Symptom-focused management
In our study, symptoms attributable to AF, palpitations and mean HR were independent predictors of increased use of rhythm control strategy in patients with paroxysmal AF. Management of paroxysmal AF has appeared to be more symptom directed what is similar to other European registry [36, 37]. This symptom-oriented approach follows an integrated management of AF according to ABC pathway [1, 38]. Unfortunately, a high proportion of symptomatic patients still did not receive rhythm control management. One possibility may be that some patients had history of unsuccessful rhythm control therapy. Possibly some patients have contraindications for particular antiarrhythmic agents or are reluctant to rhythm control strategy. Non-pharmacological therapies like AF catheter ablation and surgical AF ablation were also less commonly used for rhythm control strategy than ECV. This is also reflected in other registries [30, 33, 36].
Non-emergency centre, management by cardiologist, symptoms attributable to AF, palpitations, mean HR and AF as the main reason for hospitalization were independent predictors of increased use of rhythm control in patients with paroxysmal AF, whereas HF and mean CHA2DS2-VASc score were negatively associated with rhythm control use in subjects with paroxysmal AF. In the Balkan region, cardiologists chose rhythm control therapy more often than other specialists. In other study, cardiologists were also more likely to choose rhythm control therapy than other specialists [17]. Those with rhythm control strategy were also more often hospitalized because of AF, than patients with rate control. A similar pattern has been found in other study [39].
In the Balkans, HF was linked with decreased use of rhythm control strategy in patients with paroxysmal AF. According to guidelines, a rhythm control strategy should be used in patients who develop HF with reduced ejection fraction, as a result of tachycardiomyopathy, to make left ventricle function better after restoration of sinus rhythm [2, 40, 41].
In our study, treatment by cardiologist, chest pain, DCM and mean CHA2DS2-VASc score were associated with increased use of amiodarone, whereas paroxysmal AF and outpatients visits were independent predictors of decreased use of amiodarone. In one study [42], greater amiodarone use was also associated with physician specialty because electrophysiologists and cardiologists chose amiodarone more frequently than other specialists. DCM was associated with increased use of amiodarone probably due to its safety in patients with HF and indication for prevention of recurrent symptomatic AF in patients with HF [2, 7]. Paroxysmal AF if accompanied by repetitive symptoms and HF should ideally be managed with amiodarone, although the CASTLE-AF trial suggested that catheter ablation was associated with lower rates of death from any cause and hospital readmissions for HF along with reducing the burden of AF and improving the left ventricular ejection fraction when compared to medical therapy in AF patients with HF [43].
Propafenone is well tolerated, safe and effective in patients with recurrent AF [44]. On the other hand, propafenone is not indicated in patients with HF [2]. Unfortunately, in the Balkans about 10% of patients with HF assigned to rhythm control received propafenone despite contraindications.