Current atrial fibrillation guidelines and therapy algorithms: are they adequate?

Management of patients with atrial fibrillation in clinical practice represents a major challenge. The 2001 ACC/AHA/ESC Atrial Fibrillation Guidelines have gained wide acceptance but recent advances have required their revision in 2006. Large strategy trials comparing rhythm control to rate control using drug therapy has shown no difference in terms of major endpoints including mortality. The reason suggested by substudy analysis was that the benefits of sinus rhythm obtained with antiarrhythmic agents were offset by their side-effects. The 2006 revised Guideline version in terms of management strategy does not differ significantly from the 2001 version as both rhythm control and rate control strategies were considered acceptable. The selection of an antiarrhythmic agent is still based on the presence and the type of underlying heart disease as the fruit of a consensus more than on evidence in a safety first approach. The only difference is that class Ia agents were deleted from the treatment algorithm. Catheter ablation techniques represent one of the major developments in recent years in the management of AF patients. The Guidelines recommend catheter ablation as a second line therapy in every branch of the therapeutic flow chart. In this respect, the 2006 version of the Guidelines although consistent with current practice is not evidence-based as randomized trials comparing ablative techniques to conventional management in AF are still lacking. Furthermore, the paroxysmal form and the persistent or chronic forms are not differentiated as for the persistent and long-standing AF the results of catheter ablation are less convincing. Catheter ablation techniques are complex and carry the risk of recurrences requiring a repeat operation in 20-40% of cases and the risk of serious complications that may be life-threatening if not appropriately detected and managed. Atrial fibrillation identifies a subset of patients at high risk of stroke. The 2006 Guidelines have stratified the stroke risk into three group levels in order to better define the group for whom oral anticoagulation with warfarin is mandatory in the absence of contra-indication. In this regard, the 2006 Guideline version represents a helpful improvement.