Hi Everyone,Read this article published in the Lancet earlier this year, which I feel provides a succinct and accessible overview to help understand the various approaches to the treatment and management of symptoms in Afib.
So thought that I would share it here.
Thanks for posting - very interesting article.
Much appreciated. Have a good one 😎.
Thanks for this 
Thanks. I’ll get my husband to print it out so that I can keep it for reference.
Thanks for posting that. It's very usefully but perhaps amazing that in 2024 the guidelines differ little from those from much earlier. We need some better treatments for AF, I reckon! 
Steve
Better treatments would be great to see Steve. Where there has been progress is perhaps in a better understanding of the benefits and risks associated with the alternative treatment options. I can't quite get my head around the, at least implied view, that rhythm control, unlike rate control, brings QoL but not prognostic benefit. I can't picture being in NSR and not having a resting heart rate below 100....and even if you were you wouldn't be having an afib episode?
It is an odd thing to read, and it is mentioned often enough, too, that it seems to be a fact.
I wonder (as I come from a background somewhat involved in clinical trials) whether what the trialists measure is the whole picture. What they seem to measure is the overall effect on longevity and that stays put as an average whether the atrial issue (rather than the ventricular problem of tachycardia) is treated or not. It seems that for many, the atrium can be left doing its thing (beating nicely or quivering chaotically) without fear of dying earlier as a result. I know some people get atrial enlargement, and this can lead to persistent AF, but I don't know whether it, in itself, is "unhealthy"?
I would be surprised if longevity weren't reduced if the ventricles weren't looked after well, though. Also, a few with AF get what is called "haemodynamic instability", i.e. potentially dangerously low BP which can put the heart and kidneys at risk, and indeed, brain function. Those people's AF needs to be stabilised but, again, I think it's the rate which is affecting the valves and ventricles that leads to the temporary heart failure this brings on. Sometimes, I have read, the AF itself is stopped in ER using defibrillation type kit or something like amiodarone infusion. Of course, that will also calm the rate since the tachycardia is usually in response to the AF.
Another thought occurs to me that saying treatments are symptomatic rather than life extending is that the doctors are mostly looking at people with more than "simple AF" and have a number of other long term chronic ailments which might also reduce lifespan. Alongside many people's AF and arrhythmias lie other illnesses such as high blood pressure (itself a major cause of strokes and heart artery diseases), diabetes, sleep apnoea, and good old obesity. Those might well cloud any calculation of what AF is doing?
I am in the strange position myself of being on a waiting list for an ablation to try to stop my arrhythmias and AF - and wondering whether to go ahead. This is because my AF, of late, perhaps owing to daily 1.25mg bisoprolol, is not as bad as it used to be averaging 110-130bpm (and, indeed, it has never been as bad as some here say they have). It's even stopped me from taking the daily flecainide I have been prescribed as I fear that more than the AF symptoms (although, for me, my run of ectopic beats make me feel worse at times, much more so, than AF ever does and those are pushing me to start the flecainide or use it as needed).
Steve
Read the following in an article in the American Journal of Cardiology ( jacc.org/doi/10.1016/j.jacc... which intuitively makes more sense to me than the QoL only statements for rhythm control. The article is a couple of years old and I think that the latest guidelines are more in line with this thinking. "Evidence increasingly supports early rhythm control in patients with AF that has not become long-standing, but current clinical practice and guidelines do not yet fully reflect this change. Early rhythm control may effectively reduce irreversible atrial remodeling and prevent AF-related deaths, heart failure, and strokes in high-risk patients. It has the potential to halt progression and potentially save patients from years of symptomatic AF; therefore, it should be offered more widely."
Thanks for that. It's very in depth and the results seem clear. One issue is that the writers are heavily industry funded review so would perhaps (?) tend towards viewing AADs more favourably. This later Lancet study is also funded but only by pacemaker manufacturers and the doctors reach a somewhat different conclusion (and you can see the more positive mention of pace and ablate): thelancet.com/journals/lane....
This review is up to date and highlights that AAD drugs have a less that 1 in 2 chance of working, and are potentially toxic (thanks to prolongation of the QT interval or induction of other arrhythmias):
thepermanentejournal.org/do...
I suspect ablation of pace and ablate might offer the best way forwards, but so much depends on the vast number of confounding factors surrounding the disease, to least (as I read in the review), atrial remodelling is what causes AF, and then AF causes more atrial remodelling. Finding what causes the initial remodelling seems important, and here, it could be anything that makes the atria more "loose" and "stretched" such as obesity and hypertension.
All fascinating. It sent me off reading interesting studies and reviews .Thanks again.
Steve
All fascinating. It sent me off reading interesting studies and reviews
Please continue. Thanks for the excellent article from The Permanente Journal.
Do you have any info about the authors ? I googled their names but very limited info except for Dr Liu. Permanente states the articles are peer reviewed.
Thanks !
I don't. I tend to look at the study type, the number of shares, and the funding sources when I consider the validity of trials. I spent so many years working in this area alongside doctors that I understand why it can be difficult to weigh up studies. The newer use of meta-analysis is fascinating but carries its own raft of potential confounding issues. An individual committed and enthusiastic cardiologist with their vast knowledge and experience can be far superior, I believe.
It's a fascinating area.
Steve
Thanks for those links and particularly the Permanente Journal article. It indicates as a "pro" of Early rhythm control that it has been linked with lower all-cause mortality, cardiovascular mortality, stroke, and HF hospitalizations which is broadly in line with what is indicated in the other articles we have shared. I have also read, but don't have a source, that regarding mortality, the AFFIRM trial showed no mortality benefit between its rhythm and rate control arms. However, post-publication on-treatment analysis discovered that increased time in SR itself was associated with a 47% lower risk of mortality. Yet, this was offset by a 49% increase with the use of AADs ( antiarrhythmic drugs) used to try to maintain SR.
This is why I am self-funding a PVI ablation the week after next. I can't say that I am looking forward to it but broadly the most recent evidence and guidelines seem to favour this approach over long term use of medications. I have PAF with roughly monthly episodes which convert back into rhythm on their own - with the help of extra beta blockers to bring down rate.
Finally a link to another informative article published in New England Journal of Medicine nejm.org/doi/full/10.1056/N...
Interesting article. Thank you. Ablation moving into the no 1 seat!
Hi
Not for me.
Abnormal structural damage.
Also there are risks and its likely you will be facing low levels. Easier to control rapid or high.
Remember scarring cannot be reversed.
AND it says ablation used because of adverse AF symptoms. If AFers are controlled by meds is the best for those without worrying symptoms Pigleywigley.
Many end up with a Pacemaker as it takes over the electrical pathway.
cherio JOY. 75. (NZ)
HI
THANK YOU FOR THAT INDEPTH education for AF Forum posters.
What a great piece to keep.
After Beta Blockers not helping to bring down my rate control - Metropolol 186 with pauses at night and breathlessness with fatigue but changed to Bisoprolol 156 no pauses or breathlessness., 2 years 3 months after stroke - a private cardiac specialist introduced DILTIAZEM lowered dose of 120mg I now have a rate Day 60s and my normal 47avg bpm Night.
Separate Bisoprolol at night 2.5 for BP especially Systollic control.
Bingo Diltiazem also acts as a safe anti-arrhymic med. Joy is now happier. Still stop in exertion but I am geared low for it to happen. No more running, brisk walking or long hikes, walks but I do what I can.
Shall get this run off for my Drs etc.
THANK YOU SOOO MUCH.
cherio JOY 75. (NZ)
76 years old with A F
apixaban and hematuria 
shortness of breath
3% Afib burden and proposed medication
