Current management of symptomatic atrial fibrillation

Atrial fibrillation (AF) is the commonest arrhythmia. It presents in distin ct patterns of paroxysmal, persistent and chronic AF, and patient managemen t aims differ according to the pattern. In paroxysmal AF, drug treatment with beta -blockers, class Ic and class II I agents reduce the frequency and duration of episodes. In persistent AF (recent onset, non-paroxysmal), early cardioversion with e ither pharmacological agents or by direct current (DQ cardioversion should be actively considered, in those patients who are suitable. Patients most l ikely to cardiovert and remain in sinus rhythm include those with duration of AF of <1 year, an acute reversible cause, left atrial diameter < 50mm an d good left ventricular function on echocardiography. Recent data show that maintenance of sinus rhythm after successful cardioversion is enhanced by the use of class III drugs including amiodarone and dofetilide. In chronic or permanent AF, management is aimed at controlling the ventricu lar rate response with combinations of digoxin, beta -blockers and calcium antagonists with atrio-ventricular nodal activity (diltiazem and verapamil) . There is some debate about the prognostic significance of AR Certainly AF i s associated with an excess mortality but this is largely accounted for by its association with serious intrinsic heart disease and the thrombo-emboli c complications of the arrhythmia. Atrial fibrillation is a common default arrhythmia for the sick heart.