Management of atrial fibrillation: Therapeutic options and clinical decisions

Atrial fibrillation (AF) is the most common, sustained tachyarrhythmia seen in clinical practice. Although it is not immediately life threatening, AF can cause troublesome symptoms and poses a risk of stroke. The patient's cl inical status is often complicated by the presence of other cardiovascular or concomitant diseases. As a result, management of the patient with AF inv olves many questions and choices, all of which must be individualized. Ther e ore 3 general strategies for the management of patients with AF, includin g (1) restoration and maintenance of sinus rhythm, (2) control of ventricul ar rate, and (3) prevention of stroke. More than 1 strategy may be appropri ate in some patients, Furthermore, either pharmacologic or nonpharmacologic options can be chosen in certain situations. Although some data from rando mized clinical trials are available to aid in clinical decision-making, onl y the benefits of anticoagulation are supported by substantial evidence. Th is article explores practical approaches to several management issues and s cenarios for which there ore limited relevant clinical date. These include: (1) patient selection for ventricular rate control and assessment of treat ment, (2) choice of antiarrhythmic drug for maintenance of sinus rhythm, (3 ) inpatient versus outpatient initiation of therapy, (4) definition of anti arrhythmic drug success, (5) methods of transthoracic direct cardioversion, and (6) prediction and prevention of AF after cardiac surgery. (C) 2000 by Excerpta Medica, Inc.