Atrial fibrillation – what’s new in the treatment of a common arrhythmia

Atrial fibrillation – what’s new in the therapy of frequent arrhythmia?

Will the clinical management of atrial fibrillation change? How to treat an arrhythmia that affects up to 10 percent of. seniors? New clinical trial results presented at the European Heart Rhythm Association Congress in Lisbon are commented on by Dr. n. med. Michael M. Farkowski of the Institute of Cardiology in Warsaw, a member of the SRS PTK board and the EHRA Scientific Initiatives Committee.

This year’s EHRA Congress 2019 in Lisbon left many interesting scientific reports thatore have a real chance to permanently change clinical practice in the treatment of cardiac arrhythmias. Amongod of the reports presented were two randomized clinical trials presented in the prestigious Late Breaking Trials session on cardioversion of paroxysmal and persistent atrial fibrillation, respectivelyow (AF). Both topics are important and practical: they address a common clinical problem – AF cardioversion is one of the most commonly performed proceduresoin cardiology. Reports may prompt the clinician community to makeoin and scientistsoin order to reflect on the management of patients suffering from atrial fibrillationow – arrhythmia, on whichorą according to the latest estimatesow suffer up to 10 percent of. osob after the age of 75.

Does a patient with an attack of atrial fibrillationow lasting less than 48 hours must be immediately subjected to probie cardioversion of arrhythmias?

– This question was asked by researchers in the Netherlands in preparing and conducting the RACE 7 ACWAS study. This was a randomized, multicenter clinical trial, which was designed toorego qualified patientow with a first or subsequent attack of atrial fibrillationow, provided there is no history of fresh ischemia or episodes ofoin persistent AF. PatientoIn the study group, patients were eligible for a scheduled early outpatient visit, during which theowhich the eventual decision on deferred cardioversion was made. The ad hoc use of rate-controlling drugs for ventricularor. The control group was treated according to the local standard: pharmacological or electrical cardioversion was used. The results of the study were unequivocal: at one-month follow-up, the percentage of patientsoin sinus rhythm was the same, and the patient’s quality of lifeow of both groups did not rosignificantly. Importantly, spontaneous cardioversion occurred within 48 hours in almost 70 percent of the. patientoin the study group. The duration of the patient’s stay in the emergency room skrohas decreased by 25 percent.

Why this is an important study probably doesn’t need to be explained to anyone who has spent even a little time in an emergency room or hospital emergency department (IP/SOR). In fact, there is no on-call period without a patientoin with a fresh AF attack, and the standard treatment in such a situation is rapid proba pharmacological or electrical cardioversion. It turns out that in the vast majority of cases, theow such a seizure can pass spontaneously within 48 hours without the need for medicationoin antiarrhythmics or electrical cardioversion. This reduces the workload and resourcesow and reduces the risk of complications associated with early AF cardioversion.

How does this relate to Polish realitiesow? Due to the organization of the health care system and the waiting time for an outpatient appointment with a cardiologist, the possibility of even a partial introduction of cardioversion in patientsow with fresh AF attack from the IP/SOR remains a challenge. Doctors managing patients with paroxysmal atrial fibrillation no lessow got their hands on a well-documented argument: there is a very good chance of spontaneous recurrence of atrial fibrillationot sinus rhythm within 48 hours without the inconvenience of urgent cardioversion in the IP/SOR.

When cardioversion is already indicated: whether patients with persistent AF and an implantable cardioverter-defibrillator (ICD) should undergo external or internal (ICD discharge) electrical cardioversion?

– Another study and another interesting result. Patients were eligible for the described randomized clinical trialow with a previously implanted ICD referred for elective cardioversion of persistent AF. In the study group, cardioversion was performed by discharging the ICD with maximum energy, while in the control group, a standard external defibrillator was used, but the defibrillating electrodes were placed in the position of the przod – back. External cardioversion has been shown to be significantly more effective and does not endanger the ICD system. Moreover, external cardioversion was similarly effective in patientow with previous failed probby internal cardioversion with ICD.

The study has direct clinical implications: in patientow with an ICD, aim for external cardioversion with the position of the leads in the przod – back, and ineffective internal cardioversion in the form of eg. Inadequate ICD discharge does not exclude adhesiolysisoThe study was carried out at the HAWC in order to monitor sinus rhythm using an external defibrillator. It is important to emphasize the role of the position of the external defibrillator electrodes: in the position of the przod – back pack distance is minimal, and the discharge vector bypasses the implanted generator. A similar positioning of the defibrillator’s external electrodes may be helpful for prob cardioversion in a patientoin patients with large lateral thoracic dimensions, obese or emphysematous patients, and after unsuccessful treatments using a standard electrode array.

Sourceobackground: Press Office of the Cardiac Rhythm Section of the Polish Society of Cardiology