Challenges in Atrial Fibrillation Treatment

Deepak L. Bhatt, MD, MPH, FACC, FAHA, FSCAI, FESC: Atrial fibrillation is very common, and there are a lot of challenges to it as well. There’s been a lot of controversy through the years. For example, is rate control sufficient, or do we also need to control the rhythm, to restore normal sinus rhythm? Intuitively, it makes a lot of sense to restore normal sinus rhythm, but older trials suggested no benefit to a rhythm control strategy vs rate control alone. Obviously, you need to control the rate if someone is very quick. You want to get their heart rate down with beta-blockers, calcium channel blockers, or those sorts of medicines. But should you also restore a normal sinus rhythm? Should that be done with antiarrhythmic medications, like amiodarone and dronedarone, or should that be done with procedures? Or should it be done with medicines, and if people fail medicines, then procedures? By procedures I mean atrial fibrillation ablation.

The general feeling is that if people are healthy, not having heart failure, and asymptomatic, rate control is probably sufficient. But if they’re very symptomatic with their atrial fibrillation…it’s important to see if the rate is controlled with exercise. Even if it’s controlled at rest, it may not be well controlled with exercise, especially in younger more active people. Assuming that the rate is well controlled, if they’re still symptomatic, then that’s a reason to do more with drugs, procedures, or potentially with both. In part it depends on underlying comorbidities, patient preference, and so forth. Obviously, atrial fibrillation ablation is an invasive procedure. There can be complications, but the procedure has gotten safer, especially in experienced hands.

In patients with heart failure as well, there appears to be a benefit of ablation. Even some meta-analyses suggest there might be lower mortality in patients, especially patients with heart failure with reduced ejection fraction who have atrial fibrillation to undergo ablation. It’s a bit controversial, but there are meta-analyses that support that. It makes some intuitive sense. A patient with heart failure who decompensates with a bout of atrial fibrillation is more likely to run into trouble. So it seems to make intuitive sense that restoration of rhythm in addition to rate control could be beneficial. Also, in patients with heart failure, use of antiarrhythmics can get tricky. The rate of adverse effects can go up, the rate of drug interactions with other drugs they might be on could go up. So there is potentially a greater role for procedural atrial fibrillation if they have heart failure.

In a young person, what about them? There are a lot of challenges. On the one hand, they’re probably going to tolerate things pretty well if they’ve just rate control without rhythm control. On the other hand, the longer people are in atrial fibrillation, the harder it is to get out of it. So we’re in a theoretical appeal to try to restore normal sinus rhythm early before the left atrium remodels, dilates, and becomes fibrotic. There’s some work looking at things like MRI to see if left atrial fibrosis can help guide exactly what our therapy should be.

There are a lot of challenges in knowing exactly what to do with atrial fibrillation in different patients. Randomized clinical trials and guidelines are useful in that decision-making, and ongoing research such as the imaging research might end up being really useful in terms of tailoring therapy to different types of patients with atrial fibrillation. The patient’s voice matters if they’re symptomatic and their preferences is medical therapy and procedural therapy. Also, I always emphasize lifestyle modification, including things like reducing weight and reducing alcohol intake, that can go a long way in some patients to reduce atrial fibrillation burden.

Transcript Edited for Clarity