Cardiovascular Journal of Africa: Vol 31 No 3 (May/June 2020)

45 / 64

CARDIOVASCULAR JOURNAL OF AFRICA • Volume 31, No 3, May/June 2020 AFRICA 153
Treatment of atrial fibrillation: a comprehensive review
and practice guide
Jianhua Li, Mei Gao, Minwei Zhang, Donglu Liu, Zhan Li, Juanjuan Du, Yinglong Hou
Abstract
Atrial fibrillation (AF) is an ectopic rhythm originating in the
atrium. AF is the most common sustained cardiac arrhythmia
in clinical practice and it is an enormous burden worldwide
because of the high rates of morbidity, disability and mortal-
ity. Treatment of AF has become a hot spot in the field of
cardiovascular medicine. Recently, increasing evidence and
advancements in medical technology have helped us gain a
better understanding of AF. As a result, management of AF
has evolved in the past few years, so that we can better prevent
and control AF. Current therapy for AF mainly includes drug
therapy, catheter ablation, cryoballoon ablation, left atrial
appendage closure and the maze procedure. The goal of this
article is to update current treatment options for AF. We hope
that this article will help deliver good care to AF patients
based on the current state-of-the-art evidence.
Keywords: atrial fibrillation, drug therapy, catheter ablation, cryob-
alloon ablation, left atrial appendage closure, maze procedure
Submitted 19/8/18, accepted 23/10/19
Published online 18/3/20
Cardiovasc J Afr 2020; 31: 153–158
DOI: 10.5830/CVJA-2019-064
Atrial fibrillation (AF) is an ectopic rhythm originating in the
atrium. An electrocardiogram (ECG) of AF shows the normal
sinus P waves are replaced by f waves (350 to 600 beats per min)
and the ventricular rate is often irregular, which is characterised
by an uneven R-R interval.1,2 The prevalence of AF is higher
in men than in women and it has increased rapidly due to the
ageing population.3,4 AF is associated with an increased risk of
stroke,5 heart failure,6 myocardial infarction7 and chronic kidney
disease,8 which increases the burden on healthcare systems
around the world. Treatment of AF has become a huge challenge
in the field of cardiovascular diseases.
Risk factors and upstream treatment of AF
Previous studies have confirmed that initiation and maintenance
of AF result from atrial remodelling, including electrical and
structural remodelling, atrial energy metabolic remodelling and
autonomic neural remodelling,9-11 which are associated with a
variety of risk factors,2,12 such as valvular diseases, hypertension,
ischaemic heart diseases, heart failure, hyperthyroidism, lung
diseases, diabetes, obstructive sleep apnoea syndrome and
atrial fibrosis. In addition, obesity, smoking, alcohol abuse and
negative emotions (anger, stress, impatience and anxiety) are also
risk factors for AF. Potential reversible causes of AF should be
identified and treated where possible. Identification, prevention
and proper management of these risk factors could effectively
reduce the incidence of AF.
Upstream therapy refers to the use of non-anti-arrhythmic
drugs that target the mechanisms of AF to prevent or reduce
the occurrence of AF.13 Recent research has highlighted the
beneficial effects of lifestyle and risk-factor management for
AF as upstream therapy. Treatment with angiotensin converting
enzyme inhibitors (ACEIs) or angiotensin receptor blockers
(ARBs) will delay or even reverse atrial remodelling of individuals
with hypertension or left ventricular dysfunction, resulting in a
reduction in new-onset AF.14 Patients with cardiac surgery
will achieve clinical benefits from preventing the occurrence
of AF by using statins.15 Long-chain 3-polyunsaturated fatty
acids (n-3 PUFA) are considered to be able to prevent AF
because of their multiple effects on cardiac electrophysiology,
such as membrane stabilisation in the myocardial cell, and
antifibrotic, anti-inflammatory and antioxidant characteristics,
which may influence the mechanisms involved in the initiation
and maintenance of AF.16
Prevention or treatment of AF-related risk factors and
upstream treatment can effectively reduce the prevalence of AF
and hospital admissions of AF patients.
Drug therapy for AF
The three major drug treatment strategies for AF are rhythm
control, rate control and prevention of stroke. A guiding
principle of therapy is to eliminate reversible conditions, such
as hyperthyroidism or alcohol consumption, before treatment.
Department of Critical Care Medicine, The First Affiliated
Hospital of Xiamen University, Xiamen 361003, PR China
Jianhua Li, MD
Minwei Zhang, PhD
Department of Cardiology, Shandong Provincial
Qianfoshan Hospital, Shandong University, Jinan 250014,
PR China
Mei Gao, PhD
Donglu Liu, MD
Zhan Li, PhD
Juanjuan Du, PhD
Yinglong Hou, PhD,
Review Article