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Chapter Summary

This chapter discusses the epidemiology, pathophysiology, and classification of atrial fibrillation (AF) and atrial flutter, as well as the clinical presentation, evaluation, and management of patients with these arrhythmias (see Fuster and Hurst’s Central Illustration). Patients may have a range of presentations from asymptomatic, with the arrhythmia detected only by electrocardiography or other monitoring, to highly symptomatic. Management approaches should be individualized to patient symptoms and comorbidities. Management of AF may require cardioversion acutely for symptomatic patients, followed by strategies to prevent recurrent AF and minimize sequelae such as stroke. An important consideration in the management of AF is lifestyle modification, because conditions such as sleep apnea, obesity, excessive alcohol intake, and lack of exercise may contribute to the development or maintenance of AF. Long-term management includes anticoagulation for the prevention of thromboembolism in patients deemed to be high risk. The other pillars of management of AF are rate control and rhythm control. Emerging data support early rhythm control by antiarrhythmic drugs or catheter ablation, especially in certain subpopulations such as those with concurrent heart failure. The management of atrial flutter is analogous in most respects to that of AF, although typical atrial flutter is curative in most cases with catheter ablation.

eFig 36-01 Chapter 36: Atrial Fibrillation and Atrial Flutter


Atrial fibrillation (AF) is the most common sustained arrhythmia in the world, affecting at least 33 million individuals.1 This is likely an underestimate because it is expected to double over the next 40 years in parallel with the aging of the population and an increasing worldwide prevalence of the contributory comorbidities of obesity and the metabolic syndrome.2 While the impact of AF was historically underestimated, AF is now clearly linked with heart failure (HF),3 stroke, potentially dementia, mortality, and loss of productive life Patients treated with catheter ablation for AF have long-term rates of death, stroke, and dementia similar to patients without AF, is now clearly linked with heart failure (HF),3 stroke, and potentially dementia. Patients treated with catheter ablation for AF have long-term rates of death, stroke, and dementia similar to patients without AF, mortality, and loss of productive life. Aside from its human costs, the economic cost of AF is vast. Annually, 454,000 patients with a primary diagnosis of AF are hospitalized in the United States at a cost of $6 to $26 billion in 2011.

The foundations of AF management are the robust identification of reversible etiologies, such as thyrotoxicosis; the institution of lifestyle choices, such as controlling obesity, hypertension, and limiting alcohol ingestion; and the timely initiation of therapy to reduce the risk for stroke, to control heart rate, or to restore sinus rhythm.4

The field of AF is moving rapidly in multiple directions. Because the noninvasive electrocardiogram ...

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