67

REVIEW

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Present treatment options for atrial fibrillation
S K S Lairikyengbam, M H Anderson, A G Davies
.............................................................................................................................

Postgrad Med J 2003;79:67–73

Atrial fibrillation is the commonest sustained cardiac CLASSIFICATION

arrhythmia. It accounts for >35% of all hospital There is no general agreement on the terminology
to describe various types of atrial fibrillation.6 It
admissions for cardiac arrhythmias in the United States. may be usually classified as acute and chronic
The presence of atrial fibrillation increases the mortality atrial fibrillation.7 Chronic atrial fibrillation may
of a population by up to twofold. The risk of stroke be further subclassified as paroxysmal, persistent,
and permanent.7 8 When episodes of atrial fibril-
increases from 1.5% in patients with atrial fibrillation lation recur and each is self terminating, this is
from 50–59 years of age to up to 23.5% for such called paroxysmal atrial fibrillation. The term,
patients aged 80–89 years. Although the diagnosis of “persistent” is used when the spontaneous
remission of atrial fibrillation does not occur and
atrial fibrillation is usually straightforward, effective atrial fibrillation is likely to persist if not
treatment is not. This article will discuss how rhythm cardioverted. It is regarded as permanent when it
control of atrial fibrillation can best be achieved, the cannot be reverted to sinus rhythm, even by elec-
trical cardioversion. Most atrial fibrillation usu-
controversy over the rhythm versus rate control, the ally starts as paroxysmal atrial fibrillation. In this
maintenance of sinus rhythm with antiarrhythmic drugs simple but therapeutically useful classification,
after cardioversion, and prevention of there may be overlap between acute onset and
other types of atrial fibrillation. There are
thromboembolism. Finally, the recent advances in published complex classifications of atrial fibrilla-
various non-pharmacological approaches for the tion which are beyond the scope of this
treatment of atrial fibrillation will be highlighted. article.6 9 10
.......................................................................... MECHANISM
The mechanism of atrial fibrillation is not fully
elucidated.6 At least three mechanisms have been

A
trial fibrillation is the commonest cardiac
arrhythmia. It affects 5% of British people shown to be important in its genesis and mainte-
above the age of 65 years and 10% above nance.
75.1 It accounts for more than 35% of all hospital (1) There may be enhanced automaticity
admissions for cardiac arrhythmias in the United within the small cuffs of left atrial muscle that
States.2 Although thought to be immediately extend into the pulmonary veins. Multiple ectopic
non-life threatening, its presence increases mor- atrial beats arising from these areas may act as
tality by up to twofold.3 The most important mor- the initial triggers for episodes of atrial
bidity and mortality associated with atrial fibril- fibrillation.11 In selected patients, paroxysmal
lation result from stroke. The attributable risk of atrial fibrillation may be permanently cured by
stroke increased from 1.5% for patients with atrial radiofrequency ablation therapy eliminating this
fibrillation aged 50–59 years to 23.5% for those triggering focus.12
aged 80–89 years.4 It is also associated with (2) Electrical remodelling of the atria with
congestive heart failure. These result in a signifi- shortening of the atrial refractory period during
cant increase in the of cost of health care in the episodes of atrial fibrillation helps increase the
community. Moreover, ischaemic stroke second- duration and stability of atrial fibrillation.13 This
ary to atrial fibrillation carries about twice the phenomenon is associated with intracellular
risk of death in comparison with stroke from calcium influx,14 and is well described by the
other causes.5 Despite the high prevalence of phrase “atrial fibrillation begets atrial fibrillation”.
atrial fibrillation and the increased morbidity and (3) In chronic atrial fibrillation, multiple
mortality associated with it, its treatment strategy re-entrant waves wander over the surface of atria
remains less well defined. We review the literature supported by areas of functional conduction
See end of article for and present here the evidence based treatment
authors’ affiliations block. Such waves collide and divide and main-
options for this most common sustained cardiac
....................... tain the chaotic electrical state in chronic atrial
arrhythmia.
fibrillation.15
Correspondence to:
Dr S K S Lairikyengbam, DEFINITION
Department of Medicine, CAUSES
Atrial fibrillation is defined when there is
Bronglais General Atrial fibrillation is commonly associated with
complete absence of coordinated atrial systole
Hospital, Aberystwyth structural heart disease. The term “lone atrial
SY23 1ER, UK; resulting in the absence of P wave before each
[email protected] QRS complex in the electrocardiogram (ECG).
The P waves are replaced by fibrillatory “f ” waves .................................................
Submitted 17 June 2002
Accepted
which vary in size, shape, and timing6 (caution: Abbreviations: DCC, direct current cardioversion; ECG,
30 October 2002 atrial fibrillation with complete heart block may electrocardiogram; TOE, transoesophageal
....................... present with regular R-R intervals in the ECG). echocardiography

www.postgradmedj.com
68 Lairikyengbam, Anderson, Davies

chance of success), poor left ventricular function, dilated left

Box 1: Causes of atrial fibrillation
atrium, and electrolyte imbalance. The immediate success rate

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Cardiovascular causes reported in the literature varies from 65% to 90%.6 The
Consensus Conference on Atrial Fibrillation of the Royal Col-
• Hypertension.
• Ischaemic heart disease. lege of Physicians of Edinburgh recommends cardioversion for
• Rheumatic heart disease. atrial fibrillation of less than three months’ duration.1 It is
• Cardiomyopathy. worthwhile considering an attempt of cardioversion for young
• Pericarditis. patients with atrial fibrillation when the onset is between
• Congenital heart disease, in particular, atrial septal defect. three and six months. In a patient with atrial fibrillation who
• Postoperative cardiac surgery. is haemodynamically unstable, for example, with hypoten-
• Wolff-Parkinson-White syndrome. sion, left ventricular failure, cardiogenic shock, refractory
• Hypertrophic cardiomyopathy. angina and rapid ventricular rate (>200 beats/min), DCC
• Sick sinus syndrome. should be urgently undertaken. If delay is anticipated,
• Pulmonary embolism.
• Primary pulmonary hypertension.
ventricular rate control could be achieved with intravenous
• Diabetes mellitus. β-blockers, rate limiting calcium channel blockers, digoxin, or
amiodarone. If patient is stable and the onset of the atrial
Coexisting with other cardiac arrhythmias fibrillation is less than 48 hours, pharmacological cardiover-
• Atrioventricular re-entrant tachycardias. sion frequently works successfully. Intravenous flecainide is
• Atrioventricular nodal re-entrant tachycardias. commonly used provided there is no contraindication such as
• Atrial tachycardia. impaired left ventricular function. Efficacy may be as high as
Non-cardiovascular causes 70%–80% in the first few hours after onset of atrial fibrillation
and declines thereafter.19 If flecainide is contraindicated,
• Hyperthyroidism.
intravenous amiodarone is an alternative (fig 1). A single dose
• Pneumonia/chronic obstructive airways disease.
• Alcohol binge. of oral flecainide (300 mg) or propafenone (600 mg) were also
• Postoperative (non-cardiac surgery). found to cardiovert atrial fibrillation in 70%–80% at eight
hours.20 In a patient in whom such a strategy is effective and
who is clearly able to recognise the onset of an attack of par-
oxysmal atrial fibrillation, self administration of one of these
fibrillation” is used when no apparent cause can be identified.
drugs may be effective strategy for occasional attacks. This is
A list of clinically important causes of atrial fibrillation is pre-
known as the “pill in the pocket” strategy.
sented in box 1.
Although ibutilide or dofetilide are not yet available in the
UK for clinical use, these new class III antiarrhythmic drugs
PRINCIPLE OF TREATMENT have been approved for the treatment of atrial fibrillation in
The present treatment of atrial fibrillation is based on four the United States. Intravenous ibutilide can be used in
main principles: patients with atrial fibrillation and ischaemic heart disease.16
(1) Restoration of sinus rhythm. However, intravenous ibutilide should be avoided in patients
(2) Rate control. with severe left ventricular dysfunction and long QT
interval.21 Oral dofetilide can also be used in patients with
(3) Maintenance of sinus rhythm. atrial fibrillation and heart failure.6
(4) Prevention of thromboembolism. For stable atrial fibrillation of more than 48 hours’ duration,
However, when a patient with atrial fibrillation is seen in the elective cardioversion is performed after conventional oral
casualty department or emergency assessment unit, the top anticoagulation with the international normalised ratio range
priority is to reduce the fast ventricular rate, which can be of 2–3 for three weeks before cardioversion.1 22 However, for
achieved either by restoration of sinus rhythm or by urgent cardioversion (both electrical and pharmacological),
controlling the rate, depending on the haemodynamic stabil- patient needs to be heparinised to achieve partial thrombo-
plastin time of 1.5 to 2.5 times control before cardioversion.
ity of the patient (figs 1 and 2). Heparin should be started on
Oral anticoagulation for four weeks is necessary after success-
admission.
ful cardioversion if the onset of atrial fibrillation is more than
For some patients with atrial fibrillation who are haemody-
48 hours.1 22 This treatment strategy is based on the concept
namically stable, it is reasonable to wait for 24 hours before
that after cardioversion of atrial fibrillation (onset >48
attempting to cardiovert as many patients with paroxysmal
hours), “atrial stunning” with impaired left atrial mechanical
atrial fibrillation may revert to sinus rhythm spontaneously.16
function occurs and may last for weeks.23 This may predispose
to intracardiac thrombus formation and thromboembolism. In
RESTORATION OF SINUS RHYTHM the next four weeks the international normalised ratio should
Conventionally many clinicians attempt to revert atrial fibril- be maintained between 2 and 3 and an ECG should be
lation to sinus rhythm, although there are few convincing data performed in four weeks to decide whether to stop warfarin.
to support this approach.17 Cardioversion of atrial fibrillation is An important advance in improving the success rate of
usually achieved with synchronised direct current cardiover- electrical cardioversion is the development of the biphasic
sion (DCC). All elective DCC is performed under short general defibrillator. This device looks very similar to the conventional
anaesthesia to avoid discomfort to the patient. However as a defibrillator, although the maximum energy which may be
life saving measure for a patient with unstable atrial selected is 200 joules. Instead of giving a monophasic electri-
fibrillation, it is reasonable to perform an urgent DCC under cal shock it delivers a biphasic shock, in which the polarity of
conscious sedation if time permits. Elective DCC under the shock is automatically reversed during shock delivery. A
conscious sedation was shown to be safe and not associated randomised trial of 165 patients with atrial fibrillation which
with intolerable discomfort to the patients.18 Conventionally, compared damped sine wave monophasic with rectilinear
monophasic waveform transthoracic direct current defibrilla- biphasic transthoracic cardioversion showed an improvement
tor is used. The sequence of energy commonly used are 100 in cardioversion success from 79% to 94%.24 Despite the lower
joules, 200 joules, 300 joules, and 360 joules. It is important to levels of energy delivered by the biphasic defibrillator, it is
apply firm pressure on the paddles. The success rate of such likely that the biphasic defibrillator will become widespread in
treatment depends on many factors—for example, duration of hospitals as there is increasing evidence that it may also be
atrial fibrillation (the longer the duration, the lesser the more effective in terminating ventricular fibrillation. The

www.postgradmedj.com
Atrial fibrillation 69

Figure 1 Treatment algorithm for

acute onset atrial fibrillation. (Exclude

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hyperthyroidism and electrolyte
imbalance on admission.) DCC,
direct current cardioversion; IHD,
ischaemic heart disease; INR,
international normalised ratio; IV,
intravenous; SBP, systolic blood
pressure; TOE, transoesophageal
echocardiography; UFH,
unfractionated heparin.

biphasic defibrillator is available for clinical use in the UK and and requires quite expensive disposable catheter, it should be
is likely to become the standard defibrillator in the near considered only if biphasic cardioversion has failed. Referral to
future.25 a specialist centre will be required.
The success rate of electrical cardioversion of atrial fibrilla-
tion and maintenance of sinus rhythm can be increased by
treatment with certain antiarrhythmic drugs before and after TRANSOESOPHAGEAL ECHOCARDIOGRAPHY
cardioversion.1 Commonly used antiarrhythmic drugs include GUIDED CARDIOVERSION
those of Vaughan Williams class Ia, class Ic, and class
The serious complication of cardioversion for atrial fibrillation
III—namely, flecainide, propafenone, procainamide, quini-
is thromboembolism in 5%–7% without anticoagulation and
dine, and amiodarone. Oral dofetilide may be used where
1%–2% after conventional anticoagulation.1 However, from the
available. Oral et al have suggested that the success rate of DCC
could improve up to 100% if DCC is performed after pretreat- data of 1164 patients who underwent transoesophageal echo-
ment with intravenous ibutilide.21 In their trial, DCC was per- cardiography (TOE) guided DCC and who had atrial fibrilla-
formed after pretreatment with 1 mg of ibutilide infused over tion or atrial flutter, Grimm reported that TOE guided DCC
10 minutes. However, the drug increased risk of ventricular was associated with very low thromboembolic complications
fibrillation in patients with severe left ventricular dysfunction of <0.1%.28 This strategy involves performing TOE after intra-
and long QT interval. It is also possible to achieve cardiover- venous unfractionated heparin for 1–5 days (keeping the par-
sion by delivering the shock energy internally. The procedure tial thromboplastin time between 1.5 and 2.5 times control) or
is performed using a special defibrillator that connects to a warfarin therapy for at least five days with an international
transvenous electrode system which has electrodes in the normalised ratio of 2–3.28 When atrial thrombus is excluded,
right atrium and pulmonary artery. Despite the lower energy DCC is performed. If a thrombus is detected, DCC should be
level used in this system the local delivery of energy to the postponed and the patient should be warfarinised for six
heart achieves a high success rate. Out of 20 patients with weeks or longer.6 If the thrombus resolves, DCC can then be
chronic atrial fibrillation in whom conventional transthoracic performed; if not, it is generally abandoned.6 In a trial of TOE
(external) cardioversion failed, low energy transvenous guided cardioversion for 242 patients with atrial fibrillation
(internal) cardioversion was successful in 75%.26 In another and atrial flutter, two thirds of patients with atrial fibrillation
large multicentre trial of 500 patients, the transvenous cardio- and atrial flutter of >48 hours’ duration were successfully
version was successful in restoring sinus rhythm in >90% of cardioverted without increasing risk of thromboembolism.29
cases (which included 57% of failed external cardioversion).27 The authors also showed that the reduction in time to DCC
Low energy internal cardioversion seems to be safe and effec- was associated with better maintenance of sinus rhythm at
tive means of terminating atrial fibrillation that has been one month, in comparison with those patients who under-
resistant to conventional cardioversion. Because it is invasive went conventional oral anticoagulation before cardioversion.

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70 Lairikyengbam, Anderson, Davies

Figure 2 Treatment algorithm for

chronic atrial fibrillation. DCC, direct

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current cardioversion; HTN,
hypertension; IHD, ischaemic heart
disease; INR, international
normalised ratio; TOE,
transoesophageal echocardiography.
*If intolerant/allergic to aspirin, use
clopidogrel/modified release
dipyridamole.

The ACUTE trial which randomised 1222 patients with The rate control has some disadvantages. The atrial contri-
atrial fibrillation and atrial flutter (onset >48 hours) to TOE bution to the cardiac output is permanently lost. Atrial fibril-
guided DCC and conventional DCC showed that the success lation may cause progressive dilatation of left atrium.17 Poorly
rate of DCC was higher in patients who underwent TOE controlled permanent atrial fibrillation may result in so called
guided DCC (p=0.03).30 Although the embolic stroke was “tachycardia induced cardiomyopathy”.32 The other disadvan-
similar on both sides, the haemorrhagic complication was sig- tage is the need for long term anticoagulation therapy or
nificantly higher in patients treated with conventional DCC. antiplatelet therapy.
However, at eight weeks, there was no difference in Elderly patients with atrial fibrillation may have concomi-
maintenance of sinus rhythm or death or functional status tant atrioventricular nodal disease which slows the atrioven-
between the two groups. TOE guided DCC for atrial fibrillation tricular conduction. As ventricular rate is usually reasonable in
can be used as an effective and safe alternative to the conven- such patients, rate limiting drugs are usually not required.33
tional DCC in centres where TOE service is available.

RATE CONTROL RHYTHM CONTROL VERSUS RATE CONTROL

In case of failure of rhythm control, it is necessary to control The advantages of rhythm control are restoration of “normal
the resting ventricular rate at <90 beats/min, which is about rhythm”, symptom improvement, and freedom from long
20% higher than the heart rate while in sinus rhythm.17 31 The term anticoagulation or antiplatelet therapy. Even for patients
heart rate should not exceed 180 beats/min on exercise.1 The with atrial fibrillation with controlled ventricular rate, the left
rate control can be achieved either pharmacologically or by ventricular function improved on restoration of sinus rhythm
non-pharmacological means. The antiarrhythmic drugs which with cardioversion.34 After cardioversion, relatively few pa-
increase refractory period of the atrioventricular node and tients remain in sinus rhythm. In a trial of 236 patients with
delay atrioventricular conduction are preferred. The com- atrial fibrillation who underwent serial electrical cardiover-
monly used drugs are β-blockers, verapamil, diltiazem, and sions with prophylactic antiarrhythmic drug therapy, only
digoxin. Although digoxin remains the first choice in presence 42% and 27% of successfully cardioverted patients remained
of heart failure, it should be avoided in patients with atrial in sinus rhythm after one year and four years.35 Although res-
fibrillation associated with Wolff-Parkinson-White syndrome toration of left atrial contribution to stroke volume could be
and hypertrophic obstructive cardiomyopathy. It is relatively important in a failing left ventricle, the influence of rhythm
ineffective in paroxysmal atrial fibrillation as it fails to prevent control on the survival of patients with atrial fibrillation is not
recurrence or control rate.1 Calcium channel blockers are to be clear.17 The result of the Pharmacological Intervention in
avoided in heart failure except when the heart failure is Atrial Fibrillation trial, which randomised 252 patients with
secondary to the fast atrial fibrillation. Although amiodarone atrial fibrillation to rhythm or rate control, did not show any
is not considered in a first line drug for rate control because of significant difference in symptom improvement between the
its adverse effect, it has a place in treating patients with atrial two treatment strategies, although exercise tolerance was bet-
fibrillation with severe heart failure. ter with rhythm control at the cost of more hospitalisation.36

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Atrial fibrillation 71

The three larger unpublished trials (AFFIRM, RACE, STAF)

comparing rhythm control with rate control17 are likely to Box 2: Risk factors for ischaemic stroke associated

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resolve the issue. The AFFIRM (Atrial Fibrillation Follow-up with atrial fibrillation
Investigation of Rhythm Management) trial enrolled 4060
patients with an average follow up of 3.5 years.37 38 In the 51st • 75+ years of age.
• Previous episodes of cerebral embolism.
Annual Scientific Session of the American College of Cardiol-
• Congestive heart failure.
ogy (reported by Sue Hughes and Lisa Nainggolan38), Dr • Left ventricular dysfunction by echocardiography.
George Wyse, the chief investigator presented the result of the • Hypertension.
AFFIRM trial, which did not show significant difference in • Diabetes mellitus.
mortality, functional status, quality of life, or risk of ischaemic • Coronary artery disease.
stroke between the two groups. • Mitral or aortic valve disease.
The RACE (Rate Control versus Electrical Cardioversion for • Cardiac valve repair.
Persistent Atrial Fibrillation) trial which randomised 522 • Post-valvuloplasty.
patients with atrial fibrillation to rhythm control or rate con-
trol did not show any significant difference in mortality at the
end of three years of follow up.38 The STAF (Strategies of reduction of ischaemic stroke with aspirin therapy which was
Treatment of Atrial Fibrillation) trial aiming at randomising not statistical significant (p=0.05),42 aspirin (75–300 mg/day)
more than 2000 patients started in 1997 has not yet been pub- may be considered if warfarin is contraindicated. When
lished. patients are intolerant or allergic to aspirin, it is reasonable to
In an individual patient a decision on whether to pursue a give clopidogrel or modified release dipyridamole.43 Low risk
strategy of rhythm control or rate control will need to take into patients, for example those <65 years of age without any risk
account the evidence above, the effectiveness of treatments factor for thromboembolism, may be left alone or be given
already tried, the risks of anticoagulation in that individual, aspirin if there is no contraindication to aspirin. Patients at
the patient’s tolerance of atrial fibrillation whether paroxys- low risk or moderate risk (but not on warfarin) should be
mal or established, and the patient’s own viewpoint. Some periodically checked for any development of high risk when
patients are very aware of the presence of atrial fibrillation and warfarin should be promptly initiated.
wish to pursue a vigorous strategy of sinus rhythm Patients with recurrent attacks of paroxysmal atrial fibrilla-
maintenance. In others atrial fibrillation may be well tion at high risk of thromboembolism should receive
tolerated. The data emerging from the trials suggest that in appropriate antithrombotic therapy.44
these patients a rate control strategy may be pursued without
adverse effects.
NON-PHARMACOLOGICAL APPROACHES FOR
MAINTENANCE OF SINUS RHYTHM TREATMENT OF ATRIAL FIBRILLATION
The relapse rate after initial successful cardioversion is high at When drug treatment fails to achieve either rhythm control or
25%–50% at one month and 70%–90% at one year.1 Prophylac- rate control, the various non-pharmacological approaches to
tic antiarrhythmic drugs are usually required for a significant achieve rhythm or rate control should be considered for symp-
number of patients with atrial fibrillation after successful car- tomatic atrial fibrillation.
dioversion. Beta-blockers or Vaughan Williams class Ic
drugs—for example, flecainide or propafenone—are consid- Ablate and pace to control heart rate
ered as first line drugs.1 Paroxysmal atrial fibrillation may be This technique has been more widely practised than many
considered frequent if the episode is more than one per other non-pharmacological methods for treatment of atrial
month.39 Such patients may require antiarrhythmic drug fibrillation. In this method, the atrioventricular junction is
therapy. Sotalol may be considered as the initial antiarrhyth- completely ablated by catheter based radiofrequency energy
mic drug for patients with atrial fibrillation and ischaemic along with permanent pacing. The atrial systole is not restored
heart disease.39 When class I antiarrhythmic drugs are contra- and the patient is likely to require long term anticoagulation.
indicated as in significant ischaemic heart disease or left ven- The technique was shown to improve symptoms, quality of
tricular dysfunction, amiodarone is an alternative. In such life, exercise capacity, and left ventricular function and also
patients, oral dofetilide may also be used to maintain sinus reduce the number of hospital readmission.45 In another trial,
rhythm after cardioversion in countries where it is which enrolled 350 patients with drug refractory atrial fibril-
available.16 39 lation, atrioventricular nodal ablation with radiofrequency
energy was performed with either ventricular pacing (55% of
PREVENTION OF THROMBOEMBOLISM patients) or a dual chamber pacing (45% of patients).46
Chronic atrial fibrillation is associated with embolic stroke in Although it was not a randomised controlled trial, the trial
around 5% per year.11 Although there is lack of unanimity over showed that the survival of patients with atrial fibrillation
the relative benefit of anticoagulation and antiplatelet without structural heart disease who underwent the ablate
treatment for patients with atrial fibrillation at low to moder- and pace strategy was similar to that of the population control
ate risk of thromboembolism, there is consensus on the use of at the end of a mean follow up of 36 +/-26 months. In a
anticoagulation for those patients who are at high risk of multicentre but non-randomised trial consisting of 156
thromboembolism. The guideline of the British Committee for patients with drug refractory atrial fibrillation, atrioventricu-
Standards in Haematology recommends warfarin as the first lar junctional ablation and pacing was shown to significantly
line antithrombotic treatment for all patients with atrial improve quality of life and left ventricular ejection fractions.47
fibrillation who have at least one risk factor for There was also a trend towards improvement of exercise
thromboembolism.40 The important risk factors are presented capacity after the procedure, although it did not reach statisti-
in the box 2.1 41 cal significance.
Those patients between 65 and 75 years of age are at mod-
erate risk and may be considered for warfarin therapy. Conventional pacing to prevent atrial fibrillation
Although the analysis of pooled data of the Atrial Fibrillation, The randomised controlled trial by Andersen et al, which
Aspirin, Anticoagulation Study (AFSAK), the European Atrial enrolled 225 patients, showed that atrial pacing in the
Fibrillation Trial (EAFT), and the Stroke Prevention in Atrial treatment of sick sinus syndrome was superior to ventricular
Fibrillation 1 Study (SPAF 1) showed a 21% relative risk pacing (VVI) in preventing development of atrial fibrillation at

www.postgradmedj.com
72 Lairikyengbam, Anderson, Davies

the end of mean follow up of 40 months (14% v 23%).48 More-

over, the thromboembolic complication was lower in atrially

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paced patients (p<0.01). There was, however, no significant
difference in survival.
Permanent pacing may be required for patients with atrial
fibrillation who have symptomatic bradycardia as a result of
antiarrhythmic drug treatment or high degree atrioventricular
block.

Ablation to prevent or stop atrial fibrillation

Atrial ablation can be achieved either by catheter based tech-
nique or open heart surgery. In the catheter based technique,
multiple linear ablations are made in the right or/and left atria
by radiofrequency energy. The success rate of left atrial
ablation is higher than the right atrial ablation.39 More
recently foci of atrial tissue with abnormal automaticity trig-
gering atrial fibrillation were detected in abnormal sites
mainly within the pulmonary veins (>90%) which were con-
sidered suitable for catheter ablation.11 45 Chen et al showed
that, of all ectopic foci in the pulmonary veins which were
demonstrated to initiate atrial fibrillation, radiofrequency Figure 3 Maze procedure for atrial fibrillation. Both atrial
ablation was successful in eliminating 95% of the foci.49 More- appendages are excised and the pulmonary veins (PV) are isolated.
Appropriately placed atrial incisions not only interrupt the conduction
over, 86% of the 79 patients studied remained in sinus rhythm routes of the most common re-entrant circuits, but they also direct the
at the end of 6 +/-2 months of follow up. Although a few sinus impulse from the sinoatrial node (SAN) to the atrioventricular
potential complications namely pulmonary vein stenosis, sys- node (AVN) along a specified route. The entire atrial myocardium
temic embolism and pericardial effusion were reported, (except for the atrial appendages and pulmonary veins) is electrically
radiofrequency ablation of atrial fibrillation foci within activated by providing for multiple blind alleys off the main
pulmonary veins seems promising. conduction route between the sinoatrial node and the atrioventricular
node, thereby preserving atrial transport function postoperatively.54
Implantable atrial defibrillator LAA, left atrial appendage; RAA, right atrial appendage. (Repro-
duced with kind permission of the WB Saunders Company.)
The principle of the implantable atrial defibrillator was derived
from that of the implantable cardioverter defibrillator for the
treatment of ventricular tachyarrhythmia. It involves putting in SUMMARY
transvenous leads in the right atrium and also in coronary sinus Reduction of fast ventricular rate along with antithrombotic
which are connected to the defibrillator located subcutaneously therapy should be the first step in the treatment of atrial
in the infraclavicular region. The device is usually triggered fibrillation. Long term rhythm or rate control should be
manually at a preset delivery energy varying from 0.1 to 10.0 assessed on an individual basis, considering the safety of
joules. However, a majority of patients reported significant dis- patients, presence or absence of substrate to prevent or reduce
comfort with energy >2.0 joules.50 The Metrix system trial the chance of maintenance of sinus rhythm after cardiover-
which enrolled 51 selective patients with atrial fibrillation sion, patient tolerability of the antiarrhythmic drugs, and risk
showed success rate of 86% without significant induction of of long term anticoagulation. Although evidence is emerging
ventricular tachyarrhythmias or unsynchronised delivery of to indicate that there is no significant difference in mortality,
energy or thromboembolism.51 However, the early recurrence functional status, quality of life, or risk of ischaemic stroke
rate was high at 27%. It is considered that by terminating atrial between rhythm control and rate control of atrial fibrillation,
fibrillation promptly with the implantable atrial defibrillator it seems reasonable to try to restore sinus rhythm for a
that it will decrease the duration of atrial fibrillation and subgroup of patients with atrial fibrillation—for example,
thereby may help reduce/prevent atrial fibrillation induced patients with heart failure when restoration of left atrial con-
atrial remodelling.52 Although patient tolerability is usually poor tribution to stroke volume may help improve left ventricular
and the need for long term anticoagulation is not clear, an function. When rhythm control strategy is pursued the stand-
implantable atrial defibrillator as a back up device in addition to ard mode of restoration of sinus rhythm is DCC, although
pharmacological therapy is a therapeutic option for difficult pharmacological cardioversion is effective frequently in acute
atrial fibrillation. onset atrial fibrillation. The success rate of DCC could further
improve by treatment with antiarrhythmic drugs before
Surgical approach for treatment of atrial fibrillation
cardioversion. A low energy biphasic waveform defibrillator is
Maintenance of atrial fibrillation requires a certain critical
superior to the conventional monophasic wave defibrillator
mass of atrial tissue, to allow the propagation of multiple
and is likely to become the standard defibrillator in the near
waves of electrical depolarisation. A surgical procedure called
future. Internal cardioversion may also be considered after
the Maze operation uses multiple incisions in the atria to cre-
failed transthoracic cardioversion if such facility is available.
ate linear scars which separate the atrial myocardium into
TOE guided DCC of atrial fibrillation may be used to reduce
small strips.53 The strips remain connected at their ends,
the period of anticoagulation before cardioversion without
allowing normal depolarisation and contraction with sinus
increasing the risk of thromboembolism. When pharmaco-
rhythm. However the scars between the strips act as barriers to
logical rhythm or rate control fail, symptomatic patients with
the maintenance of the multiple electrical wavelets which are
symptomatic atrial fibrillation should be given the newer
required for persistent atrial fibrillation (fig 3).
non-pharmacological treatment options.
This operation has been refined over the years and the latest
version (Maze III procedure) achieves maintenance of sinus
rhythm in >93% of patients three months after the .....................
procedure.55 However, because of requirement for open chest
Authors’ affiliations
operation and extracorporeal circulation, this surgical technique S K S Lairikyengbam, A G Davies, Bronglais General Hospital,
is limited to a small group of patients with paroxysmal atrial Aberystwyth
fibrillation who undergo open heart surgery for other reasons.45 M H Anderson, Regional Cardiac Centre, Morriston Hospital, Swansea

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Atrial fibrillation 73

REFERENCES 29 Roijer A, Eskilsson J, Olsson B. Transoesophageal

1 Consensus Conference on Atrial Fibrillation in Hospital and echocardiography-guided cardioversion of atrial fibrillation or flutter. A

Postgrad Med J: first published as 10.1136/pmj.79.928.67 on 1 February 2003. Downloaded from http://pmj.bmj.com/ on March 11, 2023 by guest. Protected by copyright.
General Practice. Final consensus statement. Proc R Coll Physicians selection of low-risk group for immediate cardioversion. Eur Heart J
Edinb 1999;29(suppl 6):2–3. 2000;20:837–47.
2 Bialy D, Lehmann MH, Schumacjer DN, et al. Hospitalisation from 30 Klein AL, Grimm RA, Murray RD, et al. Assessment of Cardioversion
arrhythmias in the United States: importance of atrial fibrillation Using Transesophageal Echocardiography Investigators. Use of
transesophageal echocardiography to guide cardioversion in patients
(abstract). J Am Coll Cardiol 1992;19:41A.
with atrial fibrillation. N Engl J Med 2001;344:1411–20.
3 Benjamin EJ, Wolf PA, D’Agostino RB, et al. Impact of atrial fibrillation
31 Rawles JM. What is meant by a “controlled” ventricular rate in atrial
on the risk of death: the Framingham Heart Study. Circulation
fibrillation. Br Heart J 1990;63:157–61.
1998;98:946–52.
32 Fenelon G, Wijns W, Andries E, et al. Tachycardiomyopathy:
4 Wolf PA, Abbott RD, Kannel WB. Atrial fibrillation as an independent
mechanism and clinical implications. PACE 1996;19:95–106.
risk factor for stroke: the Framingham Study. Stroke 1991;22:983–8.
33 Zipes D. Specific arrhythmias: diagnosis and treatment in Braunwald’s
5 Lin HJ, Wolf PA, Kelly-Hayes M, et al. Storke severity in atrial
heart disease. In: Braunwald E, ed. A textbook of cardiovascular
fibrillation. The Framingham Study. Stroke 1996;27:1760–4. medicine. 4th Ed. Philadelphia: W B Saunders, 1992.
6 Levy S, Breithardt G, Campbell RWF, et al. Working Group Report. 34 Kubec G, Malowany L. Functional capacity of patients with atrial
Atrial fibrillation: current knowledge and recommendation for fibrillation and controlled heart rate before and after cardioversion. Can J
management. Eur Heart J 1998;19:1294–320. Cardiol 1992;8:941–6.
7 Sopher SM, Camm AJ. Theory for atrial fibrillation: control of the 35 Van Gelder IC, Crijns HJGM, Tieleman RG, et al. Chronic atrial
ventricular response and prevention of recurrence. Coron Artery Dis fibrillation. Success of serial cardioversion therapy and safety of oral
1995;6:106–14. anticoagulation. Arch Intern Med 1996;156:2585–92.
8 Waktare JEP, Camm AJ. How do we maintain sinus rhythm in 36 Hohnloser SH, Kuck KH, Lilienthal J. Rhythm or rate control in atrial
paroxysmal atrial fibrillation. Consensus statement on atrial fibrillation in fibrillation. Pharmacological Intervention in Atrial Fibrillation (PIAF): a
hospital and general practice. Proc R Coll Physicians Edinb randomised trial. Lancet 2000;356:1789–94.
1999;29:5–12. 37 Planning and Steering Committee of the AFFIRM Study for the
9 Gallagher MM, Camm AJ. Classification of atrial fibrillation. PACE NHLBI-AFFIRM Investigation. Atrial fibrillation follow-up investigation
1997;20:1603–5. of rhythm management—design. Am J Cardiol 1997;79:1198–202.
10 Levy S. Classification system of atrial fibrillation. Curr Opin Cardiol 38 Hughes S, Nainggolan L. News from the 51st Annual Scientific Session
2000;15:54–7. of the American College of Cardiology. Br J Cardiol 2002;9:206.
11 Pelosi F Jr, Morady F. Evaluation and management of atrial fibrillation. 39 Fuster V, Ryden LE, Asinger RW, et al. ACC/AHA/ESC guidelines for
Med Clin North Am 2001;85:225–44. the management of atrial fibrillation: executive summary. J Am Coll
12 Jais P, Haissaguerre M, Shah DC, et al. A focal source of atrial Cardiol 2001;38:1231–65.
fibrillation treated by discrete radiofrequency ablation. Circulation 40 Haemostasis and Thrombosis Task Force. Prepared for the British
1997;95:572–6. Committee for Standards in Haematology (BCSH). Guidelines on oral
13 Daoud EG, Bogun F, Goyal R, et al. Effect of atrial fibrillation on atrial anticoagulation: third edition. Br J Haematol 1998;101:374–87.
refractoriness in human. Circulation 1996;94:1600–6. 41 Barwolf CG. Anticoagulation in valvular heart disease and management
14 Ausma J, Dispersyn GD, Duimel H, et al. Change in ultrastructural during non-cardiac surgery. Heart 2000;84:567–72
calcium distribution in goat atria during atrial fibrillation. J Mol Cell 42 Atrial Fibrillation Investigators. The efficacy of aspirin in patients with
Cardiol 2000;32:355–64. atrial fibrillation—analysis of pooled data from 3 randomised trials. Arch
15 Moe GK, Rheinboldt WC, Abildskov JA. Computer model for atrial Intern Med 1997;157:1237–40.
fibrillation. Am Heart J 1964;67:200–20. 43 Lairikyengbam SKS, Davies AG, Jones PD. Implementation of
16 Reiffee JA, Camm AJ, Haffajee CI, et al. International consensus antithrombotic management in atrial fibrillation—a correspondence.
roundtable on atrial fibrillation. Cardiology Review 2000;17(suppl):1– Postgrad Med J 2001;77:488.
19. 44 Atrial Fibrillation Investigators. Risk factors for stroke and efficacy of
17 Carlsson J, Neuzner J, Rosenberg YD. Therapy of atrial fibrillation: antithrombotic therapy in atrial fibrillation. Arch Intern Med
rhythm control versus rate control. PACE 2000;23:891–903. 1994;154:1449–57.
18 Raipancholia R, Sentinella L, Lynch M. Role of conscious sedation for 45 Vardas PE. Non-pharmacological treatment of atrial fibrillation: a
external cardioversion. Heart 2001;86:571–2. heretic’s appraisal. PACE 2000;23:395–401.
19 Reisinger JJ, Gattere E, Heinze G, et al. Prospective comparison of 46 Ozcan C, Jahangir A, Friedman PA, et al. Long-term survival after
flecainide versus sotalol for immediate cardioversion of atrial fibrillation. ablation of the atrioventricular node and implantation of a permanent
Am J Cardiol 1998;81:1450–4. pacemaker in patients with atrial fibrillation. N Engl J Med
20 Capucci A, Boriani G, Botto GL, et al. Conversion of recent onset atrial 2001;344:1043–51.
fibrillation to sinus rhythm by a single oral loading dose of propafenone 47 Wood MA, Kay GN, Ellenbogen KA for the APT Investigators. The North
or flecainide. Am J Cardiol 1994;74:503–5. American experience with the Ablate and Pace Trial (APT) for medically
21 Oral H, Souza JJ, Michaud GF, et al. Facilitating transthoracic refractory atrial fibrillation. Europace 1999;1:22–5.
cardioversion of atrial fibrillation with ibutilide pretreatment. N Engl J 48 Andersen HR, Thensen L, Bagger J, et al. Prospective randomised trial of
Med 1999;340:1849–54. atrial versus ventricular pacing in sick sinus syndrome. Lancet
22 Anonymous. Proceeding of the American College of Chest Physicians 1994;344:1923–8.
5th Consensus on Antithrombotic Therapy, 1998. Chest 49 Chen SA, Hsieh MH, Tai CF, et al. Initiation of atrial fibrillation by
1998;114:439S–769S. ectopic beats originating from the pulmonary veins: electrophysiological
23 Harjai KJ, Mobarek SK, Cheirif J, et al. Clinical variables affecting characteristics, pharmacological responses, and effects of radiofrequency
recovery of left atrial mechanical function after cardioversion for atrial ablation. Circulation 1999;100:1879–86.
fibrillation. J Am Coll Cardiol 1994;74:503–5. 50 Jung J, Heisel A, Fries R, et al. Tolerability of internal low-energy shock
24 Mittal S, Ayati S, Stein KM, et al. Transthoracic cardioversion of atrial strengths currently needed for endocardial atrial cardioversion. Am J
fibrillation: comparison of rectilinear biphasic versus damped sine wave Cardiol 1997;80:1489–90.
monophasic shocks. Circulation 2000;101:1282–7. 51 Wellen HJ, Lan CP, Luderitz B, et al. Atrioverter: an implantable device
25 Trohman RG, Parrillo JE. Direct current cardioversion: indications, for the treatment of atrial fibrillation. Circulation 1998;98:1651–6.
techniques and recent advances. Crit Care Med 2000;28:N170–3. 52 Wijffels MCEF, Kirchhof CJHJ, Dorland RD, et al. Atrial fibrillation
26 Taramasco V, Socas A, Ricard P, et al. Internal low-energy begets atrial fibrillation. A study in awake chronically instructed goats.
cardioversion: a therapeutic option for restoring sinus rhythm in chronic Circulation 1995;92:1954–68.
atrial fibrillation after failure of external cardioversion. Europace 53 Cox JL, Schuessler RB, Cain ME, et al. Surgery for atrial fibrillation.
1999;1:179–82. Semin Thorac Cardiovasc Surg 1989;1:67–73.
27 Andrahgetti A, Scalese M. Safety and efficacy of low-energy 54 Cox JL, Schuessler RB, D’Agostino HJ Jr, et al. The surgical treatment of
cardioversion of 500 patients using two different techniques. Europace atrial fibrillation. III. Development of a definitive surgical procedure. J
2001;3:4–9. Thorac Cardiovasc Surg 1991;101:569–83.
28 Grimm RA. Transoesophageal echocardiography-guided cardiversion of 55 Cox JL, Schuessler RB, Lappas DG, et al. An 81/2-year experience with
atrial fibrillation. Echocardiography 2000;17:383–92. surgery for atrial fibrillation. Ann Surg 1996;224:267–75.

www.postgradmedj.com