1. 1 AF: Issues with Anticoagulation AFL: Anticoagulation like AF When undergoing procedures with risk for bleeding: May DC warfarin for up to one week without substituting heparin except for high risk pts. (Prosthetic valves, prior stroke or TIA). Class IIa (c) The use of low molecular heparin in AF has become common practice but it is based on extrapolation from DVT studies and from observational studies (no sufficient data)

2. 2 AF: Issues with Cardioversion AF duration unknown or over 48 hours: AC for 3 weeks before and one month after CV Risk for strokes is same for chemical or electrical CV TEE to rule out thrombus before CV is reasonable. (Class IIa, level of evidence A)

3. AF: Rate Control 60 – 80 bpm at rest, 90 – 115 with moderate exercise. AVN blocking agents (BB, CA channel blockers, Digoxin) Digoxin reduces only resting heart rate and not during activity Amiodarone can be used for rate control when others fail (severe LV dysfunction and CHF) AV junction ablation and PPM only as a last resort 3

4. AF: Rhythm Control 4 Antiarrhythmic Drug therapy: Class Ia (Quinidine, Procainamide) Claa Ic (Flecainide, Propafenon) Class III (Sotalol, Amiodarone, Dofetilide) Limited efficacy Significant side effects Pro-arrhythmic effects Increase mortality New AADs: Forget it ………

5. AF: Newer Class III AA Drugs Dofetilide Introduced in 1999. Oral agent. Prolongs APD by blocking Ikr. More effective than low dose sotalol in restoring SR Has neutral effect on mortality in HF and post MI patients. Prolongs QT interval and may cause Torsades de Points in 3-5 % of patients (dose adjusted according to creatinine clearance) Ibutilide Introduced in 1996. An injectable agent (1-2mg) Prolongs APD by enhancing a slow inward NA current 50% success in termination of acute AF (higher success rates for AFL May cause Torsades de Points in up to 8% of patients 5

6. AF: Rate vs. Rhythm Control Would a strategy of rhythm control results in: Less ischemic strokes? Improved symptoms? Better quality of live? Survival benefit? 6