java barcode reader example B Paroxysmal and Refractory Atrial Fibrillation in Objective-C

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B Paroxysmal and Refractory Atrial Fibrillation
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1 Recurrent paroxysmal atrial fibrillation It is now well established that patients with recurrent paroxysmal atrial fibrillation are at similar stroke risk as those who are in atrial fibrillation chronically Although these episodes may be apparent to the patient, many are not recognized and may be totally asymptomatic Thus, ambulatory ECG monitoring or event recorders are indicated in those in whom paroxysmal atrial fibrillation is suspected Antiarrhythmic agents are usually not successful in preventing all paroxysmal atrial fibrillation episodes However, dofetilide has been shown to be as effective as amiodarone in maintaining sinus rhythm in certain patients and does not have as many untoward effects Long-term anticoagulation is indicated except in those who are under 60 65 years of age and have no additional stroke risk factors (see above) 2 Refractory atrial fibrillation Because of trial results indicating that important adverse clinical outcomes (death, stroke, hemorrhage, heart failure) are no more common with rate control than rhythm control, atrial fibrillation should generally be considered refractory if it causes persistent symptoms or limits activity This is much more likely in younger individuals and those who are very active or engage in strenuous exercise Even in such individuals, two-drug or three-drug combinations of a blocker, rate-slowing calcium blocker, and digoxin usually can prevent excessive ventricular rates, though in some cases they are associated with excessive bradycardia during sedentary periods If no drug works, radiofrequency AV node ablation and permanent pacing ensure rate control and may facilitate a more physiologic rate response to activity, but this is used only as a last resort There is growing experience with
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ablation of foci in and around the pulmonary veins that initiate atrial fibrillation, following which sinus rhythm may be restored or maintained This therapy has become more widely accepted and is a reasonable second-line therapy for individuals with symptomatic atrial fibrillation that is refractory to pharmacologic therapy This procedure is routinely performed in the electrophysiology laboratory using a catheter-based approach and can also be performed thorascopically in the operating room by experienced surgeons
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Fang MC et al Anticoagulation for atrial fibrillation Cardiol Clin 2004 Feb;22(1):47 62 [PMID: 14994847] Gage BF et al Selecting patients with atrial fibrillation for anticoagulation: stroke risk stratification in patients taking aspirin Circulation 2004 Oct 19;110(16):2287 92 [PMID: 15477396] Gillinov AM et al Advances in the surgical treatment of atrial fibrillation Cardiol Clin 2004 Feb;22(1):147 57 [PMID: 14994854] Joglar JA et al Electrical cardioversion of atrial fibrillation Cardiol Clin 2004 Feb;22(1):101 11 [PMID: 14994851] McKeown PP et al; American College of Chest Physicians Executive summary: American College of Chest Physicians guidelines for the prevention and management of postoperative atrial fibrillation after cardiac surgery Chest 2005 Aug; 128(2 Suppl):1S 5S [PMID: 16167657] McNamara RL et al Management of atrial fibrillation: review of the evidence for the role of pharmacologic therapy, electrical cardioversion, and echocardiography Ann Intern Med 2003 Dec 16;139(12):1018 33 [PMID: 14678922] Rockson SG et al Comparing the guidelines: anticoagulation therapy to optimize stroke prevention in patients with atrial fibrillation J Am Coll Cardiol 2004 Mar 17;43(6): 929 35 [PMID: 15028346] Tamariz LJ et al Pharmacological rate control of atrial fibrillation Cardiol Clin 2004 Feb;22(1):35 45 [PMID: 14994846] Wazni OM et al Radiofrequency ablation vs antiarrhythmic drugs as first-line treatment of symptomatic atrial fibrillation: a randomized trial JAMA 2005 Jun 1;293(21):2634 40 [PMID: 15928285]
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nous class III antiarrhythmic agent ibutilide has been significantly more successful in converting atrial flutter About 50 70% of patients return to sinus rhythm within 60 90 minutes following the infusion of 1 2 mg of this agent Electrical cardioversion is also very effective for atrial flutter, with approximately 90% of patients converting following shocks of as little as 25 50 J The persistence of atrial contractile function in this arrhythmia provides some protection against thrombus formation, though the risk of systemic embolization remains increased Precardioversion anticoagulation is not necessary for atrial flutter of less than 48 hours duration except in the setting of mitral valve disease However, anticoagulation is prudent in chronic atrial flutter, particularly since transient periods of atrial fibrillation are common in these patients Chronic atrial flutter is often a difficult management problem, as rate control is difficult If pharmacologic therapy is chosen, amiodarone and dofetilide are the antiarrhythmics of choice Dofetilide is often given in conjunction with an AV nodal blocker Atrial flutter can follow a typical or atypical reentry circuit around the atrium The anatomy of the typical circuit has been well defined and allows for catheter ablation within the atrium to interrupt the circuit and eliminate atrial flutter Catheter ablation has become the preferred treatment for recurrent typical atrial flutter
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Ghali WA et al Atrial flutter and the risk of thromboembolism: a systematic review and meta-analysis Am J Med 2005 Feb; 118(2):101 7 [PMID: 15694889] Knight BP et al Role of permanent pacing to prevent atrial fibrillation: science advisory from the American Heart Association Council on Clinical Cardiology (Subcommittee on Electrocardiography and Arrhythmias) and the Quality of Care and Outcomes Research Interdisciplinary Working Group, in collaboration with the Heart Rhythm Society Circulation 2005 Jan 18;111(2):240 3 [PMID: 15657388] Lee KW et al Atrial flutter: a review of its history, mechanisms, clinical features, and current therapy Curr Probl Cardiol 2005 Mar;30(3):121 67 [PMID: 15711509] Sun JL et al Clinical comparison of ibutilide and propafenone for converting atrial flutter Cardiovasc Drugs Ther 2005 Jan;19(1):57 64 [PMID: 15883757] Wu RC et al Catheter ablation of atrial flutter and macroreentrant atrial tachycardia Curr Opin Cardiol 2002 Jan;17(1): 58 64 [PMID: 11790935]
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