Atrial fibrillation ( AF) is the most common supraventricular arrhythmia in clinical practice. It is characterized by chaotic electrical activation of the atria with rates above 300 beats per minute and variable heart rates depending on the ventricular response, although they are usually elevated (between 130 and 180 beats per minute), which manifests with symptoms of palpitations, shortness of breath, and even chest pain.
Currently, we have several tools available for the diagnosis and treatment of this type of arrhythmia. This article aims to emphasize two key aspects of treatment: the prevention of thromboembolic events and the strategy of rate control versus rhythm control.
It's important to note that AF is an arrhythmia that poses a higher embolic risk than that of people without this arrhythmia. What does this mean? There's a greater likelihood of a clot forming in the atrium due to the aforementioned chaotic electrical activation, and the resulting risk of that clot migrating into the arterial bloodstream and eventually causing a stroke, mesenteric ischemia, renal ischemia, etc. To stratify this risk, we rely on a scale called the CHA2DS2 VA Score, which includes patient characteristics (heart failure, hypertension, age, diabetes, stroke, ischemic heart disease, and previous thromboembolic events). If the patient has a score of 2 or higher, anticoagulation is indicated as a preventive treatment. Scores of 0 do not require anticoagulation. When the score is 1, the decision must be made by consensus between the patient and a specialist. The anticoagulant drug chosen depends on the patient's characteristics, but currently we have vitamin K antagonists (warfarin, acenocoumarol) and direct anticoagulants – DOACs (Dabigatran, Rivaroxaban, Apixaban and Edoxaban).
The other pillar of atrial fibrillation treatment is the rhythm strategy, that is, opting for a heart rate control strategy, leaving the patient with the arrhythmia and lowering the heart rate to normal values with medication, or a rhythm control strategy, reversing the arrhythmia to achieve a normal rhythm, either with electrical cardioversion, with antiarrhythmic drugs for reversal and prevention of arrhythmia recurrence, or with pulmonary vein isolation procedures (arrhythmia ablation).
Each point of the therapeutic approach, as well as each of the options, entails risks as well as benefits for the patient, the latter far outweighing the former, provided that the treatment is tailored to each particular case and always taking into account the preferences of each patient, who must play a central role in understanding their pathology and their options in order to reach joint decisions with their cardiologist.
By Dr. Julián Crosa Ruiz de Temiño