Friday, June 22, 2007
atrial fibrillation
Medscape: So just to summarize, can you give us a brief rundown of what your treatment continuum would be in a patient with HF and AF?
Dr. Strickberger: If they have a low EF,(ejection fraction) I would get them anticoagulated and then try to get them in normal rhythm at least once. I personally would probably give them an antiarrhythmic drug if I thought their EF would improve in normal rhythm, but I would avoid any drugs in which I had concerns about proarrhythmia. That eliminates a lot of the antiarrhythmic drugs, except for sotalol and amiodarone. Many of the large studies suggest that sotalol is safe, at least for patients with ischemic cardiomyopathy. My bias is towards amiodarone, although I think the data suggest that it is safe to use either agent. If you can maintain the patient in normal rhythm using this strategy and their EF improves, then you've achieved the primary goal. You also know that they have a tachycardia-induced cardiomyopathy and you have avoided having to give them a prophylactic defibrillator because their EF has improved. Obviously, their treatment also includes beta-blockers, an angiotensin-converting enzyme inhibitor, and perhaps other drugs.
If a patient has diastolic dysfunction and persistent AF, I might not give them a drug. Depending on the circumstances, I might just perform a cardioversion and see how long they stay in sinus rhythm. Some people will stay in sinus rhythm for a long time; in most cases, however, they don't, but given that the drugs have issues, if you can get something that works without a drug, it is worth a try. If the AF recurs relatively quickly, then I would give them a drug. If all of that fails, we would be limited to anticoagulation and rate control.
Medscape: When would you move to AF ablation or AV node ablation?
Dr. Strickberger: If they have diastolic dysfunction, I might consider a curative ablation for AF as opposed to AV node ablation. But I think for the people with dead hearts, most physicians would probably choose AV node ablation -- although I think that's a moving target today.
Supported by an independent educational grant from St. Jude Medical
Dr. Strickberger: If they have a low EF,(ejection fraction) I would get them anticoagulated and then try to get them in normal rhythm at least once. I personally would probably give them an antiarrhythmic drug if I thought their EF would improve in normal rhythm, but I would avoid any drugs in which I had concerns about proarrhythmia. That eliminates a lot of the antiarrhythmic drugs, except for sotalol and amiodarone. Many of the large studies suggest that sotalol is safe, at least for patients with ischemic cardiomyopathy. My bias is towards amiodarone, although I think the data suggest that it is safe to use either agent. If you can maintain the patient in normal rhythm using this strategy and their EF improves, then you've achieved the primary goal. You also know that they have a tachycardia-induced cardiomyopathy and you have avoided having to give them a prophylactic defibrillator because their EF has improved. Obviously, their treatment also includes beta-blockers, an angiotensin-converting enzyme inhibitor, and perhaps other drugs.
If a patient has diastolic dysfunction and persistent AF, I might not give them a drug. Depending on the circumstances, I might just perform a cardioversion and see how long they stay in sinus rhythm. Some people will stay in sinus rhythm for a long time; in most cases, however, they don't, but given that the drugs have issues, if you can get something that works without a drug, it is worth a try. If the AF recurs relatively quickly, then I would give them a drug. If all of that fails, we would be limited to anticoagulation and rate control.
Medscape: When would you move to AF ablation or AV node ablation?
Dr. Strickberger: If they have diastolic dysfunction, I might consider a curative ablation for AF as opposed to AV node ablation. But I think for the people with dead hearts, most physicians would probably choose AV node ablation -- although I think that's a moving target today.
Supported by an independent educational grant from St. Jude Medical
# posted by roodbont @ 2:55 AM 
