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Catheter ablation Pacing Surgery Implantable devices • Ablate and pace Prevent Remodeling ACE-I, ARB CCB Statins Fish oil... Rationale for maintaining sinus rhythm 1... Rate control in A

Catheter ablation Pacing

Surgery Implantable devices

• Ablate and pace

Prevent Remodeling ACE-I, ARB CCB

Statins Fish oil

Rationale for maintaining sinus

rhythm

1 Less symptoms.

1 Discontinue coumadin.

1 Better survival.

Mortality From AA Rx in AF

Flaker, et al SPAF, JACC 1992

77% 1A21% 1C2% Amio

Rate control in AFFIRM

1 < 80/min at rest.

1 < 110/min 6 minute walk.

1 80% achieved rate control and

35% were in sinus at 5 year visit.

Lenient vs strict rate control

1 614 patients (permanent AF) were

randomized to strict rate control (resting rate

<80/min with exercise rate <110/min

compared with lenient group (resting rate

<110/min

2 Primary outcome death, heart failure,

CVA, life threatening arrhythmias

3 Incidence of primary events at 3 years

12.9% (lenient) vs 14.9% (strict) - this was not statistically significantly different

Conclusion

In pts with permanent AF - lenient is as

effective as strict rate control

NEJM 2010 - Van Gelder et al 362:1363

MS

Overall Conclusion

1 There is no overriding need for

maintenance of SR in elderly less

symptomatic individuals.

2 Benefits of maintaining SR with current

drugs are counterbalanced by adverse effects of the treatment

3 Maintenance of resting heart in 90

range appears to be as effective as

<80/min.

4 Less deleterious methods of achieving

SR should be goal of future therapy.

Appendage occlusion

LA Appendage occluder

ESC guidelines 2010

Important advances in pharmacologic/non-pharmacologic treatment of AF as well as novel

Anticoagulation options