Atrial fibrillation secondary prevention
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Cafer Zorkun, M.D., Ph.D. [2]
Overview
Secondary Prevention
| Class | Drug | A-fib recurrence | Mortality |
|---|---|---|---|
| I. Voltage-gated Na+ channel blockers | |||
| Ia | Quinidine | 0.51 (0.40 to 0.64) | 2.26 (0.93 to 5.45) |
| Disopyramide | 0.52 (0.27 to 1.01) | 7.56 (0.47 to 122.66) | |
| Ic | Flecainide | 0.31 (0.16 to 0.60) | Unestimable as no deaths occurred |
| Propafenone | 0.37 (0.28 to 0.48) | 0.05 (0.00 to 1.02) | |
| II. Autonomic inhibitors and activators | |||
| IIa | Metoprolol | 0.62 (0.44 to 0.88) | 2.75 (0.39 to 19.6) |
| III. K+ channel blockers and openers | |||
| IIIa | Amiodarone | 0.19 (0.14 to 027) | 1.64 (0.59 to 4.56) |
| Dronedarone | 0.59 (0.46 to 0.75) | 0.85 (0.67 to 1.09) | |
| Sotalol | 0.51 (0.43 to 0.60) | 2.23 (1.10 to 4.50) | |
In patients with paroxysmal atrial fibrillation, a number of medications are available for after conversion of persistent AF. Dronedarone is a medication that may be used to decrease the need for hospitalization, and can be started as an outpatient therapy. It can not be given in patients with class IV heart failure, decompensated heart failure, or depressed left ventricular function. A permanent pacemaker is not recommended in patients who do not have another indication for placement of a pacemaker
"Pill-in-the-pocket" approach
As needed flecainide or propafenone can be take orally according to clinical practice guidelines from 2014 by the American College of Cardiology and American Heart Association[2]
The guidelines, give a IIa recommendation after "observed to be safe in a monitored setting." The guidelines cite one randomized controlled trial[3]. In this trial, the dose was:
- Patient weighed less than 70 kg: flecainide 200 mg or propafenone was 450 mg
- patient weighed 70 kg or more: flecainide 300 mg or propafenone was 600 mg
In the trials, the drug was first tested in a monitored setting: "After administration of the drug, heart rhythm was monitored for at least 8 hours, blood pressure was measured every 30 minutes with the use of a cuff, and a 12-lead electrocardiogram was recorded every hour."[3]
2011 ACCF/AHA/HRS Focused Updates Incorporated Into the 2006 Guidelines for the Management of Patients With Atrial Fibrillation (DO NOT EDIT) [4][5]
Preventing Hospitalization Due to Recurrent AF (DO NOT EDIT)[4][5]
| Class III (Harm) |
| "1. Dronedarone should not be administered to patients with Class IV heart failure or patients who have had an episode of decompensated heart failure in the past 4 wks, especially if they have depressed LV function (LV ejection fraction ≤ 35%). (Level of Evidence: B)" |
| Class IIa |
| "1. Dronedarone is reasonable to decrease the need for hospitalization for cardiovascular events in patients with paroxysmal AF or after conversion of persistent AF. Dronedarone can be initiated during outpatient therapy. (Level of Evidence: B)" |
Secondary Prevention with Pacing (DO NOT EDIT)[4][5]
| Class III |
| "1. Permanent pacing is not indicated for the prevention of AF in patients without any other indication for pacemaker implantation. (Level of Evidence: B)" |
Prevention of Bleeding
- It is critical to control any bleeding risk factor in patients who are receiving treatment for atrial fibrillation.[6]
- Based on NICE guideline the following interventions should be done in order to prevent bleeding:[6]
- Control uncontrolled hypertension
- Check INR properly in patients who are receiving vitamin K antagonists
- Control medication history of your patient (check for medications that can increase the risk of bleeding, such as selective serotonin reuptake inhibitor (SSRIs), Non-steroidal anti-inflammatory drugs (NSAIDs) and antiplatelet drugs)
- Ask patients to avoid excess alcohol drinking
- Treat anemia
Sources
- 2011 ACCF/AHA/HRS Focused Updates Incorporated Into the ACC/AHA/ESC 2006 Guidelines for the Management of Patients With Atrial Fibrillation [5]
- ACC/AHA/Physician Consortium 2008 clinical performance measures for adults with nonvalvular atrial fibrillation or atrial flutter [7]
References
- ↑ Lafuente-Lafuente C, Valembois L, Bergmann JF, Belmin J (2015). "Antiarrhythmics for maintaining sinus rhythm after cardioversion of atrial fibrillation". Cochrane Database Syst Rev (3): CD005049. doi:10.1002/14651858.CD005049.pub4. PMID 25820938.
- ↑ January CT, Wann LS, Alpert JS, Calkins H, Cigarroa JE, Cleveland JC; et al. (2014). "2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society". J Am Coll Cardiol. 64 (21): e1–76. doi:10.1016/j.jacc.2014.03.022. PMID 24685669.
- ↑ 3.0 3.1 Alboni P, Botto GL, Baldi N, Luzi M, Russo V, Gianfranchi L; et al. (2004). "Outpatient treatment of recent-onset atrial fibrillation with the "pill-in-the-pocket" approach". N Engl J Med. 351 (23): 2384–91. doi:10.1056/NEJMoa041233. PMID 15575054.
- ↑ 4.0 4.1 4.2 4.3 Fuster V, Rydén LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA et al. (2006) ACC/AHA/ESC 2006 Guidelines for the Management of Patients with Atrial Fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation): developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society. Circulation 114 (7):e257-354. DOI:10.1161/CIRCULATIONAHA.106.177292 PMID: 16908781
- ↑ 5.0 5.1 5.2 5.3 Fuster V, Rydén LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA et al. (2011) 2011 ACCF/AHA/HRS focused updates incorporated into the ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. Circulation 123 (10):e269-367. DOI:10.1161/CIR.0b013e318214876d PMID: 21382897
- ↑ 6.0 6.1 Perry M, Kemmis Betty S, Downes N, Andrews N, Mackenzie S, Guideline Committee (2021). "Atrial fibrillation: diagnosis and management-summary of NICE guidance". BMJ. 373: n1150. doi:10.1136/bmj.n1150. PMID 34020968 Check
|pmid=value (help). - ↑ Estes NA, Halperin JL, Calkins H, Ezekowitz MD, Gitman P, Go AS et al. (2008) ACC/AHA/Physician Consortium 2008 clinical performance measures for adults with nonvalvular atrial fibrillation or atrial flutter: a report of the American College of Cardiology/American Heart Association Task Force on Performance Measures and the Physician Consortium for Performance Improvement (Writing Committee to Develop Clinical Performance Measures for Atrial Fibrillation): developed in collaboration with the Heart Rhythm Society. Circulation 117 (8):1101-20. DOI:10.1161/CIRCULATIONAHA.107.187192 PMID: 18283199