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type=\u0022text\/css\u0022 rel=\u0022stylesheet\u0022 href=\u0022\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/advagg_css\/css__ce2QY63WIanKyr8eSq7eavr1XQRRmFD6ZSmwpyJi8lM__zXwFqpqmxrZOXXcd_TpBQpjuELbmIP9wBR5UuTDWAO4__YJWWMMdfCJuAFm5cUEp88OsodhO3ZA-2lzRfoBsSlk4.css\u0022 media=\u0022all\u0022 \/\u003E\n\u003Clink rel=\u0027stylesheet\u0027 type=\u0027text\/css\u0027 href=\u0027\/sites\/all\/modules\/contrib\/panels\/plugins\/layouts\/onecol\/onecol.css\u0027 \/\u003E\u003C\/head\u003E\u003Cbody\u003E\u003Cdiv class=\u0022panels-ajax-tab-panel panels-ajax-tab-panel-sageoa-tab-art\u0022\u003E\u003Cdiv class=\u0022panel-display panel-1col clearfix\u0022 \u003E\n  \u003Cdiv class=\u0022panel-panel panel-col\u0022\u003E\n    \u003Cdiv\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-markup\u0022 \u003E\n  \n      \n  \n  \u003Cdiv class=\u0022pane-content\u0022\u003E\n    \u003Cdiv class=\u0022highwire-markup\u0022\u003E\u003Cdiv xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block-markup\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv class=\u0022article fulltext-view \u0022\u003E\u003Cspan class=\u0022highwire-journal-article-marker-start\u0022\u003E\u003C\/span\u003E\u003Cdiv class=\u0022section abstract\u0022 id=\u0022abstract-1\u0022\u003E\u003Ch2\u003ESummary\u003C\/h2\u003E\n            \u003Cp id=\u0022p-1\u0022\u003EState-of-the-art management of atrial fibrillation (AF) requires an understanding of the general therapeutic strategies, limitations of each approach, and the factors involved in the selection of a strategy. This article discusses the merits of a rate control versus a rhythm control strategy using antiarrhythmic drugs, optimal approaches to anticoagulation in patients with AF, new catheter ablation techniques, and the use of rhythm control for younger patients, among other topics.\u003C\/p\u003E\n         \u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003EInterventional Techniques \u0026amp; Devices\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EThrombotic Disorders\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EArrhythmias\u003C\/li\u003E\u003C\/ul\u003E\u003Cul class=\u0022kwd-group clinical-trial\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003EInterventional Techniques \u0026amp; Devices\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EThrombotic Disorders\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EArrhythmias\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003ECardiology\u003C\/li\u003E\u003C\/ul\u003E\u003Cp id=\u0022p-2\u0022\u003EState-of-the-art management of atrial fibrillation (AF) requires an understanding of the general therapeutic strategies, limitations of each approach, and the factors involved in the selection of a strategy.\u003C\/p\u003E\u003Cp id=\u0022p-3\u0022\u003ERichard I. Fogel, MD, St. Vincent Hospital, Indianapolis, Indiana, USA, discussed the merits of a rate control versus a rhythm control strategy using antiarrhythmic drugs. The presumed benefits of rhythm control over rate control were not realized in 2 large clinical trials of older patients with AF [Wyse DG et al. \u003Cem\u003EN Engl J Med\u003C\/em\u003E 2002; Van Gelder IC et al. \u003Cem\u003EN Engl J Med\u003C\/em\u003E 2002]. Outcomes including all-cause mortality, hospitalization, and stroke were not significantly different between the 2 strategies, validating rate control as a management strategy for older patients with AF. According to Dr. Fogel, these results do not pertain to younger patients, especially those with \u201clone\u201d AF. In addition, in an observational study of routine clinical practice that used population-based claims data, initiation of a rhythm control strategy seemed to be superior to rate control for the endpoint of mortality, with the superiority noted after Year 4 [Ionescu-Ittu R et al. \u003Cem\u003EArch Intern Med\u003C\/em\u003E 2012].\u003C\/p\u003E\u003Cp id=\u0022p-4\u0022\u003EDr. Fogel recommended that a reasonable approach for strategy slection is attempted rhythm control in patients with 1 of the following: age \u0026lt;70 years; significant symptoms despite rate control; congestive heart failure that is exacerbated during AF; lone AF; left atrium (LA) \u0026lt;4.0 cm; and first episode of AF. Rate control is the preferred approach in patients who are aged \u0026gt;70 years, have symptoms that are well regulated with rate control, have failed prior antiarrhythmic drug therapy, or have an LA \u0026gt;4.5 cm.\u003C\/p\u003E\u003Cp id=\u0022p-5\u0022\u003EAssessment of heart rate (HR) response should include a period of prolonged monitoring, ideally with an assessment during moderate activity. A lenient resting HR goal of \u0026lt;110 bpm during activity seems reasonable and noninferior to a stricter target resting HR goal of \u0026lt;80 bpm [Van Gelder IC et al. \u003Cem\u003EN Engl J Med\u003C\/em\u003E 2010].\u003C\/p\u003E\u003Cp id=\u0022p-6\u0022\u003EPeter R. Kowey, MD, Jefferson Medical College, Philadelphia, Pennsylvania, USA, spoke about optimal approaches to anticoagulation in patients with AF. Although warfarin anticoagulation reduces rates of stroke and mortality in patients with nonvalvular AF, a number of limitations have impeded its use, including its narrow therapeutic window [Hart RG et al. \u003Cem\u003EAnn Intern Med\u003C\/em\u003E 2007]. Patients who cannot be maintained in the therapeutic range on warfarin are candidates for switching to a novel oral anticoagulant (NOAC; dabigatran, apixaban, or rivaroxaban).\u003C\/p\u003E\u003Cp id=\u0022p-7\u0022\u003EDabigatran performed better than warfarin in reducing the risk of ischemic stroke and was associated with less bleeding [Connolly SJ et al. \u003Cem\u003EN Engl J Med\u003C\/em\u003E 2009]. Rivaroxaban showed superiority to warfarin in both the primary and secondary prevention of stroke in patients with AF and \u22652 risk factors for stroke [Patel MR et al. \u003Cem\u003EN Engl J Med\u003C\/em\u003E 2011]. Apixaban was superior to warfarin on the primary outcome of stroke or systemic embolism [Granger CB et al. \u003Cem\u003EN Engl J Med\u003C\/em\u003E 2011].\u003C\/p\u003E\u003Cp id=\u0022p-8\u0022\u003ENOACs have a wide therapeutic range. Although no reversal agents exist at present, the number of fatal bleeding events is not higher than with warfarin, in part because they are short acting. Trial data demonstrate that the reduction in stroke observed with NOACs is mostly attributed to a substantial reduction in the rate of hemorrhagic stroke, more so than ischemic stroke. Nonetheless, longer-term safety and efficacy data are required, especially in older patients, those with severe renal dysfunction, and in African Americans.\u003C\/p\u003E\u003Cp id=\u0022p-9\u0022\u003EPersistent AF may be harmful in the long term, exposing patients to an increased risk of mortality and other complications including vascular dementia, said Eric N. Prystowsky, MD, St. Vincent Hospital, Indianapolis, Indiana, USA. For this reason, he agreed that rhythm control is favored in younger patients who may be facing decades of AF, as well as in patients with conditions predisposing to left ventricular (LV) diastolic dysfunction.\u003C\/p\u003E\u003Cp id=\u0022p-10\u0022\u003EConsistent with the 2006 Guideline for the Management of Patients With Atrial Fibrillation and its 2011 update [Fuster V et al. \u003Cem\u003ECirculation\u003C\/em\u003E 2006; Fuster V et al. \u003Cem\u003ECirculation\u003C\/em\u003E 2011], Dr. Prystowsky said that selection of an appropriate agent for maintaining sinus rhythm should be based on safety. When making this selection, patient\u0027s LV ejection fraction and size of the LA should be taken into consideration.\u003C\/p\u003E\u003Cp id=\u0022p-11\u0022\u003EDr. Prystowsky said that drugs other than amiodarone perform poorly in controlling rhythm when LA size is \u0026gt;5 cm. With minimal to no heart disease, or hypertension with minimal LV hypertrophy, flecainide, propafanone, sotalol, and dronedarone are first-line choices; with amiodarone and dofetalide as second-line; and catheter ablation performed in the event of failure of drug therapy.\u003C\/p\u003E\u003Cp id=\u0022p-12\u0022\u003EIn the presence of LV hypertrophy exceeding 1.4 cm, amiodarone is recommended for maintenance of sinus rhythm. For patients with coronary artery disease, safety data support the use of dofetalide, dronedarone, and sotalol as initial choices. No antiarrhythmic drug has been shown to be safe in the setting of heart failure, but amiodarone appears to be the safest choice.\u003C\/p\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-1\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003ECATHETER ABLATION TECHNIQUES STILL EVOLVING\u003C\/h2\u003E\n         \u003Cp id=\u0022p-13\u0022\u003EEvidence of rapid firing of the pulmonary veins (PV) as a trigger of AF has led to the introduction of various catheter ablation techniques targeting the PV, said Hugh Calkins, MD, Johns Hopkins University, Baltimore, Maryland, USA.\u003C\/p\u003E\n         \u003Cp id=\u0022p-14\u0022\u003ECatheter-based techniques are still evolving. The most commonly employed ablation strategy today involves the electrical isolation of the PV by creation of circumferential lesions around the right and the left PV ostia.\u003C\/p\u003E\n         \u003Cp id=\u0022p-15\u0022\u003EA meta-analysis of 4 randomized trials demonstrated an approximately 4-fold improvement in atrial tachyarrhythmia recurrence-free survival with circumferential catheter ablation of AF compared with antiarrhythmic drug therapy [Noheria A et al. \u003Cem\u003EArch Intern Med\u003C\/em\u003E 2008]. Results with the cryoballoon ablation system are nearly identical to those with catheter ablation. Because repeat procedures are required in a significant number of patients, catheter ablation probably should not be used first-line, depending on patient preference, said Dr. Calkins.\u003C\/p\u003E\n         \u003Cp id=\u0022p-16\u0022\u003ECurrent indications for catheter ablation of AF [Calkins H et al. \u003Cem\u003EJ Interv Card Electrophysiol\u003C\/em\u003E 2012]:\u003C\/p\u003E\n         \u003Cp\u003E\n            \u003C\/p\u003E\u003Cul class=\u0022list-simple \u0022 id=\u0022list-1\u0022\u003E\u003Cli id=\u0022list-item-1\u0022\u003E\n                  \u003Cp id=\u0022p-18\u0022\u003E\u25aa Symptomatic AF that is refractory to \u22651 Class 1 or a total of 3 antiarrhythmic drugs\u003C\/p\u003E\n                  \u003Cp\u003E\n                     \u003C\/p\u003E\u003Cul class=\u0022list-simple \u0022 id=\u0022list-2\u0022\u003E\u003Cli id=\u0022list-item-2\u0022\u003E\n                           \u003Cp id=\u0022p-20\u0022\u003E\u00bb Paroxysmal AF \u2013 catheter ablation recommended (Class IA, level of evidence A)\u003C\/p\u003E\n                        \u003C\/li\u003E\u003C\/ul\u003E\u003Cp\u003E\n                  \u003C\/p\u003E\n               \u003C\/li\u003E\u003Cli id=\u0022list-item-3\u0022\u003E\n                  \u003Cp id=\u0022p-21\u0022\u003E\u25aa Symptomatic AF prior to initiation of drug therapy\u003C\/p\u003E\n                  \u003Cp\u003E\n                     \u003C\/p\u003E\u003Cul class=\u0022list-simple \u0022 id=\u0022list-3\u0022\u003E\u003Cli id=\u0022list-item-4\u0022\u003E\n                           \u003Cp id=\u0022p-23\u0022\u003E\u00bb Paroxysmal AF \u2013 catheter ablation reasonable (Class IIA, level of evidence B; \u003Ca id=\u0022xref-table-wrap-1-1\u0022 class=\u0022xref-table\u0022 href=\u0022#T1\u0022\u003ETable 1\u003C\/a\u003E)\u003C\/p\u003E\n                        \u003C\/li\u003E\u003C\/ul\u003E\u003Cp\u003E\n                  \u003C\/p\u003E\n               \u003C\/li\u003E\u003C\/ul\u003E\u003Cp\u003E\n         \u003C\/p\u003E\n         \u003Cp id=\u0022p-24\u0022\u003EAge is a consideration in the management of AF, said Win-Kuang Shen, MD, Mayo Clinic, Scottsdale, Arizona, USA. Age-related structural changes in the heart that lead to functional changes such as prolonged contraction, prolonged action potential, and diminished velocity [Lakatta EG. \u003Cem\u003EHurst\u0027s The Heart\u003C\/em\u003E 2001], and age-mediated changes in the pharmacokinetics of drugs [Lee HC et al. \u003Cem\u003EJ Geriatric Cardiol\u003C\/em\u003E 2011], can affect the success of the management strategy. For example, there is an increase in the volume of distribution of fat-soluble drugs as people age, prolonging elimination half-life, and a decrease in the volume of distribution of water-soluble drugs [Cusack B et al. \u003Cem\u003EClin Pharmacol Ther\u003C\/em\u003E 1979; Lee HC et al. \u003Cem\u003EJ Geriatric Cardiol\u003C\/em\u003E 2011].\u003C\/p\u003E\n         \u003Cdiv id=\u0022T1\u0022 class=\u0022table pos-float\u0022\u003E\u003Cdiv class=\u0022table-inline\u0022\u003E\u003Cdiv class=\u0022callout\u0022\u003E\u003Cspan\u003EView this table:\u003C\/span\u003E\u003Cul class=\u0022callout-links\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022\/\u0022 class=\u0022table-expand-inline\u0022 data-table-url=\u0022\/highwire\/markup\/13152\/expansion?postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media%2Chighwire_embed\u0026amp;table-expand-inline=1\u0022 html=\u00221\u0022 fragment=\u0022#\u0022 external=\u00221\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView inline\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022\/highwire\/markup\/13152\/expansion?width=1000\u0026amp;height=500\u0026amp;iframe=true\u0026amp;postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media\u0022 class=\u0022colorbox colorbox-load table-expand-popup\u0022 rel=\u0022gallery-fragment-tables\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView popup\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/13152\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cdiv class=\u0022table-caption\u0022\u003E\u003Cspan class=\u0022table-label\u0022\u003ETable 1.\u003C\/span\u003E \n               \u003Cp id=\u0022p-25\u0022 class=\u0022first-child\u0022\u003EPatient Selection for Ablation\u003C\/p\u003E\n            \u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n         \u003Cp id=\u0022p-27\u0022\u003EMany antiarrhythmic drugs are metabolized by the cytochrome P450 P2D6 and 3A4 isoenzymes (\u003Ca id=\u0022xref-table-wrap-2-1\u0022 class=\u0022xref-table\u0022 href=\u0022#T2\u0022\u003ETable 2\u003C\/a\u003E) [Trujillo TC, Nolan PE. \u003Cem\u003EDrug Saf\u003C\/em\u003E 2000], and when used concomitantly with other drugs metabolized by these pathways, the antiarrhythmic drugs can cause prolongation of the QT interval.\u003C\/p\u003E\n         \u003Cdiv id=\u0022T2\u0022 class=\u0022table pos-float\u0022\u003E\u003Cdiv class=\u0022table-inline\u0022\u003E\u003Cdiv class=\u0022callout\u0022\u003E\u003Cspan\u003EView this table:\u003C\/span\u003E\u003Cul class=\u0022callout-links\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022\/\u0022 class=\u0022table-expand-inline\u0022 data-table-url=\u0022\/highwire\/markup\/13153\/expansion?postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media%2Chighwire_embed\u0026amp;table-expand-inline=1\u0022 html=\u00221\u0022 fragment=\u0022#\u0022 external=\u00221\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView inline\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022\/highwire\/markup\/13153\/expansion?width=1000\u0026amp;height=500\u0026amp;iframe=true\u0026amp;postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media\u0022 class=\u0022colorbox colorbox-load table-expand-popup\u0022 rel=\u0022gallery-fragment-tables\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView popup\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/13153\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cdiv class=\u0022table-caption\u0022\u003E\u003Cspan class=\u0022table-label\u0022\u003ETable 2.\u003C\/span\u003E \n               \u003Cp id=\u0022p-28\u0022 class=\u0022first-child\u0022\u003EAntiarrhythmic Agents Metabolized by P2D6 and 3A4\u003C\/p\u003E\n            \u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n         \u003Cp id=\u0022p-30\u0022\u003EThe elderly, who tend to have diffuse substrate and in whom maintenance of sinus rhythm is more difficult, have not been well represented in studies of left atrial ablation for AF [Calkins H et al. \u003Cem\u003EJ Interv Card Electrophysiol\u003C\/em\u003E 2012]. Most studies of atrioventricular (AV) nodal ablation in older patients have been conducted in patients refractory to medical therapy. Compared with drug therapy, AV nodal ablation plus permanent pacing has been shown to reduce symptoms and rates of hospital admission with comparable survival, but most studies of this approach are observational in nature, and this procedure should be reserved for severely symptomatic patients refractory to medical therapy [Chatterjee NA et al. \u003Cem\u003ECirc Arrhythm Electrophysiol\u003C\/em\u003E 2012].\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cul class=\u0022copyright-statement\u0022\u003E\u003Cli class=\u0022fn\u0022 id=\u0022copyright-statement-1\u0022\u003E\u00a9 2013 MD Conference Express\u00ae\u003C\/li\u003E\u003C\/ul\u003E\u003Cspan class=\u0022highwire-journal-article-marker-end\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Cspan id=\u0022related-urls\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Ca href=\u0022http:\/\/mdc.sagepub.com\/content\/13\/2\/6.abstract\u0022 class=\u0022hw-link hw-link-article-abstract\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView Summary\u003C\/a\u003E\u003C\/div\u003E  \u003C\/div\u003E\n\n  \n  \u003C\/div\u003E\n\u003C\/div\u003E\n  \u003C\/div\u003E\n\u003C\/div\u003E\n\u003C\/div\u003E\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_openurl.js?nzo01d\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_tables.js?nzo01d\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}