There were significantly lower values for left-ventricular ejection fraction AFIB cohorts. Multivessel disease was detected in A multivariate analysis was performed in the AFL group.
This data suggests that typical atrial flutter constitutes a manifestation for previously asymptomatic CAD. Due to the inclusion criteria, CAD has to be considered silent and stable in most of the patients.
Therefore, the presence of typical atrial flutter in formerly healthy patients should raise suspicion of otherwise silent CAD and initiate further investigations and risk-stratification with particular emphasis on the individual CHA2DS2-VASc-Scores. Oxford University Press is a department of the University of Oxford. It furthers the University's objective of excellence in research, scholarship, and education by publishing worldwide.
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Oxford Academic. Google Scholar. However, the disorder can increase the risk of stroke, heart failure and other complications. There are effective treatments for atrial flutter, including medication or procedures designed to scar small areas of heart tissue ablation. Explore Mayo Clinic studies testing new treatments, interventions and tests as a means to prevent, detect, treat or manage this condition.
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Atrial flutter Atrial flutter is a type of heart rhythm disorder in which the heart's upper chambers atria beat too quickly. Request an Appointment at Mayo Clinic. If the cardioversion was performed using the TEE-guided approach with intravenous heparin as the method of anticoagulation, it is advisable to continue intravenous heparin until therapeutic oral anticoagulation is achieved.
The decision to initiate and continue anticoagulation for AF shorter than a duration of 48 hours should be based on the presence of other risk factors for thromboembolism. On account of the left atrial appendage accounting for the source of most thrombi in patients with nonvalvular AF, several interventions gave been designed for left atrial appendage closure and thus stroke reduction. The Watchman device, a closure device deployed percutaneously that blocks the left atrial appendage has been approved by the FDA for stroke prevention in patients with non valvular AF who are at an increased risk of stroke and who have no contra indication to short term anti coagulation.
The Lariat device is another percutaneous system for left atrial appendage exclusion; however, its labelling is not specific for stroke prevention.
The restoration and maintenance of sinus rhythm can be beneficial for patients with bothersome symptoms. However, management of patients with asymptomatic or minimally symptomatic AF has been controversial for many years. Selecting appropriate patients for a rhythm-controlling strategy are well articulated by clinical practice guidelines. A rhythm-control strategy often requires the use of antiarrhythmic drugs that may have significant and even life-threatening side effects, and procedures that carry uncommon, but potentially life-threatening or disabling complications.
Some nonrandomized trials have reported an increase in mortality among patients who were on long-term antiarrhythmic therapy for AF, presumably from the proarrhythmic effects of the drugs. This study demonstrated that a rhythm-control strategy is no better than a ventricular rate control strategy with regard to quality of life, incidence of stroke, or mortality at a follow-up of approximately 5 years.
A meta-analysis of 5 randomized controlled trials comparing rate-control with rhythm-control strategies included more than 5, patients and demonstrated that a rate-control strategy is not inferior to a rhythm-control strategy. Acutely, restoration of sinus rhythm may be achieved with either pharmacologic or electrical cardioversion. It is important to remember that electrical and pharmacologic cardioversion are no different with regard to the risk of thromboembolic stroke. Therefore, the requirements for anticoagulation apply equally to either treatment strategy and are largely dictated by the patient-specific thromboembolic risk profile discussed previously.
Electrical cardioversion is more effective than pharmacologic cardioversion. The administration of an antiarrhythmic drug may promote more successful direct current cardioversion and subsequent maintenance of sinus rhythm.
Similarly, it is reasonable to add an antiarrhythmic drug for any patient who develops an early AF recurrence after direct-current electrical cardioversion and to consider a repeat attempt after the drug has been initiated and reaches steady-state blood levels. Contemporary use of pharmacologic cardioversion in the US occurs in nonelective scenarios in the emergency department or intensive care unit, and also in stable outpatients treated with a unique type of rhythm control strategy referred to as a pill-in-the-pocket approach.
Elective pharmacologic cardioversion is uncommon in the U. S given the superiority of a planned electrical cardioversion under sedation with appropriate airway management personnel on hand. The intravenous agents approved in the US for immediate pharmacologic cardioversion of AF are procainamide, amiodarone, and ibutilide Table 2.
Amiodarone is the most commonly used drug in emergency department and intensive care unit settings. Pharmacologic conversion of AF can be achieved with oral drugs. The pill-in-the-pocket approach is sometimes used with class Ic drugs like flecainide or propafenone and may be useful for select outpatients in order to quickly abort AF episodes shortly after onset.
This approach has the potential to reduce emergency department visits and hospitalizations, but must be carefully initiated and supervised. It is recommended that the first such application of this strategy is done in a monitored environment, such as an emergency department, in order to establish patient-specific safety. Includes information from January et al. Many oral agents are available for long-term maintenance of sinus rhythm in patients with AF Table 3. Class Ia antiarrhythmic drugs quinidine, procainamide, and disopyramide have become less commonly prescribed than in the past because of their side effect profiles.
The class Ic agents, namely flecainide and propafenone, have more favorable side effect profiles and are more commonly utilized. However, the use of these medications does have some degree of risk. The Cardiac Arrhythmia Suppression Trial CAST has shown that flecainide and encainide are associated with an increase in mortality when used for the suppression of ventricular arrhythmias in patients who have had a myocardial infarction with ventricular dysfunction.
Flecainide and propafenone are usually well tolerated and are appropriate first-line options for the treatment of AF in patients without structural heart disease, left ventricular hypertrophy, or marked pre-existing conduction disease ie, complete left bundle branch block.
Drugs such as sodium channel blockers are expected to widen the QRS duration thereby increasing vulnerability to heart block among patients with very significant pre-existing His-Purkinje system dysfunction.
Sotalol is a class III antiarrhythmic that has beta-blocking properties and is generally well tolerated. Patients may have difficulty tolerating the beta blocker side effects, such as fatigue, and there is a potential risk of excessive bradycardia.
As with other class III antiarrhythmic agents, sotalol causes QT prolongation and may result in ventricular proarrhythmia, such as torsades de pointes.
Careful monitoring of renal function, electrolytes, and QT interval is recommended. In addition, initiation in hospital while on telemetry monitoring should be considered although it is not required by the FDA.
Lastly, drug interactions should be carefully avoided, particularly those resulting in QT prolongation. Dofetilide, a class III antiarrhythmic, has good efficacy rates and is one of the best tolerated antiarrhythmic drugs in terms of its side effects profile. Importantly, dofetilide has also been shown to be safe for patients with cardiomyopathy, CHF, and ischemic heart disease.
Therefore, dofetilide may be considered as an alternative treatment option to amiodarone. Like sotalol, dofetilide drug causes QT prolongation that may result in proarrhythmia and rarely death if excessive and is restricted to patients without advanced renal disease. Its use has been restricted by the FDA to certified prescribers and requires monitored initiation in a hospital setting followed by structured outpatient follow-up.
Unlike sotalol, however, dofetilide does not cause excessive bradycardia and thus can be administered to patients without concern for exacerbating preexisting bradycardia.
Dofetilide has many potentially lethal drug-to-drug interactions, including with many commonly prescribed antibiotics and antihypertensive drugs. Despite these limitations, many patients experience improved AF control with dofeilide with fewer daily side effects compared with other antiarrhythmic drugs. Amiodarone is generally reserved for patients with AF for whom other antiarrhythmic drugs have been contraindicated, ineffective, or poorly tolerated.
This is primarily because amiodarone has potential time- and dose-dependent organ toxicities that can affect the liver, thyroid, lungs, and eyes. It is recommended that baseline tests be performed at initiation of the drug, including an ophthalmologic examination, pulmonary spirometry and diffusion capacity tests, and blood tests to assess liver and thyroid function.
The blood tests are often repeated at regular intervals, approximately every 6 to 12 months, and the ophthalmologic examination should be performed yearly. Dronedarone is an antiarrhythmic drug designed to function similarly to amiodarone but without the molecular iodine interface associated with some of the previously described amiodarone toxicities.
Early enthusiasm for this drug, based on results from the initial studies, was later tempered by safety concerns and limitations. The biggest safety concern with this drug involves use in patients with CHF. It also has some important drug-to-drug interactions, including with the anticoagulant drug dabigatran.
That said, it is a reasonable treatment option for patients without structural heart disease or advanced liver disease and does not require hospital-based initiation like dofetilide.
It has also been one of the most heavily studied antiarrhythmic drugs on the market. Implantable cardiac devices are also used in the treatment of patients with AF. There is a substantial incidence of sinus node and AV node dysfunction in the AF population requiring cardiac pacing. Pacemakers have several purposes, including bradycardia pacing support, ventricular response regularization, and AF suppression or termination.
Clinical practice guidelines detail the recommended uses of implantable pacemakers and anti-tachycardia devices. Sinus node dysfunction in association with AF is often referred to as tachycardia-bradycardia syndrome. Sinus node dysfunction can be exacerbated by medications used to control AF and the presence of a pacemaker may allow use of or up titration of rate-controlling or antiarrhythmic medications.
Pacemakers are also implanted in conjunction with catheter ablation of the AV node. This type of ablation is the ultimate method of ventricular rate control and is often reserved for patients with permanent or paroxysmal AF refractory to medical or ablative therapy. The potential benefits of this type of approach extend beyond simply controlling ventricular response, because there is evidence that regularization of the ventricular rhythm also confers hemodynamic or symptomatic benefits, particularly in the heart failure population in conjunction with the use of a biventricular pacemaker.
This approach has been shown to be effective and leads to improved quality of life for patients. However, this approach does not address the fibrillating atria, and such patients still require systemic anticoagulation for thromboembolism and stroke prevention.
Several features of pacemaker systems may be useful for patients with AF. A pacemaker that has the capability to change automatically into a nontracking pacing mode at the onset of an episode of AF known as mode switching is essential to avoid the rapid heart rate that might otherwise occur when the pacemaker responds to rapid atrial activity by pacing the heart inappropriately fast in the ventricles. Implantable atrial defibrillators have been developed, either as a stand-alone device or in combination with a ventricular defibrillator.
However, the atrial defibrillator has not been widely accepted by patients or physicians. In general, patients have difficulty tolerating even the low-energy internal cardioversion shocks or frequent antitachycardia pacing sequences without the deep sedation provided during conventional external cardioversion.
Catheter ablation has emerged as a safe and effective alternative to antiarrhythmic drug therapy for the maintenance of sinus rhythm. However, as is the case with antiarrhythmic drug therapy, it has not demonstrated a reduced risk of mortality, stroke, or heart failure and thus is not regarded as a substitute for stroke prevention strategies.
Postablation, spontaneous electrical impulses originating from within any of the 4 PVs cannot propagate into the atrial body to initiate or trigger AF. Pulmonary vein isolation is thus a stand-alone treatment approach, but has also been incorporated into larger ablative efforts aimed at non-PV triggers and substrate modification.
Substrate modification or ablation of non-PV triggers are often incorporated into procedures for patients with persistent or long-standing persistent AF. Outcomes data suggest that PVI alone without substrate modification works best in patients with paroxysmal AF.
The role for more extensive ablation for patients with persistent AF remains unclear after the recent STAR AF II trial showing no reduction in the rate of recurrence after extensive ablation. Experienced centers have reported high rates of successful AF ablation resulting in discontinuation of antiarrhythmic drug therapy. In virtually all studies involving catheter ablation, efficacy rates are lower among patients with persistent AF and long-standing persistent AF.
The degree of atrial myopathy, scar burden and comorbidities may also influence outcomes. Weight loss strategies for patients with obesity and treatment of sleep apnea are recognized as increasingly important in clinical outcomes. There are currently 2 different energy sources in use for the purposes of catheter ablation. The more commonly used radiofrequency current leads to tissue death by heating and is applied using a point-by-point method. Cryoablation uses cryogenic energy delivered in a single step by means of a balloon resulting in tissue necrosis by freezing.
The FIRE and ICE trial comparing the 2 energy sources concluded that cryoablation was not inferior to radiofrequency ablation with respect to efficacy in patients with drug refractory paroxysmal atrial fibrillation. However phrenic nerve injury was more common 2. While such phrenic nerve injuries typically resolve spontaneously, it may take up to 1 year and can be associated with significant morbidity.
Other procedure-related complications include serious events such as stroke 0. Procedures typically take 4 to 6 hours, involve the use of radiation X-ray, and have an expected hospital course of overnight observation with planned discharge the next day. Recurrence of AF after a blanking period of 3 months postablation may indicate recovery of pulmonary vein conduction and can be an appropriate indication for repeat ablation or antiarrhythmic therapy. Oral anticoagulation is recommended for at least 3 months following ablation and thereafter based on the individual patient risk for stroke.
The original Cox-Maze surgical procedure for the treatment of AF has substantially evolved from its initial form. In general, it involves a series of incisions or lesions in the atria. These are carefully placed to compartmentalize the atrial tissue to channel atrial activity and prevent the re-entry required for the maintenance of AF.
To a certain extent, there has been a confluence with some of the lesions sets delivered during catheter ablation techniques. For example, achieving anatomic PVI is now considered standard with both approaches. Non-incisional lesions may be placed using bipolar radiofrequency, cryothermy, or microwave energy.
Outcomes associated with surgical approaches are comparable with catheter ablation reported higher in some series and offer the advantage of concomitant exclusion of the left atrial appendage. The incidence of perioperative complications has been low but perhaps higher than catheter ablation. The invasiveness of this approach makes it a less desirable option for patients with AF alone, but it might be attractive for patients undergoing cardiac surgery for another indication eg, valve replacement or coronary bypass surgery or for patients with a particularly strong indication for exclusion of the left atrial appendage ie, recurrent thrombus despite antithrombotic therapy.
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