eMedicine Specialties > Cardiology > Arrhythmias

Atrial Fibrillation: Follow-up

Author: Lawrence Rosenthal, MD, PhD, Associate Professor of Medicine, Director, Section of Cardiac Electrophysiology and Pacing, Fellowship Director of Clinical Cardiac Electrophysiology, Department of Internal Medicine, Division of Cardiovascular Medicine, University of Massachusetts Memorial Medical Center
Coauthor(s): David D McManus, MD, Assistant Professor of Medicine, Cardiac Electrophysiology Section, Cardiology Division, University of Massachusetts Medical Center
Contributor Information and Disclosures

Updated: Oct 29, 2009

Follow-up

Further Inpatient Care

  • Monitor INR values of patients on warfarin (desired range 2-3). Attention to drug-drug interactions (particularly with amiodarone) is necessary.
  • Monitor patients on antiarrhythmic agents for signs of proarrhythmia. Worsening liver or renal function can alter antiarrhythmic drug clearance and may require altered antiarrhythmic drug dosing. Careful monitoring of heart rate, blood pressure, and for physical signs of congestive heart failure is necessary. The QTc interval is also an important predictor of proarrhythmic events in patients on type IA and III agents.
  • Monitor liver function, thyroid function, and lung function in patients treated with amiodarone.

Further Outpatient Care

  • Assessment and reassessment of thromboembolic risk is necessary.
  • Periodic ECG monitoring (especially when taking antiarrhythmics) and Holter monitoring are often necessary to assess for paroxysmal atrial fibrillation and/or rate control.

Deterrence/Prevention

  • Experimental and clinical data suggest that renin-angiotensin system (RAS) antagonists and HMG-CoA reductase inhibitors (statins) may decrease the incidence of atrial fibrillation and increase the likelihood of successful cardioversion.10,11,12,13
  • Fish oil preparations have been shown to reduce ventricular arrhythmias in at-risk populations (coronary artery disease) and may also protect against atrial fibrillation.
  • Treatment of underlying cardiovascular risk factors such as hypertension, coronary artery disease, valvular heart disease, obesity, sleep apnea, diabetes, and heart failure is likely to decrease the incidence of atrial fibrillation.

Prognosis

  • Epidemiologic studies have shown that individuals in sinus rhythm live longer than do individuals with atrial fibrillation. The AFFIRM trial addressed whether rate control and anticoagulation are sufficient goals for asymptomatic, elderly patients. The results showed that medical therapies aimed at rhythm control offered no survival advantage over rate control and anticoagulation.
  • Atrial fibrillation likely mediates this effect on overall prognosis through its association with thromboembolic events, particularly stroke.
  • Development of atrial fibrillation predicts heart failure and is associated with worse NYHA HF class.
  • Atrial fibrillation may cause tachycardia-mediated cardiomyopathy if adequate rate control is not established. Atrial fibrillation may also worsen heart failure in individuals who are dependent on the atrial component of the cardiac output. Those with hypertensive heart disease and those with valvular heart disease are particularly at high risk for developing heart failure when atrial fibrillation occurs.

Patient Education

For excellent patient education resources, visit eMedicine's Heart Center and Stroke Center. Also, see eMedicine's patient education articles Atrial Fibrillation, Heart Rhythm Disorders, Stroke, and Supraventricular Tachycardia.

Miscellaneous

Medicolegal Pitfalls

  • Proper anticoagulation is extremely important in both paroxysmal and persistent atrial fibrillation.
  • Anticoagulation before and after cardioversion is necessary.
  • Use of antiarrhythmic agents requires regular, drug-specific follow-up testing.

Special Concerns

  • Warfarin is contraindicated during pregnancy.
  • Give special consideration to patients who are noncompliant and patients who are at risk for falling. These patients may be better off with antiplatelet agents such as aspirin.
 


More on Atrial Fibrillation

Overview: Atrial Fibrillation
Differential Diagnoses & Workup: Atrial Fibrillation
Treatment & Medication: Atrial Fibrillation
Follow-up: Atrial Fibrillation
Multimedia: Atrial Fibrillation
References
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References

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Further Reading

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Contributor Information and Disclosures

Author

Lawrence Rosenthal, MD, PhD, Associate Professor of Medicine, Director, Section of Cardiac Electrophysiology and Pacing, Fellowship Director of Clinical Cardiac Electrophysiology, Department of Internal Medicine, Division of Cardiovascular Medicine, University of Massachusetts Memorial Medical Center
Lawrence Rosenthal, MD, PhD is a member of the following medical societies: American College of Cardiology, American Heart Association, and Massachusetts Medical Society
Disclosure: Nothing to disclose.

Coauthor(s)

David D McManus, MD, Assistant Professor of Medicine, Cardiac Electrophysiology Section, Cardiology Division, University of Massachusetts Medical Center
Disclosure: Nothing to disclose.

Medical Editor

Alan D Forker, MD, Professor of Medicine, Program Director of Cardiovascular Fellowship, University of Missouri at Kansas City School of Medicine; Director, Outpatient Lipid Diabetes Research Center, MidAmerica Heart Institute of St Luke's Hospital
Alan D Forker, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Cardiology, American College of Physicians, American Heart Association, American Medical Association, American Society of Hypertension, and Phi Beta Kappa
Disclosure: Research Grant Grant/research funds Hospital contracts to do research; I am a hospital employee with no personal profit; Speakers Bureau Honoraria Speaking and teaching

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Brian Olshansky, MD, Professor of Medicine, Department of Internal Medicine, University of Iowa College of Medicine
Brian Olshansky, MD is a member of the following medical societies: American Autonomic Society, American College of Cardiology, American College of Chest Physicians, American College of Physicians, American College of Sports Medicine, American Federation for Clinical Research, American Heart Association, Cardiac Electrophysiology Society, Heart Rhythm Society, and New York Academy of Sciences
Disclosure: Guidant/Boston Scientific Honoraria Speaking and teaching; Medtronic Honoraria Speaking and teaching; Guidant/Boston Scientific Consulting fee Consulting; Reliant Grant/research funds Other; Novartis Honoraria Speaking and teaching; Novartis Consulting fee Consulting

CME Editor

Amer Suleman, MD, Consultant in Electrophysiology and Cardiovascular Medicine, Department of Internal Medicine, Division of Cardiology, Medical City Dallas Hospital
Amer Suleman, MD is a member of the following medical societies: American College of Physicians, American Heart Association, American Institute of Stress, American Society of Hypertension, Federation of American Societies for Experimental Biology, Royal Society of Medicine, and Society of Cardiac Angiography and Interventions
Disclosure: Nothing to disclose.

Chief Editor

Jeffrey N Rottman, MD, Professor of Medicine and Pharmacology, Director, Clinical Cardiac Electrophysiology Fellowship Program, Vanderbilt University School of Medicine; Chief, Department of Cardiology, Nashville Veterans Affairs Medical Center
Jeffrey N Rottman, MD is a member of the following medical societies: American Heart Association and North American Society of Pacing and Electrophysiology (NASPE)
Disclosure: Nothing to disclose.

 
 
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