Atrial Fibrillation (AF) is highly prevalent common cardiac arrhythmia that poses a substantial risk of morbidity and death, albeit available therapies. According to the Women Health Initiative, AF affects approximately 2.7 to 6.1 million individuals. AF is culpable for 75,000 to 100,000 strokes annually. Recent studies reveal that AF is associated with increased myocardial infarction (Johnsen et al., 2017). The disorder affects women than men of ages more significant than 75, and the clinical repercussions of AF for women are a specific concern as they are more likely to develop myocardial infections and have a higher general mortality risk compared to men.
Discussion
Patients with Atrial Fibrillation poses atria that quickly contracts at an estimated per minute beat rate of 400-600, resulting in a heartbeat pace that is generally considered 'irregularly.’ For that matter, the heart's capacity to pump may be damaged, resulting in the accumulation of blood in the atria. This accumulation increases the risks of developing systemic embolism and stroke (Johnsen et al., 2017). Albeit numerous root risk factors and biomarkers are attributed to developing AF, the most prevalent risk factors comprise of chronic lung disease, untreated atrial flutter, coronary artery disease, thyroid ailment, excessive alcohol consumption, and age greater than 60 years.
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A pooled study by Brandes (2018) indicates that AF has a profound morbidity risk and it is an unfettered risk factor for demise. The gravest and immobilizing complication of the condition a thromboembolic stroke; atrial fibrillation is an individualistic risk factor that increases incidences of stroke. The authors add that the financial implications of AF are substantial as its US approximated incremental cost is $26 million per year with $6 dedicated to AF while the rest is siphoned to other cardiovascular expenses (Brandes et al.,2018). This data suggests that the high costs are due to hospitalizations and readmissions. Other contributing factors of the entire cost are testing, medication, and outpatient care paradigm. Notably, AF is attributed to escalations in missed workdays and temporary disability.
Current Management and Best Practices
A Women Health Initiative study demonstrates a meta-analysis of 5 randomized trials, through which the management of AF has been condensed from a rate control /rhythm control approach. Rate control blended with anticoagulation proves to be the most effective front-line treatment synonymous with rhythm control. An AFFIRM study by Gerber (2020) reveals that savings arising from the control group were grounded in fewer days spent in hospital. This is a result of cardioversion and drug costs (Gerber et al., 2020). The resolution to either control ventricular rate or restore normal sinus rhythm is indubitably fundamental to the management of AF. The selected treatment method is based on the clinical evaluation of the patient, including a comprehensive medical history, thyroid test, physical exam, and echocardiography.
Rate Control
The primary objective of pharmacological solutions for control and management is to lower the ventricular rate during exertion and at rest while avoiding excessive bradycardia. Digoxin, non-dihydropyridine (DH) calcium channel blocker, and beta-blockers have distinct systems of actions, albeit they have a similar effect on the ventricular rate. According to the AFFIRM study, almost three quarters of patients subjected under a beta-blocker achieved the primary objective compared to a half of the subjects under non- DHP calcium channel blockers. Patients with severe chronic obstructive pulmonary diseases or preserved left ventricular systolic function prefer non-DHP calcium channel blockers like diltiazem and verapamil (Gerber et al., 2020). It is worth noting that the American Heart Association (AHA) recommends that the management of ventricular rate in subjects with AF or paroxysmal should use a non-DHP calcium channel blocker or beta-blocker.
Anticoagulation
For patients under anticoagulation therapy, AHA guidelines offer warfarin, a (Vitamin K antagonist) with an international normalized ratio of 2.0-3.0 with apixaban, dabigatran, and rivaroxaban as treatment alternatives. Conversely, non-VKA oral anticoagulants are highly preferred by various patient populations. Dabigatran is known to mitigate the danger of systemic embolism as well as stroke in subjects with non-valvular atrial fibrillation. Rivaroxaban and apixaban use a different mechanism that functions directly inhibiting factor Xa the coagulation deluge (Gerber et al., 2020). There are benefits to anticoagulating with these two including lesser drug-food and drug-drug interaction compared to warfarin, decreased rates if intracranial bleeding and the nonexistent necessity for routine blood checks as well as dose modifications
Rhythm Control
The treatment of AF with an antiarrhythmic drug has been recommended by the American College of Cardiology, American Heart Association, and Heart Rhythm Society guidelines. Depending on comorbidities and the underlying heart disease, options include flecainide, amiodarone, dronedarone, sotalol, and propafenone. Amiodarone is widely prescribed for AF and is the most reliable antiarrhythmic drug. Regardless, a universal adoption is restricted by pulmonary, thyroid, and liver toxicities. Dronedarone is used in cases with fewer noncardiovascular adverse events. It is advisable to avoid using this drug as it increases the risk of stroke or even death. For patients without structural heart impairment, flecainide and propafenone should be used but limited for patients with initial myocardial infarction. Solatol is used as an antiarrhythmic drug linked to increased risk of ventricular proarrhythmia; hence higher doses should be approached with caution.
Catheter Ablation
Today, CA is the most popular alternative to normalize sinus rhythm for candidates who do not respond to antiarrhythmic drug therapy. It is a mildly invasive procedure where a catheter is placed into the heart through large blood vessels. Due to its complexity, practice guidelines suggest that this is a useful rhythm control for patients with symptomatic paroxysmal AF refractory (Madan et al., 2019). It can be regarded as first-line therapy recurring symptomatic paroxysmal AF for rhythm control prior to pharmacologic therapy is attempted. Albeit its popularity, the procedure comes with risks, including hemorrhagic complications and thromboembolism.
Summary
Based on the differences and similarities mentioned in is paper, it is fair to deduce that there is an increased complication rate with undisrupted anticoagulation before catheter ablation. The use of uninterrupted Xa inhibitors such as rivaroxaban is safe and an effective option to narrowing the gap for catheter ablation procedures. There is a need for further investigations from practitioners to determine the best strategy that incorporates their experience in practice and current management guidelines to instigate a plan that will impact women’s health.
Works Cited
Brandes, A., Smit, M. D., Nguyen, B. O., Rienstra, M., & Van Gelder, I. C. (2018). Risk factor management in atrial fibrillation. Arrhythmia & electrophysiology review , 7 (2), 118.
Gerber, D. A., Stefanick, M., Hlatky, M., Yang, J., Hedlin, H., Haring, B., & Perez, M. (2020). Dietary protein intake and incident atrial fibrillation in postmenopausal women from the women's health initiative. Journal of the American College of Cardiology , 75 (11 Supplement 2), 5.
Johnsen, S. P., Dalby, L. W., Täckström, T., Olsen, J., & Fraschke, A. (2017). Cost of illness of atrial fibrillation: a nationwide study of societal impact. BMC health services research , 17 (1), 714.
Madan, N., Itchhaporia, D., Albert, C. M., Aggarwal, N. T., & Volgman, A. S. (2019). Atrial fibrillation and heart failure in women. Heart failure clinics , 15 (1), 55-64.
