Practical Approach to the Treatment of Early AF with Antiarrhythmic Drug Therapy
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Video Transcription
0:37
Consider the case of a 72-year-old gentleman with hypertension who had a pulmonary embolus two months ago.
0:44
He comes into your office for heart rhythm follow-up and has persistent atrial fibrillation that was initially discovered at the time of his pulmonary embolism.
0:57
You evaluate this patient, and you discover that he's had dyspnea with yard work since recovering from his PE acutely. He is on a Pixaban. He is taking Toprol XL for rate control.
1:11
He has a normal thyroid profile. He does not have an elevated brain natriuretic peptide. His renal function is preserved, and an echocardiogram reveals normal ventricular function.
Video Summary
Early rhythm control can improve outcomes in patients with atrial fibrillation (AF), but it is important to determine the degree of urgency for rhythm control therapy. Patients with significant symptoms, cardioversion requirements, ER visits or hospitalizations, and complications of AF are more likely to benefit from early rhythm control. It is crucial to consider the presence of heart failure with preserved ejection fraction (HEF-PEF) in these patients. Structural heart disease and severe cases with underlying deformities may not respond well to early rhythm control. The choice of antiarrhythmic drug should be based on comorbidities and the presence of structural heart disease. Amiodarone should be avoided as a first-line agent due to its potential adverse effects. Class Ic agents, class III agents, and multichannel blockers are suitable for patients without structural heart disease. Class 3 medications require careful monitoring, avoidance in patients with moderate to severe CKD, and vigilance for drug-drug interactions. Dronedarone is an option but should be avoided in heart failure reduced ejection fraction and permanent AF. Delaying ablation does not necessarily have negative implications for rhythm control, as long as high-quality rhythm control is implemented. Early rhythm control improves outcomes, and the majority of patients should be considered for it, tailoring the treatment to each patient's needs and safety considerations.
Keywords
atrial fibrillation
rhythm control
heart failure with preserved ejection fraction
antiarrhythmic drug
structural heart disease
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