1. Atrial Fibrillation: Rate/Rhythm Control
Non Pharmacological Management
Dr Akshay Mehta
Dr B Nanavati Hospital
Asian Heart Institute

2. Two most important things to know
 Type of AF
Symptoms due to AF

3. First Diagnosed Episode of AF
Paroxysmal Persistent (> 7 Long standing Permanent
(usually days or Persistent (accepted)
<= 48 h) requires CV) ( >1 year)

4. EHRA score of AF-related
symptoms
EHRA class Explanation
EHRA I ‘No symptoms’
EHRA II ‘Mild symptoms’; normal daily activity not
affected
EHRA III ‘Severe symptoms’; normal daily activity
affected
EHRA IV ‘Disabling symptoms’; normal daily activity
discontinued

5. Choosing Rate v/s Rhythm Control
Two types of settings
Acute/Unstable
Non acute/Stable

6. Acute/Unstable setting
Rate Control Rhythm Control
Cause: underlying cond severe AF Sx or
Ex- pneumonia, PE, Thyroid h-dynamic instab
No severe AF Sx or
h-dynamic instab pharmac cv electric cv
Older age
Large LA

7. How Rate
Control ?

8. Acute/Unstable setting
Rhythm control – (Sx or hemody instab)
Pharmac cv Electrical cv
* <48 hrs *can > 48 hrs
* No electrolyte *ischemia
imbalance *hypoten
* No ECG *HF
sign of severe *Preexcited AF with
ongoing ishemia instability
* Hemodynamic stable + , -

9. ESC 2012

10. Recommendations for
anticoagulation pericardioversion

11. ………..recommendations for
anticoagulation pericardioversion

12. Non Acute/Stable Setting :
Rate Control v/s Rhythm control
INCLUDES RATE CONTROL
OAC for Both

13. AIMS of management of AF
patients:
• Prevent complications
• Reduce symptoms (palpitations, dyspnoea,
fatigue, and dizziness)
 antithrombotic therapy
 control of ventricular rate
 Rx of associated CV disease
• ± Additional rhythm control therapy by
cardioversion, antiarrhythmic drug therapy, or
ablation therapy

14. Randomized trials comparing rate
control with rhythm control
• Atrial Fibrillation Follow-up Investigation of Rhythm
Management (AFFIRM) : no difference in all cause mortality
(primary outcome) or stroke rate
• The Rate Control versus Electrical cardioversion for persistent
atrial fibrillation (RACE) trial :rate control not inferior to rhythm
control for prevention of cardiovascular mortality and morbidity
(composite endpoint).
• The Atrial Fibrillation and Congestive Heart Failure
(AF-CHF) trial : in patients with an LVEF ≤35%, no difference in
cardiovascular mortality (primary outcome) symptoms
of congestive heart failure, or in the secondary outcomes
including death from any cause and worsening of heart failure

15. However….
• These studies enrolled predominantly older patients (average
70 y)
• Most of whom had persistent AF and heart disease,
• Follow-up extended over just a few years
• Pts were at a stage where difficult to maintain sinus rhythm
Hence :
• Data don’t necessarily apply in young
• Must not lose “window” of opportunity due to electrical and
structural remodeling

16. Hence…
 Rate control may be reasonable initial therapy in
older patients with persistent AF with mild
symptoms
 For younger individuals, especially those with
paroxysmal lone AF, rhythm control may be a better
initial approach.

17. When to do Rate Control ?

18. How to do long-term rate control

19. How MUCH rate control ?
< 80, 110 Exercise test if
excessive heart rate
is anticipated during
More strict rate exercise
Symptoms control
Rate
Control 24 h ECG for safety
No or tolerable Accept lenient
symptoms rate control
resting<110/mt

20. Rhythm Control
Rhythm control therapy is reasonable to
ameliorate symptoms, in paroxysmal/persistent
AF

21. When to do Rhythm Control ?

22. AAD Therapy to maintain sinus rhythm in
patients with recurrent paroxysmal or persistent
atrial fibrillation.
β-Blockers are recommended for prevention
of adrenergic AF-I C & should be considered
for rhythm (+ rate) control in a first episode
of AF - IIa
2011 Writing Group Members et al. Circulation
2011;123:104-123
Copyright © American Heart Association

23. Antiarrhythmic drugs v/s left atrial ablation
for rhythm control in AF ESC 2012

24. Catheter ablation for AF using the CARTO contact
mapping system

25. Recommendations for surgical
ablation of AF

26. Recommendations for LAA
closure/occlusion/excision - ESC 2012

27. Recommendation for atrioventricular
node ablation in AF patients
Should be considered
 When the rate cannot be controlled with pharmacological agents and
 when AF cannot be prevented by antiarrhythmic therapy or is
associated with intolerable side effects,
 when direct catheter-based or surgical ablation of AF is not indicated,
has failed, or is rejected. IIa
Should be considered for patients with permanent AF and an indication
for CRT (IIa)
Should be considered for CRT nonresponders in whom AF prevents
effective biventricular stimulation and amiodarone is ineffective or
contraindicated- IIa
• In patients with any type of AF and severely depressed LV function
biventricular stimulation should be considered after AV node
ablation.

28. Summary- management of patients with
recurrent paroxysmal AF
Recurrent Paroxysmal AF
Minimal or no Disabling
symptoms symptoms in AF
Anticoagulation Anticoagulation
and rate control* and rate control
as needed as needed
No drug for AAD therapy *
prevention of
AF
AF ablation if AAD
treatment fails

29. Summary- management of patients with recurrent
persistent or permanent AF
Recurrent Persistent AF Permanent AF
Minimal or no Disabling Anticoagulation and rate
symptoms control* as needed
symptoms in AF
Anticoagulation and Anticoagulation and
rate control* as rate control
needed
AAD drug therapy
Electrical cardioversion as
needed
Continuous anticoagulation as
needed and therapy to maintain
sinus rhythm *
Consider ablation for severely symptomatic
recurrent AF after failure of greater than or equal
to 1 AAD plus rate control

30. THANK YOU!!!