ACC/AHA Focused Update: Management of Atrial Fibrillation

Background and Purpose: Atrial fibrillation (AF) is the most common arrhythmia in the world and frequently leads to morbidity or mortality. Management of AF continues to evolve relatively quickly; recent developments have now prompted an update to the 2006 ACC/AHA guidelines.

Key Points:

1. In the RACE II trial of heart rate control (JW Cardiol Mar 15 2010), aiming for a resting heart rate of <110 beats per minute was noninferior to aiming for <80 beats per minute; a new Class III recommendation thus advises against such strict rate control.

2. In the ACTIVE A trial involving patients considered poor candidates for warfarin treatment, a combination of clopidogrel and aspirin appeared to be more efficacious than aspirin alone but also conferred a higher bleeding risk (JW Cardiol Mar 31 2009). This combination is now considered an option in patients who have difficulty with warfarin (Class IIb).

3. Although not a potent antiarrhythmic, dronedarone is a reasonable therapy for decreasing rates of recurrence in patients with histories of AF (Class IIa). It can be initiated on an outpatient basis but is contraindicated in patients with NYHA class IV heart failure symptoms or a recent episode of decompensated heart failure (Class III).

4. Catheter ablation now carries

• A Class I (rather than Class IIa) recommendation for treating symptomatic paroxysmal AF that is uncontrolled with antiarrhythmic agents;

• A Class IIa recommendation for treating persistent symptomatic AF;

• A Class IIb recommendation for treating symptomatic paroxysmal AF in the presence of left atrial dilatation or left ventricular (LV) dysfunction.