphasic defibrillator

• Performed in sedated patients treated with i.v. midazolam and/or
propofol or etomidate.
• BP monitoring and oximetry during the procedure
• In case of post-cardioversion bradycardia: prepare atropine or
isoproterenol, or temporary transcutaneous pacing
Pharmacological Cardioversion
• Indicated in haemodynamically stable patients
• Choice of a specific drug is based on the type and severity of
associated heart disease
• Pharmacological cardioversion is more effective in recent onset AF
 Pharmacological Cardioversion

• Class Ic agents are indicated in patients without significant LV hypertrophy, LV systolic

dysfunction, or ischaemic heart disease
• Results in prompt (3 - 5 h) restoration of sinus rhythm in >50% of patients
• An atrioventricular node-blocking drug should be instituted in patients treated with
class Ic AADs (especially flecainide) to avoid transformation to AFL with 1:1 conduction
Pharmacological Cardioversion

• The most rapidly cardioverting drug, including patients with mild HF

and ischaemic heart disease,
• More effective than amiodarone or flecainide.
Pharmacological Cardioversion

• Amiodarone, mainly indicated in HF patients,

• has a limited and delayed effect but can slow heart rate within 12 h
Pharmacological Cardioversion

• Ibutilide is effective to convert atrial flutter to sinus rhythm

Follow up after Cardioversion
• It is important to balance symptoms and AAD side-effects
• detect whether an alternative rhythm control strategy including AF catheter
ablation, or a rate control approach is needed
Catheter Ablation: Indication
Risk factor for reccurence: • patient age,
• LA size, • renal dysfunction,
• AF duration, • Substrate visualization (MRI)

No single predictor score has been presently identified as consistently

superior to others

The most intensely evaluated risk predictors should be considered and

adjusted to individual patient before deciding ablation
Catheter Ablation: Indication
Results of multiple RCTs showed
superiority of AF catheter ablation vs. AADs

In general:
Ablation is recommended as a second-line therapy after failure (or
intolerance) of class I or class III AADs
Catheter Ablation: Indication
Catheter Ablation: Efficacy in HFrEF
• AF catheter ablation in patients with HFrEF results in better outcome
than AAD and rate control:
• Higher rates of preserved sinus rhythm
• greater improvement in LVEF, exercise performance, and QoL

Ablation should be considered in patients with HFrEF who

have been selected for rhythm control
Catheter Ablation: Complication

• Complications occur mostly within the first 24 h after the procedure, but some
may appear 1 - 2 months after ablation
 Catheter Ablation

Aggressive control of modifiable risk

factors may improve arrhythmia-free
survival after catheter ablation
Catheter Ablation: Follow up
Surgery for AF
• Surgery had significant reduction in stroke risk at 5 years and a greater
likelihood of maintaining sinus rhythm
• Surgical AF ablation concomitant to other cardiac surgery significantly
increases the need for pacemaker implantation with biatrial (but not
left-sided) lesions
 Long-term antiarrhythmic drug therapy for
rhythm control

The decision to initiate long-term AAD

therapy needs to balance symptom
burden, possible adverse drug
reactions, and patient preferences
Long-term antiarrhythmic drug therapy for
rhythm control
Long-term antiarrhythmic drug therapy for
rhythm control
Long-term antiarrhythmic drug therapy for
rhythm control
AADs:
• Class Ia (quinidine and disopyramide) and sotalol have been
associated with increased overall mortality
• AADs selection depends on the underlying disease

Non-AADs:
• Drugs that affect the atrial-remodelling process could prevent new-onset AF
• It is important to assess underlying conditions and targeted upstream
therapy for intense risk-factor control in AF.
Long-term antiarrhythmic drug therapy for
rhythm control
Long-term antiarrhythmic drug therapy for
rhythm control
THANK YOU