1. Rhythm and Rate Control for Atrial Fibrillation Tom Wallace, MD Cardiac Electrophysiology CHI St. Vincent Heart Clinic Arkansas

2. Approach to Atrial Fibrillation Type – Structurally normal heart? – Secondary causes? Symptomatic – Can be difficult in elderly patients who complain of fatigue Stroke risk – CHADS 2 VASC score

3. Rate Control & Anticoagulation Very reasonable for asymptomatic AF patients Patient stays in AF Evidenced based interventions to improve mortality: – Maintain HR < 110 bpm – Appropriate anticoagulation for stroke prevention

4. Types of AF Paroxsymal – < 7 days; spontaneous termination Persistent – > 7 days – DCCV Longstanding Persistent – > 1 yr Permanent – No hope of restoring NSR

5. Rhythm Control Attempt to restore and maintain normal sinus rhythm Patients who have symptomatic AF Antiarrhythmic medications Cardioversion Catheter ablation

6. Symptoms of AF Palpitations, fluttering SOB DOE Fatigue Syncope (rarely) Exertional limitations

7. A difficult question to answer --- Patients have to be compliant with oral anticoagulation. Even in excellent clinical trials, the time in the therapeutic range (TTR) for warfarin. (Goal INR 2-3) is 60-70% Rhythm Control – Improved Stroke Risk?

8. Crude incidence rates of stroke/TIA by CHADS2 score. Meytal Avgil Tsadok et al. Circulation. 2012;126:2680-2687

9. Stroke/TIA rates in patients who filled prescriptions for rhythm versus rate control therapy: adjusted Kaplan–Meier curves. Meytal Avgil Tsadok et al. Circulation. 2012;126:2680-2687

10. Catheter Ablation for Stroke Prevention Annualized risk of CVA 1.6% after catheter ablation Annualized risk of CVA 2.7% with anti- arrhythmic medications Catheter ablation peri-procedural risk of TIA/CVA 0.25% on uninterrupted warfarin therapy Reynolds et al. Circ Cardiovasc Qual Outcomes. 2012; 5 (2): 171-181 Di Biase et al. Circ 2014; 129: 2638-2644

11. Mortality Benefit of Rhythm Control? None

12. Rhythm Control Advantage Improved Quality of Life And Improved Stroke Risk

13. Thank you