From the Guidelines
Recurrent atrial fibrillation is very common in the general population, affecting approximately 50-70% of patients within one year after their initial diagnosis if left untreated, as supported by the 2019 European Heart Journal study 1. After a first episode of atrial fibrillation, about 10% of patients will experience recurrence within the first year even with treatment, and this rate increases to roughly 20-30% within five years despite appropriate therapy. The likelihood of recurrence depends on several factors including age, underlying heart disease, hypertension, diabetes, obesity, sleep apnea, and alcohol consumption, as noted in the 2006 acc/aha/esc guidelines for the management of patients with atrial fibrillation 1. Some key points to consider in the management of atrial fibrillation include:
- Patients with paroxysmal atrial fibrillation (episodes that terminate spontaneously) have a better prognosis than those with persistent atrial fibrillation (episodes lasting longer than 7 days) 1.
- Management typically involves a combination of rate control medications (such as beta-blockers, calcium channel blockers), rhythm control medications (antiarrhythmics like amiodarone, flecainide, or propafenone), anticoagulation therapy (warfarin, apixaban, rivaroxaban, dabigatran, or edoxaban), and lifestyle modifications.
- Catheter ablation may be considered for patients with symptomatic recurrences despite medical therapy, with success rates ranging from 60-80% after a single procedure, though multiple procedures are often needed, as discussed in the 2019 European Heart Journal study 1. It is essential to weigh the risks and benefits of each treatment approach, considering the individual patient's characteristics, medical history, and preferences, to optimize outcomes and improve quality of life. The 2019 European Heart Journal study 1 highlights the importance of considering the interplay between atrial fibrillation and heart failure, as the two conditions are closely linked and can have a significant impact on morbidity and mortality. By prioritizing a comprehensive and personalized approach to managing atrial fibrillation, healthcare providers can help reduce the risk of recurrence and improve patient outcomes.
From the Research
Prevalence of Atrial Fibrillation
- Atrial fibrillation (AF) affects approximately 2% of the total population 2.
- In the US, approximately 10.55 million adults have atrial fibrillation (AF) 3.
Recurrence of Atrial Fibrillation
- The incidence of atrial fibrillation recurrence ranges from 40 to 50%, despite attempts of electrical cardioversion and administration of antiarrhythmic drugs 4.
- Recurrent atrial fibrillation depends on a combination of several parameters, and each patient should be individually assessed for such a risk of recurrence 4.
- Combination therapy with flecainide and metoprolol significantly reduced recurrences at 1-year follow-up when compared with flecainide alone in the whole population (66.7 vs. 46.8%; P < 0.001) and in patients with persistent AF (71.1 vs. 43.6%; P = 0.025) 2.
Risk Factors for Atrial Fibrillation Recurrence
- Clinical, therapeutic, biochemical, ECG, and echocardiographic parameters after electrical cardioversion and ablation are highlighted as predictors of atrial fibrillation recurrence 4.
- Identifying predictors of success in maintaining sinus rhythm after cardioversion or ablation may allow a better selection of patients to undergo these procedures 4.
Treatment and Management
- Restoration and maintenance of normal sinus rhythm is a desirable goal for many patients with AF; however, this strategy is limited by the relatively small number of antiarrhythmic drugs (AADs) available for AF rhythm control 5.
- Flecainide has proven to be more effective than other AADs for the acute termination of recent onset AF, and is moderately effective and equivalent to other AADs for the chronic suppression of paroxysmal and persistent AF 5.
- Guidelines for administration and use of flecainide are summarized, and it is noted that flecainide is underutilized, likely due to a perceived risk of ventricular proarrhythmia 5.