Atrial fibrillation control and cardioversion

Abstract

Stefan Hohnloser and colleagues (Nov 25, p 1789)1Hohnloser SH Kuck K-H Lilienthal J Rhythm or rate control in atrial fibrillation—Pharmacological Intervention in Atrial Fibrillation (PIAF): a randomised trial.Lancet. 2000; 356: 1789-1794Summary Full Text Full Text PDF PubMed Scopus (1047) Google Scholar compared in an open study, rate control by diltiazem with cardioversion by amiodarone, with of without electrical cardioversion, for symptomatic persistent atrial fibrillation. Their main outcomes were symptom relief, exercise tolerance, and quality-of-life. They clearly state that this disorder does not necessarily have prognostic implications, and that treatment priority is to resolve symptoms. We suggest that many patients with persistent atrial fibrillation would prefer their five-fold risk of stroke, and increased risk of early mortality to be addressed before less severe symptoms.2Benjamin EJ Wolf PA D'Agostino RB et al.Impact of atrial fibrillation on the risk of death: the Framingham Heart Study.Circulation. 1998; 98: 946-952Crossref PubMed Scopus (3694) Google Scholar Epidemiological evidence strongly supports cardioversion for persistent atrial fibrillation.3Levy S Breithardt G Campbell RWF et al.Atrial fibrillation: current knowledge and recommendations for management.Eur Heart J. 1998; 19: 1294-1320Crossref PubMed Scopus (302) Google Scholar This practice should be continued until more mortality endpoints are reported. We are confused as to why patients restored to sinus rhythm remained on anticoagulation for the full study period, which raised their risk of bleeding, and might have masked potential improvements in quality of life.4Golzari H Cebul RD Bahler RC Atrial fibrillation: restoration and maintenance of sinus rhythm and indicators for anticoagulation therapy.Ann Intern Med. 1996; 125: 311-323Crossref PubMed Scopus (84) Google Scholar Anticoagulation is important for reducing embolic risk in atrial fibrillation only until patients have stable sinus rhythm. Finally, we are concerned that the primary endpoint of symptoms did not include reduced exercise tolerance (fatigue), which Hohnloser and colleagues note is associated with atrial fibrillation. Instead, this outcome was secondary, measured by exercise performance in patients cardioverted to sinus rhythm were not reflected in the SF-36, a generic quality-of-life score. This assessment may not adequately reflect such differences between treatment groups. A key factor in restoring and sustaining sinus rhythm that is commonly overlooked is the speed at which treatment is started. We support opportunistic screening for atrial fibrillation in primary and secondary care by checking a patients’ pulse5Baxter J Crebtree L Hildreth A et al.Atrial fibrillation.Lancet. 1998; 352: 1858Summary Full Text Full Text PDF PubMed Scopus (5) Google Scholar along with systems to enable fast referral and cardioversion if required. Atrial fibrillation control and cardioversionAuthors' reply Full-Text PDF