4. Rhythm Management of AF

 

Recommendation 1 – Treatment of precipitating or reversible conditions (2010)

We recommend the optimal treatment of precipitating or reversible predisposing conditions of AF prior to attempts to restore or maintain sinus rhythm (Strong Recommendation, Low Quality Evidence).

 

Recommendation 2 – Rhythm control strategy for patients symptomatic on rate control therapy (2010)

We recommend a rhythm-control strategy for patients with AF or AFL who remain symptomatic with rate-control therapy or in whom rate-control therapy is unlikely to control symptoms (Strong Recommendation, Moderate Quality Evidence).

 

Figure 2: Approach to rate and/or rhythm control of AF in patients presenting with symptomatic AF

(Figure 3 from 2014 Update)

Recommendation 3 – Goal of rhythm control therapy (2010)

We recommend that the goal of rhythm-control therapy should be improvement in patient symptoms and clinical outcomes, and not necessarily the elimination of all AF (Strong Recommendation, Moderate Quality Evidence).

Values and preferences (2010)

Recommendations 1-3 place a high value on the decision of individual patients to balance relief of symptoms and improvement in QOL and other clinical outcomes with the potentially greater adverse effects of the addition of class I or class III antiarrhythmic drugs to rate-control therapy.

 

Recommendation 4 – Maintenance antiarrhythmic drugs first-line in patients with recurrent AF (2010)

We recommend use of maintenance oral antiarrhythmic therapy as first-line therapy for patients with recurrent AF in whom long-term rhythm control is desired (see figures below) (Strong Recommendation, Moderate Quality Evidence).

 

Figure 3: Summary of recommendations for choice of rhythm-control therapy in patients with normal systolic left ventricular function and no history of congestive heart failure

(Figure 4 from 2012 Update)

 

Figure 4: Summary of recommendations for choice of rhythm-control therapy in patients with a history of congestive heart failure (current or remote) or left ventricular systolic dysfunction.

(Figure 5 from 2012 Update):

Recommendation 5 – Avoid antiarrhythmic in patients with advanced sinus or AV node disease (2010)

We recommend that oral antiarrhythmic drug therapy should be avoided in patients with AF or AFL and advanced sinus or AV nodal disease unless the patient has a pacemaker or implantable defibrillator (Strong Recommendation, Low Quality Evidence).

 

Recommendation 6 – AV blocking agent to be used along with a class I antiarrhythmic drug (2010)

We recommend that an AV blocking agent should be used in patients with AF or AFL being treated with a class I antiarrhythmic drug (eg, propafenone or flecainide) in the absence of advanced AV node disease (Strong Recommendation, Low Quality Evidence).

Values and preferences (2010)

Recommendations 4 to 6 place a high value on the decision of individual patients to balance relief of symptoms and improvement in QOL and other clinical outcomes with the potentially greater adverse effects of class I and class III antiarrhythmic drugs compared with rate-control therapy.

 

Recommendation 7 – ‘Pill in the pocket’ therapy in patients with infrequent AF (2010)

We recommend intermittent antiarrhythmic drug therapy (“pill in the pocket”) in symptomatic patients with infrequent, longer-lasting episodes of AF or AFL as an alternative to daily antiarrhythmic therapy (Strong Recommendation, Moderate Quality Evidence).

Values and preferences (2010)

This recommendation places a high value on the results of clinical studies demonstrating the efficacy and safety of intermittent antiarrhythmic drug therapy in selected patients.

 

Table 6: Characteristics of antiarrhythmic medications used for acute pharmacological cardioversion

(Table 1 from 2018 Update)

Medication

Dose

Time to Conversion

Risks

Class Ia

Procainamide

15-18 mg/kg IV over 30-60 minutes

~60 minutes

Hypotension

Bradycardia

Ventricular proarrhythmia

Class Ic

flecainide

300 mg po (> 70 kg)

200 mg po (≤ 70 kg)

2-6 hours

Hypotension

Bradycardia and conversion pauses

1:1 conduction of atrial flutter*

propafenone

600 mg po (> 70 kg)

450 mg po (≤ 70 kg)

2-6 hours

Class III

ibutilide

1 mg IV over 10 min

May repeat x 1

30-60 minutes

QT prolongation

Torsades de pointes**

Hypotension

amiodarone

150 mg IV bolus then

60 mg/h x 6 hours then

30 mg/h x 18hours

8-12 hours

Hypotension

Bradycardia

Atrioventricular block

Torsades de pointes

Phlebitis

vernakalant

3 mg/kg IV over 10 minutes, followed by

2 mg/kg IV if no conversion

12-30 minutes

Hypotension

Bradycardia

Non-sustained ventricular tachycardia***

*Class Ic drugs (flecainide and propafenone) should be used in combination with AV nodal blocking agents (beta-blockers or calcium channel inhibitors). Class IC agents should be avoided in patients with ischemic heart disease or significant structural heart disease

**Consider pre-treating with 1-4 g of IV MgSO4. Ibutilide should be avoided in patients with hypokalemia, baseline QT prolongation, or significant structural heart disease

***Vernakalant should be avoided in patients with hypotension, recent ACS, or significant structural heart disease

 

Table 7: “Pill-In-The-Pocket” Antiarrhythmic drug therapy

 (Table 2 from 2018 Update)

Appropriate Candidates for PIP

1) symptomatic patients

2) sustained AF episodes (e.g. ≥ 2 hours)

3) AF episodes that occur less frequently than monthly

4) absence of severe or disabling symptoms during an AF episode (e.g. fainting, severe chest pain, or breathlessness)

5) ability to comply with instructions, and proper medication use

Contraindication to PIP

1) Significant structural heart disease (e.g. left ventricular systolic dysfunction [LVEF] < 50%, active ischemic heart disease, severe left ventricular hypertrophy)

2) abnormal conduction parameters at baseline (e.g. QRS duration > 120 msec, PR interval > 200 msec; or evidence of pre-excitation)

3) clinical or electrocardiographic evidence of sinus node dysfunction/bradycardia or advanced AV block

4) hypotension (systolic BP < 100mmHg)

5) prior intolerance to any of the PIP-AAD medications

PIP Administration

Immediate release oral AV nodal blocker (one of diltiazem 60 mg, verapamil 80 mg, or metoprolol tartrate 25 mg) 30 minutes prior to the administration of a class Ic AAD (300 mg of flecainide or 600 mg of propafenone if ≥ 70 kg; 200 mg of flecainide or 450 mg of propafenone if < 70 kg)

Initial ED monitoring

Telemetry for at least 6 hours

Blood pressure monitoring every 30 minutes

12-lead ECG monitoring every 2 hours

Determinants of initial treatment Failure

1) AF persistence > 6 hours after PIP-AAD administration or electrical cardioversion required for termination

2) Adverse events including symptomatic hypotension (systolic BP ≤ 90 mmHg), symptomatic conversion pauses (> 5 seconds), symptomatic bradycardia after sinus rhythm restoration, pro-arrhythmia (conversion to atrial flutter/tachycardia, or episodes of ventricular tachycardia), severe symptoms (dyspnea, presyncope, syncope), or a > 50% increase in QRS interval duration from baseline.

Instructions for subsequent use

Patients should take the AV nodal agent 30 minutes after the perceived arrhythmia onset, followed by the Class Ic AAD 30 minutes following the AV nodal agent.

Following AAD administration patients should rest in a supine or seated position for the next 4 hours, or until the episode resolves.

Patients should present to the emergency department in the event that:

1) the AF episode did not terminate within 6-8 hours

2) they felt unwell after taking the medication at home (e.g. a subjective worsening of the arrhythmia following AAD ingestion, or if they developed new or severe symptoms such as dyspnea, presyncope, or syncope)

3) more than one episode occurred in a 24-hour period (patients were advised not to take a second PIP-AAD dose within 24 hours)

4) if the AF episode was associated with severe symptoms at baseline (e.g. significant dyspnea, chest pain, pre-syncope, or symptoms of stroke), even in the absence of PIP-AAD use.

 

Recommendation 8 – Electrical or pharmacological cardioversion for sinus rhythm restoration (2010)

We recommend electrical or pharmacologic cardioversion for restoration of sinus rhythm in patients with AF or AFL who are selected for rhythm-control therapy and are unlikely to convert spontaneously (Strong Recommendation, Low Quality Evidence).

Recommendation 9 – Pre-treatment with antiarrhythmic drugs before electrical cardioversion (2010)

We recommend pre-treatment with antiarrhythmic drugs prior to electrical cardioversion in patients who have had AF recurrence post cardioversion without antiarrhythmic drug pre-treatment (Strong Recommendation, Moderate Quality Evidence).

Values and preferences (2010)

Recommendations 8 and 9 place a high value on the decision of individual patients to pursue a rhythm-control strategy for improvement in QOL and functional capacity.

 

Recommendation 10 – For symptomatic bradycardia, dual-chamber pacing (2010)

We suggest that patients requiring pacing for the treatment of symptomatic bradycardia secondary to sinus node dysfunction, atrial or dual-chamber pacing be generally used for the prevention of AF (Conditional Recommendation, High Quality Evidence).

Recommendation 11 – Pacemaker to be programmed to minimize ventricular pacing (2010)

We suggest that, in patients with intact AV conduction, pacemakers be programmed to minimize ventricular pacing for prevention of AF (Conditional Recommendation, Moderate Quality Evidence).

Values and preferences (2010)

Recommendations 10 and 11 recognize a potential benefit of atrial or dual-chamber pacing programmed to minimize ventricular pacing to reduce the probability of AF development following pacemaker implantation.

Cite this page content

Andrade, Jason G. et al. 2018 Focused Update of the CCS Guidelines for the Management of Atrial Fibrillation. Can J Cardiol, 2018;34: 1371 - 1392

Verma, Atul et al. 2014 Focused Update of the CCS Guidelines for the Management of Atrial Fibrillation. Can J Cardiol 2014;30:1114-1130

Skanes, Allan C. et al. Focused 2012 Update of the CCS Atrial Fibrillation Guidelines: Recommendations for Stroke Prevention and Rate/Rhythm Control. Can J Cardiol 2012;28:125-136

Gillis, Anne M. et al. 2010 CCS Atrial Fibrillation Guidelines. Can J Cardiol 2010;27:27-97