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.