Comprehensive Management Of Atrial Fibrillation Research Articles

Feasibility and diagnostic yield of a photoplethysmography-based arrhythmia screening and integrated management pathway in a chronic obstructive pulmonary disease outpatient clinic

Abstract Background Guidelines recommend opportunistic screening for atrial fibrillation (AF) in high-risk populations, including chronic obstructive pulmonary disease (COPD) patients. Purpose We aimed to assess the feasibility and yield of a photoplethysmography (PPG) smartphone app-based pathway for AF detection within a COPD outpatient clinic. Methods Ninety-nine eligible patients from the COPD outpatient clinic at the Maastricht University Medical Center+ underwent a 14-days PPG app-based AF screening. PPG-based AF detection triggered an electrocardiogram (ECG) for AF diagnosis and initiation of a comprehensive AF management. Patients’ adherence and system usability were assessed. Results Patient onboarding was easy, and patients demonstrated good adherence to the protocol (101% [82%-123%]). The usability of the PPG app was satisfactory with a high score in the System Usability Score questionnaire (80.0 [55.0-92.5]). Among 99 patients (mean age 66±9 years; 54% female), 8% had a prior AF diagnosis. Premature beats were common, with 96% of patients showing isolated premature beats (<6 in 960 PPG recordings) and 32% frequent premature beats (≥6 in 210 PPG recordings). The PPG algorithm suspected paroxysmal AF in 6 new cases. AF could be confirmed in 2 patients through resting 12-lead ECG and 1-lead handheld ECG device. One patient who was lost to follow-up. In the remaining 3 patients with suspected AF PPG recordings, analysis of 24-hour, 48-hour and 7-day Holter recordings revealed high burden premature (supra)ventricular beats. Two of these patients manifested self-terminating short episodes of supraventricular tachycardia. Conclusion 14-days opportunistic PPG app-based screening is feasible in COPD outpatient care and results in the detection of new AF cases and premature beats. This novel digital approach offers a practical method to implement recommended AF screening in COPD patients.

Antiarrhythmic Drugs vs. Ablation for Atrial Fibrillation

Summary:
 Atrial fibrillation (AF) is a common and potentially life-threatening cardiac arrhythmia that affects millions of individuals worldwide. The treatment landscape for AF has traditionally comprised antiarrhythmic drugs (AADs), which aim to restore and maintain normal heart rhythm. However, over the past two decades, catheter ablation has emerged as an alternative therapeutic approach in the management of AF. This article systematically compares the effectiveness, safety, and long-term outcomes of AADs and catheter ablation as treatment strategies for atrial fibrillation.
 Introduction:
 Atrial fibrillation (AF) is characterized by disorganized electrical activity in the atria, causing irregular and often rapid heart rhythm. Over the years, pharmacological therapy with antiarrhythmic drugs (AADs) has been the mainstay of AF treatment. Nonetheless, catheter ablation has gained significant momentum due to its ability to directly target the arrhythmogenic substrate within the heart.1
 Efficacy:
 
 Antiarrhythmic Drugs: Various classes of AADs inhibit specific ion channels or receptors to normalize cardiac electrical conduction. While AADs can effectively restore sinus rhythm in many patients, their long-term success in maintaining sinus rhythm is modest, with recurrence rates ranging from 40% to 60% within one year.2
 Catheter Ablation: Ablation procedures selectively target and destroy the abnormal electrical pathways contributing to AF. In well-selected patients, catheter ablation has demonstrated higher efficacy rates than AADs, particularly in paroxysmal AF, with success rates reaching 70-80% or more after a single procedure.2
 
 Safety Profile:
 
 Antiarrhythmic Drugs: Although generally well-tolerated, AADs have notable adverse effects, including pro-arrhythmia, organ toxicity, and drug-drug interactions. These side effects often limit their usage or require careful patient monitoring.3
 Catheter Ablation: While catheter ablation is generally safe, it has a finite risk of procedural complications, such as vascular injury, cardiac perforation, and stroke. Nonetheless, the overall complication rate is low, ranging from 1% to 5%, and is further decreasing with advancements in technology and operator experience.3
 
 Quality of Life and Symptom Control:
 
 Antiarrhythmic Drugs: Effective rate control with AADs can significantly improve symptom burden and quality of life in patients with persistent or permanent AF.4
 Catheter Ablation: Successful ablation procedures can offer long-term freedom from AF symptoms, eliminating or reducing the dependence on AADs and their associated side effects.4
 
 Long-Term Outcomes:
 
 Antiarrhythmic Drugs: AAD therapy is often lifelong, and patients may require multiple medication adjustments due to loss of efficacy or intolerable side effects. However, AADs remain a treatment option for patients with contraindications for ablation or in those who prefer medical management.4
 Catheter Ablation: Successful ablation procedures have been associated with excellent long-term outcomes, with sustained freedom from AF achieved in approximately 60-70% of patients at 1-5 years of follow-up. Repeat ablations may be necessary in some cases.4
 
 Conclusion:
 While both antiarrhythmic drugs and catheter ablation have their advantages and disadvantages in the management of atrial fibrillation, catheter ablation has emerged as a promising treatment strategy, offering higher success rates and long-term symptom control compared to AADs. However, individual patient characteristics, preferences, and comorbidities should guide the selection of the optimal treatment approach, ensuring personalized and comprehensive management of atrial fibrillation. Further research is needed to refine patient selection criteria, improve ablation techniques, and optimize the use of antiarrhythmic drugs to enhance treatment outcomes for AF patients.
 References
 
 Asad ZUA, Yousif A, Khan MS, Al-Khatib SM, Stavrakis S. Catheter Ablation Versus Medical Therapy for Atrial Fibrillation: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Circ Arrhythm Electrophysiol. 2019;12(9):e007414.
 Andrade JG, Deyell MW, Macle L, Wells GA, Bennett M, Essebag V, et al. EARLY-AF Investigators. Progression of Atrial Fibrillation after Cryoablation or Drug Therapy. N Engl J Med. 2023;388(2):105-16.
 Charitakis E, Metelli S, Karlsson LO, Antoniadis AP, Rizas KD, Liuba I, et al. Comparing efficacy and safety in catheter ablation strategies for atrial fibrillation: a network meta-analysis. BMC Med. 2022;20(1):1-3.
 Deshpande R, AlKhadra Y, Singanallur P, Botchway A, Labedi M. Outcomes of catheter ablation versus antiarrhythmic therapy in patients with atrial fibrillation: a systematic review and meta-analysis. J Interv Card Electrophysiol. 2022;65(3):773-802.

Chinese consensus on the use of antiarrhythmic drugs for rhythm control in atrial fibrillation

Rhythm control is crucial part of comprehensive management of atrial fibrillation (AF). Rhythm control can reduce the burden of AF effectively, reduce symptoms, and improve the prognosis in early AF. Antiarrhythmic drugs (AADs) are the first-line treatment for rhythm-control strategies. This consensus focuses on the principle of rhythm control in AF, the characteristics of AADs, and the medication recommendations for patients in different populations suffering from AF. Hence, this consensus aims to support clinical decision-making for AF therapy.

Clinical Significance of Application of Comprehensive Management of Atrial Fibrillation

To improve the accuracy of detection of arrhythmia in patients with atrial fibrillation (AF) and to enable the scientific management and assessment of AF, a comprehensive management tool for AF is proposed, which is helpful for medical staff to systematically evaluate and manage patients with AF. A professional view of atrial fibrillation (AF View) was designed to unify the statistical information of AF event, and display the statistical distribution data of AF events and trend data of other physiological parameters or characteristics such as heart rate, blood pressure and ST value during the patient monitoring period in a centralized manner. A multi-dimensional summary information was obtained from AF View. In addition, the monitoring period and monitoring parameters or characteristics in the AF View can be adjusted so as to obtain the summary information under different periods and parameters or characteristics, and get the condition of AF of the patient. Accurate detection and comprehensive management of AF were achieved. The application of AF comprehensive management proposed in this study is helpful for medical staff to know the condition of AF patients in real time and adjust the treatment plan in time.

Abstract 9396: Evaluation of the ABC Pathway for Comprehensive Management of Atrial Fibrillation in 20,933 Patients from the ENGAGE AF-TIMI 48 Trial

Introduction: Pts with atrial fibrillation (AF) are at high risk of morbidity and mortality beyond ischemic stroke. The ABC (Atrial Fibrillation Better Care) comprehensive care approach was devised to improve overall care and is endorsed by the 2020 ESC AF Guideline. The impact of the ABC pathway in a large, well-phenotyped population is unclear. Methods: ENGAGE AF-TIMI 48 was an RCT of edoxaban vs. warfarin in pts with AF and CHADS 2 score ≥2. In this exploratory analysis, pts were classified as treated according to the ABC pathway if they met all components depicted in Fig 1 . CV outcomes were compared between pts whose care was vs. was not concordant with the ABC pathway using a Cox proportional hazards model including CHA 2 DS 2 -VASc score. Randomized treatment interaction was assessed using interaction p-values. Results: Of 20,933 pts, 35% were treated concordant with the ABC pathway. These pts were younger (age <75y: 61.9% vs. 56.5%), had less frequent prior CAD (23.3% vs. 38.8%), DM (30.3% vs. 39.4%), and stroke/TIA (18.6% vs. 33.7%). Treatment consistent with the ABC pathway was associated with lower rates of stroke/SEE (HR 0.58, 95% CI 0.50-0.67), major bleeding (HR 0.71, 95% CI 0.62-0.81), MACE (HR 0.57, 95% CI 0.52-0.62), and CV death (HR 0.57, 95% CI 0.50-0.64; p<0.001 for each; Fig 2 ). Lower rates of CV events in patients treated according to the ABC pathway were generally consistent by randomized treatment. Conclusions: In this non-randomized analysis, comprehensive management of AF consistent with the ABC pathway as outlined by the 2020 ESC Guideline on AF is associated with lower adjusted rates of multiple CV outcomes including CV mortality.

On-demand mobile health infrastructures to allow comprehensive remote atrial fibrillation and risk factor management through teleconsultation.

BackgroundAlthough novel teleconsultation solutions can deliver remote situations that are relatively similar to face‐to‐face interaction, remote assessment of heart rate and rhythm as well as risk factors remains challenging in patients with atrial fibrillation (AF).Hypothesis.Mobile health (mHealth) solutions can support remote AF management.MethodsHerein, we discuss available mHealth tools and strategies on how to incorporate the remote assessment of heart rate, rhythm and risk factors to allow comprehensive AF management through teleconsultation.ResultsParticularly, in the light of the coronavirus disease 2019 (COVID‐19) pandemic, there is decreased capacity to see patients in the outpatient clinic and mHealth has become an important component of many AF outpatient clinics. Several validated mHealth solutions are available for remote heart rate and rhythm monitoring as well as for risk factor assessment. mHealth technologies can be used for (semi‐)continuous longitudinal monitoring or for short‐term on‐demand monitoring, dependent on the respective requirements and clinical scenarios. As a possible solution to improve remote AF care through teleconsultation, we introduce the on‐demand TeleCheck‐AF mHealth approach that allows remote app‐based assessment of heart rate and rhythm around teleconsultations, which has been developed and implemented during the COVID‐19 pandemic in Europe.ConclusionLarge scale international mHealth projects, such as TeleCheck‐AF, will provide insight into the additional value and potential limitations of mHealth strategies to remotely manage AF patients. Such mHealth infrastructures may be well suited within an integrated AF‐clinic, which may require redesign of practice and reform of health care systems.

Implementation of an on-demand app-based heart rate and rhythm monitoring infrastructure for the management of atrial fibrillation through teleconsultation: TeleCheck-AF.

During the coronavirus 2019 (COVID-19) pandemic, outpatient visits in the atrial fibrillation (AF) clinic of the Maastricht University Medical Centre (MUMC+) were transferred into teleconsultations. The aim was to develop anon-demand app-based heart rate and rhythm monitoring infrastructure to allow appropriatmanagement of AF through teleconsultation. In line with the fundamental aspects of integrated care, including actively involving patients in the care process and providing comprehensive care by a multidisciplinary team, we implemented a mobile health (mHealth) intervention to support teleconsultations with AF patients: TeleCheck-AF. The TeleCheck-AF approach guarantees the continuity of comprehensive AF management and supports integrated care through teleconsultation during COVID-19. It incorporates three important components: (i) a structured teleconsultation (‘Tele’), (ii) a CE-marked app-based on-demand heart rate and rhythm monitoring infrastructure (‘Check’), and (iii) comprehensive AF management (‘AF’). In this article, we describe the components and implementation of the TeleCheck-AF approach in an integrated and specialized AF-clinic through teleconsultation. The TeleCheck-AF approach is currently implemented in numerous European centres during COVID-19.

Paradigm shifts in pathophysiology and management of atrial fibrillation-atale of the RACE trials in the Netherlands.

In the past 20 years the Netherlands-based RACE trials have investigated important concepts in clinical atrial fibrillation (AF). Their scope ranged from rhythm versus rate control to early or delayed cardioversion and also included early comprehensive management of AF in two trials, one focusing on early ‘upstream therapy’ and risk factor management and the other on integrated chronic nurse-led care. Studies were mostly triggered by simple clinical observations including futility of electrical cardioversion in persistent AF; many patients with permanent AF tolerating day-after-day ‘uncontrolled’ resting heart rates of up till 110 beats/min; patients being threatened more by vascular risks than AF itself; and insufficient guideline-based treatments for AF. Also the observation that recent-onset atrial fibrillation generally converts spontaneously, obviating cardioversion, triggered one of the studies. The RACE trials shifted a number of paradigms and by that could change the AF guidelines. The initial ‘shock-and-forget’ attitude made place for increased attention for anticoagulation, and in turn, broader vascular risks were recognised. In a nutshell, the adage eventually became: ‘look beyond the ECG, treat the patient’.Electronic supplementary materialThe online version of this article (10.1007/s12471-020-01476-0) contains supplementary material, which is available to authorized users.

Patient-Centered Educational Resources for Atrial Fibrillation.

Education has long been recognized as an important component of chronic condition management. Whereas education has been evaluated in atrial fibrillation (AF) populations as part of multifaceted interventions, it has never been tested as a single entity. The aim of this review is to describe the rationale for and role of education as part of comprehensive AF management. The development and use of educational material as part of the intervention of a randomized controlled trial, the HELP-AF (Home-Based Education and Learning Program in AF) study, will be described. This study was designed to determine the impact of a home-based structured educational program on outcomes in individuals with AF. An educational resource was developed to facilitate delivery of 4 key messages targeted at empowering individuals to self-manage their condition. The key messages focused on strategies for managing future AF episodes, the role of pharmacotherapy in the treatment of AF, the appropriate use of medicines to manage stroke risk and the role of cardiovascular risk factor management in AF. To support structured educational visiting, an educational booklet titled Living Well With Atrial Fibrillation (AF) was developed by a multidisciplinary team and was further refined following input from expert clinicians and patient interviews. Using a structured educational visiting approach, education was delivered by trained clinicians within the patient's home.

Risk factors for death, stroke, and bleeding in 28,628 patients from the GARFIELD-AF registry: Rationale for comprehensive management of atrial fibrillation

BackgroundThe factors influencing three major outcomes–death, stroke/systemic embolism (SE), and major bleeding–have not been investigated in a large international cohort of unselected patients with newly diagnosed atrial fibrillation (AF).Methods and resultsIn 28,628 patients prospectively enrolled in the GARFIELD-AF registry with 2-year follow-up, we aimed at analysing: (1) the variables influencing outcomes; (2) the extent of implementation of guideline-recommended therapies in comorbidities that strongly affect outcomes. Median (IQR) age was 71.0 (63.0 to 78.0) years, 44.4% of patients were female, median (IQR) CHA2DS2-VASc score was 3.0 (2.0 to 4.0); 63.3% of patients were on anticoagulants (ACs) with or without antiplatelet (AP) therapy, 24.5% AP monotherapy, and 12.2% no antithrombotic therapy. At 2 years, rates (95% CI) of death, stroke/SE, and major bleeding were 3.84 (3.68; 4.02), 1.27 (1.18; 1.38), and 0.71 (0.64; 0.79) per 100 person-years. Age, history of stroke/SE, vascular disease (VascD), and chronic kidney disease (CKD) were associated with the risks of all three outcomes. Congestive heart failure (CHF) was associated with the risks of death and stroke/SE. Smoking, non-paroxysmal forms of AF, and history of bleeding were associated with the risk of death, female sex and heavy drinking with the risk of stroke/SE. Asian race was associated with lower risks of death and major bleeding versus other races. AC treatment was associated with 30% and 28% lower risks of death and stroke/SE, respectively, compared with no AC treatment. Rates of prescription of guideline-recommended drugs were suboptimal in patients with CHF, VascD, or CKD.ConclusionsOur data show that several variables are associated with the risk of one or more outcomes, in terms of death, stroke/SE, and major bleeding. Comprehensive management of AF should encompass, besides anticoagulation, improved implementation of guideline-recommended therapies for comorbidities strongly associated with outcomes, namely CHF, VascD, and CKD.Trial registrationClinicalTrials.gov NCT01090362

A comparison of clinical characteristics and long-term prognosis in asymptomatic and symptomatic patients with first-diagnosed atrial fibrillation: The Belgrade Atrial Fibrillation Study

BackgroundTo investigate baseline characteristics and long-term prognosis of carefully characterized asymptomatic and symptomatic patients with atrial fibrillation (AF) in a ‘real-world’ cohort of first-diagnosed non-valvular AF over a 10-year follow-up period. Methods and resultsWe conducted an observational, non-interventional, and single-centre registry-based study of consecutive first-diagnosed AF patients. Of 1100 patients (mean age 52.7±12.2years and mean follow-up 9.9±6.1years), 146 (13.3%) had asymptomatic AF.Persistent or permanent AF, slower ventricular rate during AF (<100/min), CHA2DS2–VASc score of 0, history of diabetes mellitus and male gender were independent baseline risk factors for asymptomatic AF presentation (all p<0.01) with a good predictive ability of the multivariable model (c-statistic 0.86, p<0.001).Kaplan–Meier 10-year estimates of survival free of progression of AF (log-rank test=33.4, p<0.001) and ischemic stroke (log-rank test=6.2, p=0.013) were significantly worse for patients with asymptomatic AF compared to those with symptomatic arrhythmia. In the multivariable Cox regression analysis, intermittent asymptomatic AF was significantly associated with progression to permanent AF (Hazard Ratio 1.6; 95% CI, 1.1–2.2; p=0.009). ConclusionsIn a ‘real-world’ setting, patients with asymptomatic presentation of their first-diagnosed AF could have different risk profile and long-term outcomes compared to those with symptomatic AF. Whether more intensive monitoring and comprehensive AF management including AF ablation at early stage following the incident episode of AF and increased quality of oral anticoagulation could alter the long-term prognosis of these patients requires further investigation.

Insights from the RCPE UK Consensus Conference on approaching the comprehensive management of atrial fibrillation

Consensus Conference on approaching the comprehensive management of atrial fibrillationEdinburgh, UK, 1–2 March 2012This article provides some insights from the Royal College of Physicians of Edinburgh UK Consensus Conference on approaching the comprehensive management of atrial fibrillation. The four key questions addressed by the conference were: how can we best detect atrial fibrillation (AF)? Should the treatment of AF be targeted towards control of rhythm, rate or both? What is the most effective and safest delivery of thromboprophylaxis in AF? And what are the differences between physician and patient expectations with regard to the management of AF? The key recommendations from the consensus conference were that detection of AF must be improved; a national screening programme should be introduced; uptake of oral anticoagulants must be increased and methods of engaging patients in their AF management should be improved; aspirin should not be used for stroke prevention in AF; and in relation to rate and rhythm control for AF, relief of symptoms should be the goal of treatment. The Consensus Statement and its background papers are recommended reading for the development of local guidelines for management, and for the management of individual patients.

Early and comprehensive management of atrial fibrillation: executive summary of the proceedings from the 2nd AFNET-EHRA consensus conference ‘research perspectives in AF’

Atrial fibrillation (AF) causes important mortality and morbidity on a population-level. So far, we do not have the means to prevent AF or AF-related complications adequately. Therefore, over 70 experts on atrial fibrillation convened for the 2nd AFNET/EHRA consensus conference to suggest directions for research to improve management of AF patients (Appendix 1). The group defined three main areas in need for research in AF: 1. better understanding of the mechanisms of AF; 2. Improving rhythm control monitoring and management; and 3. comprehensive cardiovascular risk management in AF patients. The group put forward the hypothesis that successful therapy of AF and its associated complications will require comprehensive therapy. This applies e.g. to the "old" debate of "rate versus rhythm control", since rhythm control is generally added to underlying (continued) rate control therapy, but also to the emerging debate of "antiarrhythmic drugs versus catheter ablation", of which both may be needed in most patients to maintain sinus rhythm, but also to therapy of conditions that predispose to AF and contribute to cardiovascular complications such as stroke, cognitive decline, heart failure, and acute coronary syndromes. We call for research initiatives aiming at a better understanding of the different causes of AF and its complications, and at development and validation of mechanism-based therapies. The future of AF therapy may require a combination of management of underlying and concomitant conditions, early and comprehensive rhythm control therapy, adequate control of ventricular rate and cardiac function, and continuous therapy to prevent AF-associated complications (e.g. antithrombotic therapy). The reasons for these suggestions are detailed in this paper.

Early and comprehensive management of atrial fibrillation: Proceedings from the 2nd AFNET/EHRA consensus conference on atrial fibrillation entitled 'research perspectives in atrial fibrillation'

Atrial fibrillation (AF) is already an endemic disease, and its prevalence is soaring, due to both an increasing incidence of the arrhythmia and an age-related increase in its prevalence. Indeed, 1–2% of the population suffer from AF at present, and the number of affected individuals is expected to double or triple within the next two to three decades both in Europe and in the USA.1–4 Although epidemiological data for other parts of the world are less robust, a similar increase in AF in the community can be assumed in other countries. Atrial fibrillation causes marked morbidity and mortality on a population basis. Epidemiological observations suggest that AF is still associated with a doubling of mortality, even after adjustment for confounders.2,5 This observation from the last millennium appears to continue into current randomized trials in AF patients. Also, AF is the single most important risk factor for ischaemic stroke. Furthermore, strokes associated with AF result more often in death or permanent disability than strokes that occur as a result of other aetiologies.6–9 The presence of AF is also associated with a marked reduction in everyday functioning and quality of life.10–13 The harm associated with AF and the perceived detrimental effects of the arrhythmia on general health contrast with the outcome of six trials that compared a ‘rate control’ therapy strategy, aiming at accepting AF and controlling the ventricular rate, with an antiarrrhythmic drug-based ‘rhythm control’ therapy strategy, aiming at maintenance of the ‘natural’ sinus rhythm. Apart from a slight improvement in 6 min walk test in a small trial14 and post hoc analyses,15 the outcome of patients randomized to rhythm control therapy was not better than patients randomized to rate control therapy,14,16–20 …

Barriers to Anticoagulation in Patients With Atrial Fibrillation

See related article, pages 227–230. Atrial fibrillation (AF) is not a benign cardiac arrhythmia but instead confers a 5-fold increased risk of stroke compared with age-matched people in sinus rhythm.1 AF patients also have a worse outcome after stroke, with elevated mortality and stroke recurrence rates,2 longer hospital stays,3 and lower discharge rates to their own homes.3 Current estimates suggest that AF afflicts ≈2.2 million Americans,4 whereas in the United Kingdom ≈740 000 individuals are thought to have AF,5 with >46 000 new cases being diagnosed each year.6 Given the increasing prevalence of AF and the associated thromboembolic complications, there are significant numbers of patients who require chronic oral anticoagulation (OAC). Current guidelines7,8 recommend that AF patients at moderate to high risk of stroke should be commenced on chronic anticoagulation with a vitamin K antagonist (VKA). These recommendations are based on data from meta-analyses of 13 randomized controlled trials which have demonstrated significant reductions in stroke9,10 and mortality10 with the use of warfarin. Despite the overwhelming evidence of the benefit of warfarin thromboprophylaxis in patients with AF, such therapy remains significantly underused. OAC care varies considerably from country to country and physicians tend to undertreat more than overtreat.11,12 Physicians’ dilemma of whether to prescribe warfarin is reflected in the recent Euro Heart Survey of AF patients, which revealed that only 67% of patients eligible for VKAs were actually prescribed it,13 although actual ‘real-life’ prescription of OAC may be significantly lower than this. So, why are eligible patients with AF not prescribed OAC? Warfarin itself is plagued by a number of inherent problems, the most important being the narrow therapeutic international normalized ratio (INR) window (target INR 2.5, range 2.0 to 3.0) which must be maintained, given that …

Cost effectiveness of therapies for atrial fibrillation. A review.

Atrial fibrillation is the most common supraventricular tachyarrhythmia encountered in clinical practice, affecting over 5% of persons over the age of 65 years. A common pathophysiological mechanism for arrhythmia development is atrial distention and fibrosis induced by hypertension, coronary artery disease or ventricular dysfunction. Less frequently, atrial fibrillation is caused by mitral stenosis or other provocative factors such as thyrotoxicosis, pericarditis or alcohol intoxication. Depending on the extent of associated cardiovascular disease, atrial fibrillation may produce haemodynamic compromise, or symptoms such as palpitations, fatigue, chest pain or dyspnoea. Arrhythmia-induced atrial stasis can precipitate clot formation and the potential for subsequent thromboembolism. Comprehensive management of atrial fibrillation requires a multifaceted approach directed at controlling symptoms, protecting the patient from ischaemic stroke or peripheral embolism and possible conversion to or maintenance of sinus rhythm. Numerous randomised trials have demonstrated the efficacy of warfarin--and less so aspirin (acetylsalicylic acid)--in reducing the risk of embolic events. Furthermore, therapeutic strategies exist that can favourably modify symptoms by restoring and maintaining sinus rhythm with cardioversion and antiarrhythmic prophylaxis. However, the risks and benefits of various treatments is highly dependent on patient-specific features, emphasising the need for an individualised approach. This article reviews the findings of cost-effectiveness studies published over the past decade that have evaluated different components of treatment strategies for atrial fibrillation. These studies demonstrate the economic attractiveness of acute management options, long term warfarin prophylaxis, telemetry-guided initiation of antiarrhythmic therapy, approaches to restore and maintain sinus rhythm, and the potential role of transoesophageal echocardiographic screening for atrial thrombus prior to pharmacological or electrical cardioversion. Further, we discuss the merits and limitations of the cost-effectiveness analyses in the context of overall treatment strategies. Finally, we identify areas that will require additional research to achieve the goal of effective and economically efficient management of atrial fibrillation.