• reduce symptoms
• reduce risk of cardiomyopathy
• reduce risk of thromboembolism, thus reducing the risk of stroke

• overall rate vs rhythm has not shown to be differentiated in outcomes (AFFIRM)
• ACP states rate should be considered in all patietns with af even if rhythm control is eventually incorporated
• rate control is recommended strategy for mos tolder patients with asymptomatic or minimally symptomatic af
• in contrast rhythm control may be more reasonable in younger patients < 65 years
• type of af influences choices
• because paroxysmal af ends spontaneously, symptoms during episode determine strategy
• in persistent af, choices are between rate alone or rate and aad with or w/out cardioversion
• permanent af focus is rate

• Na channel blockade
• procainamide, quinidine
• rhythm

• Class IB

• Na channel 
• lidocaine
• rhythm

• Class II

• beta blockade
• metroprolol, atenolol, carvedilol
• rate control

• K channel blockade
• Rhythm control
• amiodarone, ibutilide

• Ca2 channel blockade
• nondihydropyridine (non dhp) agents
• diltiazem
• verapamil
• rate control

• Multaq - moa has characteristics of all 4 categories and is not known which of these is key in producing its clinical effects
• rate and rhythm

• non cardiac
• hearing loss, visual disturbances, dizziness, taste disturbance delirium, confusion, seizures and
• psychosis
• cardiac effects
• heart failure
• proarrhythmia; class I and class III aads can increase the frequency of an existing arrhythmia or cause the development of a new type of arrhythmia

direct electrical current

pharmacologic

• dc 90% success rate but must undergo sedation or anesthesia
• aad less effective and toxicities can also be a factor

• acute management in hemodynamically unstable patient with af < 48 hours duration af can be main factor in worsening acute hf, hypotension or worsening angina in CAD patient Cardioversion is needed immediately here.
• or hemodynamically stable patient with debilitating symptoms. usu cardioversion is tried at least once in patients ≤65 and in patients ≥ 65 who are symptomatic despite rate control

• what is rate of normal sinus rhythm at 12 months after cardioversion

What is ablation?

What are two types of ablation?

• ablation is the destruction or removal of tissue. In af, ablation can be used in select patients for either rate or rhythm control.
• radiofrequency waves which destroy tissue by heating is one method.
• cryotherapy, which destroys the tissue by freezing it and rewarming is another.
• both cases require cardiac catheterization to guide the ablation instruments to the site.

• patients with rapid ventricular rate that produces cardiomyopathy or symptoms and in whom pharmacological therapy is inadequate
• more often in persistent compared to paroxysmal.

• persistent need for anti coagulation
• loss of av synchrony
• lifelong need for pacemaker and its associated risk with insertion and cath procedures

• if AAD's are inadequate ablation of ectopic stimuli can be performed
• most common targets are pulmonary veins.
• Most common uses:
• mostly symptomatic af that's affecting quality of life 
• patients ≤ 35 with symptomatic AF
• with sinus node dysfunction in whom aad use may create the need for pacemaker
• patients who are strongly against drug therapy

• when ablation procedures are not effective for rhythm control.
• called cox maze performed while patient on bypass
• designed to interrupt the reentrant circuits thought to be responsible for AF by creating multiple incisions in the right and left atria. these incisions cause scar tissue that essentially guides the impulses and prevents reentrant circuits from forming.
• most commonly performed as a concomitant precedure in patients who are undergoing open heart surgery for another reason.

• insertion of a WATCHMAN devise