Lesson topic №25. Нарушения ритма (Cardiac arrhythmia in the outpatient setting)

Atrial fibrillation: better symptom management

Rate control is an integral part of AF management, and is often sufficient to improve AF-related symptoms.

Lenient rate control (heart-rate target <110 bpm) is an acceptable initial approach, regardless of HF status (with the exception of tachycardia-induced cardiomyopathy), unless symptoms call for stricter rate control.

Pharmacological rate control can be achieved with beta-blockers, digoxin, diltiazem, and verapamil, or combination therapy.

Atrial fibrillation: better symptom management

Beta-blockers are often first-line rate-controlling agents, largely based on better acute rate control.

Non-dihydropyridine calcium channel blockers (NDCC) verapamil and diltiazem provide reasonable rate control.

Amiodarone can be useful as a last resort when heart rate cannot be controlled with combination therapy.

Ablation of the atrioventricular node and pacemaker implantation can control ventricular rate when medication fails.

Atrial fibrillation: better symptom management

The «rhythm control strategy» refers to attempts to restore and maintain sinus rhythm, and may engage a combination of treatment approaches, including cardioversion, antiarrhythmic medication, and catheter ablation.

The primary indication for rhythm control is to reduce AF-related symptoms and improve quality of life.

Atrial fibrillation: better symptom management

Synchronized cardioversion is recommended for haemodynamically unstable patients.

Synchronized direct current electrical cardioversion is the preferred choice in haemodynamically compromised AF patients as it is more effective than pharmacological cardioversion.

In stable patients, either pharmacological cardioversion or electrical cardioversion can be attempted; pharmacological cardioversion is less effective but does not require sedation.

A wait-and-watch approach with rate control medication only and cardioversion when needed within 48 h of symptom onset was as safe as and non-inferior to immediate cardioversion of paroxysmal AF, which often resolves spontaneously within 24 h.

Pre-treatment with amiodarone, sotalol or propafenone should be considered to facilitate the success of electrical cardioversion.

Atrial fibrillation: better symptom management

Atrial fibrillation: better symptom management

«Pill in the pocket»

In selected outpatients with rare paroxysmal AF episodes, a self-administered oral dose of propafenone (450-600 mg) may be preferred (permitting an earlier conversion), provided that the drug safety and efficacy has previously been established in the hospital setting.

Should not be used in ischemic heart disease and/or significant structural heart disease.

Atrial fibrillation: better symptom management

Antiarrhythmic drugs used for long-term maintenance of sinus rhythm in AF patients

Atrial fibrillation: better symptom management

Antiarrhythmic drugs used for long-term maintenance of sinus rhythm in AF patients

•Should be discontinued in case of excessive QT prolongation (>500 ms)

•ECG at baseline, after 4 weeks

•Contraindicated in manifest hyperthyroidism

•Numerous and frequent extracardiac side-effects may warrant discontinuation of amiodarone, thus making it a second-line treatment when other choices are possible

Atrial fibrillation: better symptom management

Antiarrhythmic drugs used for long-term maintenance of sinus rhythm in AF patients

Atrial fibrillation: better symptom management

Antiarrhythmic drugs used for long-term maintenance of sinus rhythm in AF patients