1. Practical Rate and Rhythm Management of Atrial Fibrillation
New Paradigm in Managing Atrial Fibrillation: A Campaign to Promote Optimal Patient Care
Slide set developed by: Michael C. Delaughter, MD, PHD: EP-Cardiology PA Michael Eifling, MD: Texas Heart Institute at St. Luke’s Episcopal Hospital and Baylor University Rohit Mehta, MD: Sanger Heart and Vascular Institute

2. Management Principles of AF
Cornerstones of AF Management
Rate Control
Rhythm Control
Anticoagulation
Control of symptoms
Control of symptoms
Prevention of thromboembolism
Treatment or prevention of Tachycardia Induced Cardiomyopathy (CMP)
Reduction in Hospitalizations
Minimization of bleeding risk
Therapeutic Goals
Regardles of whether AF is paroxysmal or persistent, and whether rate or rhythm control is preferred, symptom control, avoidance of hospitalization and appropriate anticoagulation are key.
Reduction in Hospitalizations 2 2

3. Rate versus Rhythm Control for AF
The AFFIRM, RACE and AF-CHF trials have shown no mortality benefit from a rhythm control strategy compared to a rate control strategy.
Therefore, a rate control strategy, without attempts at restoration or maintenance of sinus rhythm (SR), is reasonable in some patients with AF, especially those who are elderly and asymptomatic.
If rate control offers inadequate symptomatic relief, restoration of SR may become a long-term goal.
Restoration and maintenance of SR continues to be a reasonable treatment approach in many patients with AF.
Rate versus Rhythm Control is a key decision point in AF management and should be driven by the patient’s symptoms and AAD / procedural risk.
Knight, et al, Practical Rate and Rhythm Management of Atrial Fibrillation, January 2010 ed. 3 3

4. Ventricular Rate Control
Principles of a Rate Control Strategy:
Adequate control of the ventricular response during AF can significantly improve symptoms and is critical to avoid tachycardia-mediated cardiomyopathy.
Most patients managed using a rhythm control strategy also require medications for rate control.
Rate control during atrial flutter tends to be more difficult than during AF.
What is Adequate Rate Control?
Control of the ventricular rate during AF is important both at rest and with exertion.
No standard method for assessment of heart rate control has been established.
Criteria for rate control vary with patient age but usually involve achieving ventricular rates between 60 and 80 bpm at rest and between 90 and 115 bpm during moderate exercise.
For the AFFIRM trial, adequate control was defined as an average HR up to 80 bpm at rest and either an average rate up to 100 bpm during Holter monitoring with no rate above 100% of the maximum age-adjusted predicted exercise HR, or a maximum HR of 110 bpm during a 6-min walk test.
In the RACE trial, rate control was defined as less than 100 bpm at rest.
Only about 5%of patients from these trials required AV ablation to achieve HR control.
Knight, et al, Practical Rate and Rhythm Management of Atrial Fibrillation, January 2010 ed. 4

5. Ventricular Rate Control: Drugs to Control the Ventricular Response
Beta blockers are the most effective drug class for rate control.
Calcium channel antagonists (nondihydropyridine) are good choices for patients with asthma or COPD requiring beta agonist inhaler therapy.
Digoxin provides relatively poor rate control during exertion and should be reserved for patients with systolic HF.
Digoxin does not convert AF to SR and may perpetuate AF.
Digoxin is marginally effective as a sole agent, but may prove useful in combination with beta blocker or calcium channel antagonists, particularly in hypotensive patients.
Knight, et al, Practical Rate and Rhythm Management of Atrial Fibrillation, January 2010 ed. with modifications. 5

6. Ventricular Rate Control: Drugs to Control the Ventricular Response
A combination of a beta blocker and either a calcium channel antagonist or digoxin may be needed to control the HR.
The choice of medication should be individualized and the dose modulated to avoid bradycardia.
Beta blockers and calcium channel antagonists should be used cautiously in patients with HF.
AV nodal blocking drugs at doses required to control the ventricular response can cause symptomatic bradycardia that requires pacemaker therapy.
Knight, et al, Practical Rate and Rhythm Management of Atrial Fibrillation, January 2010 ed. 6

7. Ventricular Rate Control: Drugs to Control the Ventricular Response
Some antiarrhythmic drugs that are used to maintain sinus rhythm, such as sotalol, dronedarone, and amiodarone, also provide some control of the ventricular response when patients are in AF.
Amiodarone should rarely be used for rate control because of its potential for toxicity.
IV digoxin or nondihydropyridine calcium channel antagonists given to patients with AF and WPW may accelerate the ventricular response and are not recommended.
Knight, et al, Practical Rate and Rhythm Management of Atrial Fibrillation, January 2010 ed. 7

8. Ventricular Rate Control: AV Nodal Ablation
Ablation of the AV conduction system and permanent pacing (the “ablate and pace” strategy) is an option for patients who have rapid ventricular rates despite maximum medical therapy and often yields remarkable symptomatic relief.
There is growing concern about the negative effects of long- term RV pacing.
Biventricular pacing, on the other hand, may overcome many of the adverse hemodynamic effects associated with RV pacing and is preferred when systolic dysfunction is present.
Catheter ablation of the AV node should not be attempted without a prior trial of medication to control the rate.
Knight, et al, Practical Rate and Rhythm Management of Atrial Fibrillation, January 2010 ed. with modifications. 8

9. CHADS2 Risk Stratification Scheme
Anticoagulation HRS Education 3/25/2017 1:32 PM
Risk Factors
Score
C Recent congestive heart failure 1
H Hypertension
A Age 75 years
D Diabetes mellitus
S2 History of stroke or transient ischemic attack 2
It is critical to apply a risk scheme to quantify risk for stroke in AF. The CHADS2 scoring system is commonly used by several different guidelines and represents the current recommendation for stroke risk assessment of the ACC/AHA/ESC guidelines for the management of AF.
Background:
Several risk stratification schemes currently exist to aid physicians in selecting appropriate antithrombotic therapy for patients with AF. In order to assess the quality of such tools, 2 current and 1 new classification scheme (CHADS2) were assessed for their predictive value. The CHADS2 combined conclusions and recommendations from the AFI and the SPAF Investigators to create a scheme that assigned point values to comorbidities. The points are totaled to create the score. The CHADS acronym refers to the comorbidities it assesses and assigns a point value based on the risk factor. The C refers to recent CHF, the H stands for hypertension, A stands for age 75 or greater, and D is for diabetes, each of which receives 1 point. Two points are assigned for history of stroke or TIA. Patients are assessed for these risk factors and the total provides a guideline for risk and management of a patient. For example, a patient with recent CHF and diabetes would receive a score of 2 and would fall into the moderate-risk category. However, a patient who only has hypertension would have a score of 1.
EP: Progress Indicators
1. Awareness of the existence of the CHADS2 risk index for assessment of stroke risk in patients with nonvalvular atrial fibrillation. (knowledge)
2. Calculate a CHADS2 risk score for assessment of stroke risk in patients with nonvalvular atrial fibrillation. (performance)
Learning Objectives
1. Outline the CHADS2 risk index for assessment of stroke risk in patients with nonvalvular atrial fibrillation (AF) and calculate a CHADS2 risk score for such patients [Progress Indicators 1, 2]
Instructional Objectives
1. Presented with clinical information for a patient with nonvalvular AF, participants will be able to identify the CHADS2 risk index as an appropriate assessment tool to determine stroke risk.
2. Given pertinent patient information, participants will be able to calculate a CHADS2 risk score for a patient with nonvalvular AF.
CARD:
Progress Indicators
PCP:
1. Outline the CHADS2 risk index for assessment of stroke risk in patients with nonvalvular atrial fibrillation (AF) [Progress Indicator 1]
2. Calculate a CHADS2 risk score for a patient with nonvalvular AF and describe the usefulness of the score in making appropriate anticoagulation management decisions [Progress Indicators 2,3]
Rockson et al. J Am Coll Cardiol. 2004;43: 9

10. Maintenance of Sinus Rhythm: Principles of Antiarrhythmic Drug Therapy
AF is a chronic disorder and is likely to recur in most patients without antiarrhythmic drugs (AADs).
Pharmacological therapy is indicated in patients who can tolerate AADs and who have a reasonable chance to maintain sinus rhythm.
Pharmacological therapy is indicated to suppress symptoms, improve exercise capacity, improve hemodynamic function, and prevent tachycardia-induced cardiomyopathy.
The risk of stroke may not be reduced by suppression of AF.
Before administering an antiarrhythmic drug, precipitants of AF such as hypertension, valve disease, CHF, hyperthyroidism, and OSA should be identified and corrected.
Antiarrhythmic drug (AAD) choice is based on side-effect profiles and presence of structural heart disease, heart failure, or hypertension.
Drug choice should be individualized and account for underlying renal and hepatic function.
Knight, et al, Practical Rate and Rhythm Management of Atrial Fibrillation, January 2010 ed.

11. Maintenance of Sinus Rhythm: Principles of Antiarrhythmic Drug Therapy
Drugs should be used to decrease the frequency and duration of episodes, and to improve symptoms.
AF recurrence without symptoms is not indicative of treatment failure and does not necessitate a change in AAD therapy.
An AAD should be abandoned when it does not result in symptomatic improvement or causes adverse events.
Ensure normal electrolyte status and appropriate anticoagulation prior to starting antiarrhythmic drug therapy.
Initiate AV nodal blockade prior to the use of antiarrhythmics such as flecainide that do not provide substantial AV node blockade.
Initiate therapy at a low dose and titrate up as needed and after evaluating drug effects on ECG parameters.
Knight, et al, Practical Rate and Rhythm Management of Atrial Fibrillation, January 2010 ed.

12. ACC/AHA/ESC Guidelines Maintenance of Sinus Rhythm in Specific Patient Populations
No (or minimal) Heart Disease
Hypertension
Coronary Artery Disease
Heart Failure
Substantial LVH
AmiodaroneDofetilide
Flecainide PropafenoneSotalol
Dofetilide Sotalol No
Yes
Flecainide PropafenoneSotalol
Amiodarone
AmiodaroneDofetilide
CatheterAblation
AmiodaroneDofetilide
CatheterAblation
CatheterAblation
CatheterAblation
CatheterAblation
Amiodarone
Calkins et al. HeartRhythm 2007 HRS/EHRA/ECAS Expert Consensus Statement on Catheter and Surgical Ablation of Atrial Fibrillation; 4: 1-46 12 12

13. Maintenance of Sinus Rhythm in Specific Patient Populations Suggested Scheme Including Dronedarone
No (or minimal) Heart Disease
Hypertension
Coronary Artery Disease
Heart Failure
Substantial LVH
Dofetilide Sotalol Dronedarone
AmiodaroneDofetilide
Flecainide Propafenone Sotalol Dronedarone No
Yes
Flecainide Propafenone Sotalol Dronedarone
AmiodaroneDronedarone
Amiodarone
Dofetilide
Catheter
Ablation
CatheterAblation
CatheterAblation
CatheterAblation
Amiodarone
Amiodarone
Dofetilide
CatheterAblation
Abbreviation: LVH, left ventricular hypertrophy. Modified from Fuster, V. et al. J. Am. Coll. Cardiol. 48, e149–e246 (2006). 13 13

14. Rationale for Initial Trial of Medical Therapy
The relative safety and efficacy of ablation vs. antiarrhythmic drugs has not been firmly established but large randomized trials are ongoing
Ablation:
Complication rate: 5.9%
Single-procedure success rate without AADs: 57%
Multiple-procedure success rate without AADs: 71%
Multiple-procedure success rate with AADs: 77%
AAD Therapy:
Adverse event rate: 30% (common but less severe)
Success rate: 52%
Calkins et al. CircEP. 2009;2:

15. Atrial Fibrillation Ablation Candidates
Anticoagulation HRS Education 3/25/2017 1:32 PM
Symptomatic Paroxysmal or Persistent Atrial Fibrillation
Second-line Therapy
Failure of Class IC or Class III agent
Intolerance to Medical Therapy, Refusal of Medical Therapy
Other Considerations:
Young patients with paroxysmal atrial fibrillation, in whom decades-long drug therapy is undesirable
Congestive Heart Failure due to tachycardia-induced cardiomyopathy, in whom drug choices are limited by the presence of CHF 15

16. Atrial Fibrillation Ablation Candidates
Limitations in Efficacy
Longstanding Persistent Atrial Fibrillation (>1 year)
Enlarged LA (>55 mm)
Age > 70 years
Left atrial or Left atrial appendage thrombus is an absolute contraindication to atrial fibrillation ablation.
Calkins et al. HeartRhythm 2007 HRS/EHRA/ECAS Expert Consensus Statement on Catheter and Surgical Ablation of Atrial Fibrillation; 4: 1-46 16

17. Atrial Fibrillation Ablation Outcomes
Definition of success includes:
Freedom from symptomatic atrial fibrillation
Freedom from all atrial fibrillation
Facilitation of antiarrhythmic therapy
Eradication of anticoagulant therapy
Duration of Success:
Freedom from atrial fibrillation at one year
Freedom from late atrial fibrillation
Most common accepted success definition
Freedom from atrial fibrillation off antiarrhythmic therapy at one year
Late recurrences: greater than 12 months
Calkins et al. HeartRhythm 2007; HRS/EHRA/ECAS Expert Consensus Statement on Catheter and Surgical Ablation of Atrial Fibrillation; 4: 1-46

18. Atrial Fibrillation Ablation Outcomes
Blanking period of 2 months post ablation
Early recurrence of AF events termed “early events”
Minimum of symptomatic monitoring
Suggested asymptomatic surveillance at 6 month intervals
30 day auto-triggered monitors
Symptom triggered event monitors with weekly asymptomatic transmissions
24-72 hour Holter monitoring.
Calkins et al. HeartRhythm 2007; HRS/EHRA/ECAS Expert Consensus Statement on Catheter and Surgical Ablation of Atrial Fibrillation; 4: 1-46

19. Atrial Fibrillation Ablation Outcomes
Paroyxsmal
70-80% success at freedom from atrial fibrillation at one year off anti-arrhythmic therapy.
30% of patients required 2 procedures to achieve this result.
Most utilized pure-pulmonary vein isolation approach
Persistent
Similar success rates in persistent patients with similar end-point and need for repeat procedure
More commonly requires substrate modification (targeting of CFAE) and linear ablation
Long-Standing Persistent
Utilizing stepwise approach (PV isolation Linear ablation CFAE), some studies have demonstrated 70-80% freedom from atrial fibrillation at one year off anti-arrhythmic therapy
Calkins et al. HeartRhythm 2007; HRS/EHRA/ECAS Expert Consensus Statement on Catheter and Surgical Ablation of Atrial Fibrillation; 4: 1-46

20. Atrial Fibrillation Ablation Outcomes
Randomized Trials:
Paroxysmal Atrial Fibrillation (Flecainide or Sotalol vs Ablation)
One year freedom from atrial fibrillation (AF)
37% freedom from AF in anti-arrhythmic arm
87% freedom from AF in ablation arm
Persistent Atrial Fibrillation (Ablation vs. Cardioversion)
One year freedom from AF or atrial flutter
74% freedom from AF in ablation arm
58% freedom from AF in cardioversion arm
Calkins et al. HeartRhythm 2007; HRS/EHRA/ECAS Expert Consensus Statement on Catheter and Surgical Ablation of Atrial Fibrillation; 4: 1-46

21. Atrial Fibrillation Ablation Outcomes
Randomized Trials:
Paroxysmal or Persistent Atrial Fibrillation
One year freedom from AF (ablation vs. anti-arrhythmic (AA) drug)
9% freedom from AF in the AA arm
56% freedom from AF in the ablation arm
Paroxysmal Atrial Fibrillation
One year freedom from AF (ablation vs anti-arrhythmic (AA) drug)
22% freedom from AF in AA arm
86% freedom from AF in ablation arm
Stabile et al. European Heart Journal 2006; 27:

22. Atrial Fibrillation Ablation Outcomes
Paroxysmal Atrial Fibrillation
One year freedom from AF (ablation vs anti-arrhythmic (AA) drug)
22% freedom from AF in AA arm
86% freedom from AF in ablation arm
Paroxysmal and Persistent Atrial Fibrillation
One year freedom from AF (ablation vs. anti-arrhythmic (AA) drug)
7% freedom from AF in AA arm
75% freedom from AF in ablation arm
63% of AA treated patients crossed over
Stabile et al. European Heart Journal 2006; 27:

23. Final Summary for AF Ablation
Anticoagulation HRS Education 3/25/2017 1:32 PM
Identifying appropriate ablation candidates
Failing medical therapy
Refusing medical therapy
Need for symptoms
Young patients 
Differences in approach for paroxysmal and persistent patients
Lesion set
Utility of isuprel post ablation
Likelihood of recurrence / need for additional procedures (see Cappato, Circulation, AF registry outcomes paper)
Definition of success / likelihood of success
Managing atypical flutter / need for confirmation of block across lines 
Surgical based ablation
Relative efficacy vs. catheter based
Rationale / benefit of appendage ligation / resection
Cox III – the “gold standard”
Efficacy of other lesion sets, modalities (bipolar RF, cryo, HIFU) vs. Cox
Take home point:
AF will attain epidemic status over the next 50 years. 23