Northside Hospital Gwinnett Family Medicine Residency Program, Strickland Family Medicine Center, Lawrenceville, GA (Dr. Osayande); Northside Hospital Cardiovascular Institute, Atlanta, GA (Dr. Sharma) amimi.osayande@northside.com
Dr. Osayande reported no potential conflict of interest relevant to this article. Dr. Sharma received a grant from Biotronic in 2019 to support an educational conference; was provided with honoraria in 2019 for serving on the speakers’ bureaus of Pfizer and Bristol Myers Squibb; and received financial support for education and training from Medtronic (2018) and from Abbott, manufacturer of the EnSite Precision Cardiac Mapping System described in this article (2018 and 2019).
Ablation sits far along on the spectrum of atrial fibrillation therapy, where its indications and potential efficacy call for careful consideration.
› Refer patients with atrial fibrillation (AF) to Cardiology for consideration of catheter ablation, a recommended treatment in select cases of (1) symptomatic paroxysmal AF in the setting of intolerance of antiarrhythmic drug therapy and (2) persistence of symptoms despite antiarrhythmic drug therapy. A
› Continue long-term oral anticoagulation therapy post ablation in patients with paroxysmal AF who have undergone catheter ablation if their CHA2DS2–VASc score is ≥ 2 (men) or ≥ 3 (women). C
› Regard catheter ablation as a reasonable alternative to antiarrhythmic drug therapy in select older patients with AF, and refer to a cardiologist as appropriate. B
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence B Inconsistent or limited-quality patient-oriented evidence C Consensus, usual practice, opinion, disease-oriented evidence, case series
References
CASE
Jack Z, a 75-year-old man with well-controlled hypertension, diabetes controlled by diet, and atrial fibrillation (AF) presents to the family medicine clinic to establish care with you after moving to the community from out of town.
The patient describes a 1-year history of AF. He provides you with an echocardiography report from 6 months ago that shows no evidence of structural heart disease. He takes lisinopril, to control blood pressure; an anticoagulant; a beta-blocker; and amiodarone for rhythm control. Initially, he took flecainide, which was ineffective for rhythm control, before being switched to amiodarone. He had 2 cardioversion procedures, each time after episodes of symptoms. He does not smoke or drink alcohol.
Mr. Z describes worsening palpitations and shortness of breath over the past 9 months. Symptoms now include episodes of exertional fatigue, even when he is not having palpitations. Prior to the episodes of worsening symptoms, he tells you that he lived a “fairly active” life, golfing twice a week.
The patient’s previous primary care physician had encouraged him to talk to his cardiologist about “other options” for managing AF, because levels of his liver enzymes had started to rise (a known adverse effect of amiodarone1) when measured 3 months ago. He did not undertake that conversation, but asks you now about other treatments for AF.
Atrial fibrillation is the most common sustained cardiac arrhythmia, characterized by discordant electrical activation of the atria due to structural or electrophysiological abnormalities, or both. The disorder is associated with an increased rate of stroke and heart failure and is independently associated with a 1.5- to 2-fold risk of all-cause mortality.2
In this article, we review the pathophysiology of AF; management, including the role of, and indications for, catheter ablation; and patient- and disease-related factors associated with ablation (including odds of success, complications, risk of recurrence, and continuing need for thromboprophylaxis) that family physicians should consider when contemplating referral to a cardiologist or electrophysiologist for catheter ablation for AF.
What provokes AF?
AF is thought to occur as a result of an interaction among 3 phenomena:
enhanced automaticity of abnormal atrial tissue
triggered activity of ectopic foci within 1 or more pulmonary veins, lying within the left atrium
re-entry, in which there is propagation of electrical impulses from an ectopic beat through another pathway.
