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Management of the older person with atrial fibrillation
1Department of Medicine, Division of Cardiology, Westchester Medical Center/New York Medical College, Valhalla, USA. WSAronow@aol.com
Insights
Atrial fibrillation (AF) management involves immediate cardioversion for acute symptoms and drug therapy for rate control. Long-term anticoagulation with warfarin or aspirin is crucial for stroke prevention in AF patients.
Area of Science:
- Cardiology
- Electrophysiology
Background:
- Atrial fibrillation (AF) increases risks of mortality, stroke, and coronary events compared to sinus rhythm.
- Rapid ventricular rates in AF can lead to tachycardia-related cardiomyopathy.
Purpose of the Study:
- To outline current management strategies for atrial fibrillation.
- To detail treatment options for rate control and stroke prevention in AF.
Main Methods:
- Review of established guidelines and clinical practices for AF management.
- Discussion of pharmacological and non-pharmacological interventions for AF.
- Emphasis on anticoagulation strategies based on stroke risk.
Main Results:
- Immediate direct-current (DC) cardioversion is recommended for hemodynamically unstable AF patients.
- Pharmacological options include beta-blockers, verapamil, diltiazem, and amiodarone for rate control.
- Warfarin (INR 2.0-3.0) or aspirin is indicated for stroke prevention based on patient risk stratification.
Conclusions:
- Treatment decisions for AF should be individualized based on clinical presentation and risk factors.
- Rate control and anticoagulation are key components in managing AF to reduce morbidity and mortality.
- Pacemakers may be necessary for specific bradycardia-related symptoms in AF patients.
Abstract:
Atrial fibrillation (AF) is associated with a higher incidence of mortality, stroke, and coronary events than is sinus rhythm. AF with a rapid ventricular rate may cause a tachycardia-related cardiomyopathy. Immediate direct-current (DC) cardioversion should be performed in patients with AF and acute myocardial infarction, chest pain due to myocardial ischemia, hypotension, severe heart failure, or syncope. Intravenous beta blockers, verapamil, or diltiazem may be given to slow immediately a very rapid ventricular rate in AF. An oral beta blocker, verapamil, or diltiazem should be used in persons with AF if a fast ventricular rate occurs at rest or during exercise despite digoxin. Amiodarone may be used in selected patients with symptomatic life-threatening AF refractory to other drugs. Nondrug therapies should be performed in patients with symptomatic AF in whom a rapid ventricular rate cannot be slowed by drugs. Paroxysmal AF associated with the tachycardia-bradycardia syndrome should be treated with a permanent pacemaker in combination with drugs. A permanent pacemaker should be implanted in patients with AF and with symptoms such as dizziness or syncope associated with ventricular pauses greater than 3 seconds that are not drug-induced. Elective DC cardioversion has a higher success rate and a lower incidence of cardiac adverse effects than does medical cardioversion in converting AF to sinus rhythm. Unless transesophageal echocardiography has shown no thrombus in the left atrial appendage before cardioversion, oral warfarin should be given for 3 weeks before elective DC or drug cardioversion of AF and should be continued for at least 4 weeks after maintenance of sinus rhythm. Many cardiologists prefer, especially in older persons, ventricular rate control plus warfarin rather than maintaining sinus rhythm with antiarrhythmic drugs. Digoxin should not be used to treat patients with paroxysmal AF. Patients with chronic or paroxysmal AF at high risk for stroke should be treated with long-term warfarin to achieve an International Normalized Ratio of 2.0 to 3.0. Patients with AF at low risk for stroke or with contraindications to warfarin should receive 325 mg of aspirin daily.