Q J Med 2004; 97: 179-180
QJM vol. 97 no. 3 (c) Association of Physicians 2004; all rights reserved.
Correspondence |
Controlling persistent atrial fibrillation
Sir,The recent review of rate or rhythm control in persistent atrial fibrillation by Boos and colleagues1 favours a rate control strategy in patients with NYHA > II symptoms or LVEF < 40%. However, there is a lack of evidence on how atrial fibrillation should be managed in these patients.2,3 In the trials reported by Boos et al., mean ejection fraction was either not reported or > 50%, diuretic use was low, and few patients had an established diagnosis of heart failure according to guideline criteria.4
The prevalence of atrial fibrillation (AF) in heart failure ranges from 10%–50%, depending upon the severity of symptoms (NYHA class).2,3 AF may cause or exacerbate heart failure symptoms, and is associated with a worse prognosis.5–8
Patients with AF and heart failure may have more to gain from restoring atrial contraction (‘atrial kick’) than those without significant ventricular dysfunction. Studies have shown improvement in exercise capacity (including 6 min walk distance), peak oxygen consumption and cardiac output following cardioversion.8–10 It is likely to be more difficult to cardiovert and maintain sinus rhythm in patients who have heart failure, and therefore a much more aggressive policy in terms of preparation for cardioversion, and for maintenance of sinus rhythm, is likely to be required. However, there is evidence that aggressive treatment with ACE inhibitors,11,12 beta-blockers,13 angiotensin receptor blockers14,15 and amiodarone,16,17 may reduce the propensity to develop atrial fibrillation, and may even restore sinus rhythm without having to resort to electrical means. It is likely that aldosterone antagonists will show similar benefits. Most of these treatments also improve the symptoms of heart failure, and are therefore justified or mandated in this population.
Patients with heart failure were poorly represented in trials comparing rate control versus rhythm control of AF, and as they may gain more by having sinus rhythm restored, it is inappropriate to conclude which strategy should be preferred. In addition to AF-CHF, the CAFÉ-II study aims to randomize 400 patients to an aggressive strategy of cardioversion versus rhythm control in the Humberside region (population 1.5 million) of the UK. The results of these studies should be awaited before making confident predictions that may be incorrect.
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Department of Cardiology University of Hull Castle Hill Hospital Kingston-upon-Hull e-mail: rhidianshelton{at}btinternet.com
References
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13. McMurray JJV, Dargie HJ, Ford I, Lopez-Sendon JL, Remme WJ, Sharpe N, Blank A, Staiger C. Carvedilol reduces supraventricular and ventricular arrhythmias after myocardial infarction: evidence from the CAPRICORN study. Circulation 2001; 104(suppl. II):II–700.
14. Madrid AH, Bueno MG, Rebollo JMG, et al. Use of Irbesartan to maintain sinus rhythm in patients with long-asting persistent atrial fibraillation. Circulation 2002; 106:331–6.
15. Nakashima H, Kumagai K, Urata H, Gondo N, Ideishi M, Arakawa K. Angiotensin II antagonist prevents electrical remodelling in atrial fibrillation. Circulation 2000; 101:2612–17.
16. Khand A, Cleland J.G.F., Deedwania P. Prevention of and Medical Therapy for Atrial Arrhythmias in Heart Failure. Heart Fail Rev 2002; 7:267–83.[CrossRef][Medline]
17. Tieleman RG, Gosselink AT, Crijns HJ, van Gelder IC, van den Berg MP, de Kam PJ, van Gilst WH, Lie KI. Efficacy, safety, and determinants of conversion of atrial fibrillation and flutter with oral amiodarone. Am J Cardiol 1997; 79:53–7.[CrossRef][Web of Science][Medline]
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