Real-life observations of clinical outcomes with rhythm- and rate-control therapies for atrial fibrillation RECORDAF (Registry on Cardiac Rhythm Disorders Assessing the Control of Atrial Fibrillation). Progression of atrial fibrillation in the REgistry on Cardiac rhythm disORDers assessing the control of Atrial Fibrillation cohort: clinical correlates and the effect of rhythm-control therapy. Atrial fibrillation: the rate versus rhythm management controversy. Atrial fibrillation in patients with heart failure: Role of catheter ablation therapies. Performance of an expedited rhythm control method for recent onset atrial fibrillation in a community hospital. Symptomatic and asymptomatic atrial fibrillation after pulmonary vein ablation and the impact on quality of life. Randomized trial of rate-control versus rhythm-control in persistent atrial fibrillation: the Strategies of Treatment of Atrial Fibrillation (STAF) study. An evaluation of the strategy of maintenance of sinus rhythm by antiarrhythmic drug therapy after ablation and pacing therapy in patients with paroxysmal atrial fibrillation. Rate control vs rhythm control in patients with nonvalvular persistent atrial fibrillation: the results of the Polish How to Treat Chronic Atrial Fibrillation (HOT CAFE) Study. Rhythm Control Versus Rate Control and Clinical Outcomes in Patients With Atrial Fibrillation: Results From the ORBIT-AF Registry. A randomized clinical trial of early invasive intervention for atrial fibrillation (EARLY-AF) - methods and rationale. Cardiac rate normalization in chronic atrial fibrillation: comparison of long-term efficacy of treatment with amiodarone versus AV node ablation and permanent His-bundle pacing. Radiofrequency ablation vs antiarrhythmic drugs as first-line treatment of paroxysmal atrial fibrillation (RAAFT-2): a randomized trial. Long-term efficacy and safety of two different rhythm control strategies in elderly patients with symptomatic persistent atrial fibrillation. Randomized Study Comparing Combined Pulmonary Vein–Left Atrial Junction Disconnection and Cavotricuspid Isthmus Ablation Versus Pulmonary Vein–Left Atrial Junction Disconnection Alone in Patients Presenting With Typical Atrial Flutter and Atrial Fibrillation A randomized assessment of the incremental role of ablation of complex fractionated atrial electrograms after antral pulmonary vein isolation for long-lasting persistent atrial fibrillation. Assessment of clinical factors associated with a successful catheter ablation outcome in younger patients with atrial fibrillation.
OBJECTIVES RECORDAF is the first worldwide , prospect i ve , observational survey of management of atrial fibrillation ( AF ) in unselected , community-based patients . BACKGROUND Primary outcomes were therapeutic success and clinical outcomes associated with rhythm-control and rate-control strategies . METHODS Patients with recent-onset AF were included ( n = 5,604 ) . Treatment strategy ( rhythm control or rate control ) was noted at baseline . Follow-up was 12 months . Therapeutic success required that strategy was unchanged without clinical events . Further maintenance of sinus rhythm was required in the rhythm-control group , and heart rate ≤80 beats/min in the rate-control group . RESULTS Data from 5,171 patients were assessable . Therapeutic success was 54 % overall ( rhythm control 60 % vs. rate control 47 % ) , a result driven by control of AF : rhythm control , 81 % vs. rate control , 74 % . After adjustment for propensity score quintiles , the rhythm-control strategy was significantly related to superior therapeutic success ( odds ratio : 1.34 , 95 % confidence interval : 1.15 to 1.55 ; p = 0.0002 ) . Clinical events occurred in 18 % of patients . The arrhythmia management strategy was not predictive of clinical events . The type ( persistent ) , presence at baseline visit , and duration ( > 3 months ) of AF , together with age older than 75 years and the presence of heart failure , predicted progression to permanent AF . The choice of rhythm control reduced the likelihood of AF progression ( odds ratio : 0.20 , 95 % confidence interval : 0.17 to 0.25 ; p < 0.0001 ) . CONCLUSIONS Clinical outcomes in AF patients were driven mainly by hospitalizations for arrhythmia/proarrhythmia and other cardiovascular causes , but not by the choice of rate or rhythm strategy . Rhythm-control patients progressed less rapidly to permanent AF INTRODUCTION Paroxysmal atrial fibrillation ( AF ) may progress to persistent AF . We studied the clinical correlates and the effect of rhythm-control strategy on AF progression . METHODS RecordAF was a worldwide prospect i ve survey of AF management . Consecutive eligible patients with recent-onset AF were included and allocated to rate or rhythm control according to patient/physician choice . A total of 2,137 patients were followed up for 12 months . Atrial fibrillation progression was defined as a change from paroxysmal to persistent/permanent AF . RESULTS Progression of AF occurred in 318 patients ( 15 % ) after 1 year . Patients with AF progression  were older ; had a higher diastolic blood pressure ; and more often had a history of coronary artery disease , stroke or transient ischemic attack , hypertension , or heart failure . Patients treated with rhythm control were less likely to show progression than those treated only with rate control ( 164/1542 [ 11 % ] vs 154/595 [ 26 % ] , P < .001 ) . Multivariable analysis showed that history of heart failure ( odds ratio [ OR ] 2.2 , 95 % CI 1.7 - 2.9 , P < .0001 ) , history of hypertension ( OR 1.5 , 95 % CI 1.1 - 2.0 , P = .01 ) , and rate control rather than rhythm control ( OR 3.2 , 95 % CI 2.5 - 4.1 , P < .0001 ) were independent predictors of AF progression . The propensity score-adjusted OR of AF progression in patients with rate rather than rhythm control was 3.3 ( 95 % CI 2.4 - 4.6 , P < .0001 ) . CONCLUSIONS Although heart failure and hypertension are associated with AF progression , rhythm control is associated with lower risk of AF progression The fundamental management strategy for atrial fibrillation ( AF ) is still debated . There is no doubt that those patients at risk of thromboembolic events should be offered anticoagulant therapy . However , it is uncertain whether rhythm control ( restoration and maintenance of sinus rhythm ) or rate control ( adjustment to a physiological ventricular rate while allowing AF to continue ) is the preferred primary treatment option for the reduction of symptoms and major cardiovascular ( CV ) outcomes associated with AF . Several well conducted trials comparing the two strategies led to the conclusion that there was little to choose between them . However , guidelines leaned towards recommending rate control as the initial strategy , and reserved rhythm control for those who remained symptomatic . Recently this status quo is being increasingly challenged by the clear demonstration that left atrial catheter ablation is effective at suppressing AF resistant to traditional antiarrhythmic drugs , such as those that failed to demonstrate any superiority when compared with rate control . Also , recently introduced antiarrhythmic therapy may have superior efficacy with regard to reducing unexpected CV hospitalization , CV mortality and stroke . In addition , there is a growing perception that atrial remodelling should be best prevented by early rhythm control rather than delaying until rate control has proven unsatisfactory . For these reasons the results of large r and omised clinical trials , which recruit patients soon after the presentation of AF and compare ' aggressive ' modern rhythm control against the guideline approach of primary rate control , are eagerly awaited . In the meantime the pendulum of clinical opinion has begun to swing towards a rhythm control strategy Atrial fibrillation ( AF ) represents the most common sustained cardiac arrhythmia in patients with heart failure ( HF ) . AF in HF patients is associated with worsening of symptoms and also results in a substantial increase in mortality . Although HF patients in sinus rhythm have a better outcome than patients with AF , several r and omized studies investigating pharmacological rhythm control versus rate control have shown no advantage of one strategy over the other in terms of patient outcomes . Catheter-based ablation therapy is a newer therapeutic option with a rapidly evolving and changing role in the management of this arrhythmia . In the present review , the authors discuss the epidemiology , pathophysiology and prognostic significance of AF in patients with HF . Exclusively addressed are studies investigating catheter-based ablation for rhythm-control and rate-control therapies in the management of AF in HF patients BACKGROUND A st and ard approach to recent onset atrial fibrillation ( AF ) in the emergency department ( ED ) in the United States has not been established . PURPOSE The purpose of this prospect i ve clinical trial was to determine how an ED protocol emphasizing rhythm control for recent onset AF compared similar patients receiving  st and ard therapy  in the same facility . METHODS We enrolled consecutive patients presenting to our community hospital with recent onset AF into a protocol , which called for rhythm control with procainamide and if unsuccessful electrical cardioversion and discharge home . We compared this prospect i ve cohort with matched historical controls . Primary outcome was admission rate . We also compared ED conversion rates and lengths of stay ( LOS ) . We reported 30-day data on the study group including ED recidivism , recurrent AF , outpatient follow-up , and any important adverse events . RESULTS Fifty-four patients were enrolled in the study group with 4 being admitted compared with 30 of 50 in the historical control group . Ninety-four percent of the study group converted compared with 28 % in the historical control . Both hospital and ED LOS were significantly shorter for the study group . Six patients had recurrent AF , and 4 of those returned to the ED . CONCLUSION An ED protocol that uses rhythm control decreased hospital admission and LOS , and there were no adverse events at 30 days BACKGROUND The aim of this prospect i ve study was to evaluate the recurrences of atrial fibrillation ( AF ) and flutter ( AFL ) after circumferential pulmonary vein ablation ( CPVA )  using repetitive long-term Holter recordings , and to evaluate the change in quality of life ( QoL ) , especially in patients with asymptomatic AF recurrences . METHODS A total of 149 patients with AF were followed up with 7-day Holter monitoring at 3 , 6 , and 12 months after CPVA .  We calculated the burden of AF/AFL defined as the percentage of time in AF/AFL , and patients with documented arrhythmia were divided into isolated symptomatic episodes of arrhythmia , mixed symptomatic/asymptomatic arrhythmia , or isolated asymptomatic arrhythmia . The QoL was analyzed with SF-36 question naires in patients with sinus rhythm after CPVA , and in patients with recurrence of symptomatic and asymptomatic arrhythmia , respectively . RESULTS Asymptomatic arrhythmia was observed in 44 % of the patients with documented arrhythmia at 12 months of follow-up . In patients with persistent AF , 63 % of the documented arrhythmia at 12 months of follow-up was asymptomatic and often persistent . In the subgroup of patients with asymptomatic arrhythmia , the QoL improved significantly in the physical scores , in contrast to patients with symptomatic arrhythmia who had unchanged or worsened QoL scores . CONCLUSIONS Asymptomatic arrhythmia is very common after AF ablation . Our data indicate that these patients improve their physical component of the QoL significantly , which may be considered a palliative success of treatment . We suggest that patients with asymptomatic AF recurrences are carefully evaluated before considering reablation . Repetitive rhythm monitoring after AF ablation is very important considering the postablation management of anticoagulant therapy OBJECTIVES This study was design ed to compare two treatment strategies in patients with atrial fibrillation(AF ) :  rhythm-control ( restoration and maintenance of sinus rhythm ) and rate-control ( pharmacologic or invasive rate-control and anticoagulation ) . BACKGROUND Atrial fibrillation is the most common arrhythmia . It is unclear whether a strategy of rhythm- or rate-control is better in terms of mortality , morbidity , and quality of life . METHODS The Strategies of Treatment of Atrial Fibrillation ( STAF ) multicenter pilot trial r and omized 200 patients ( 100 per group ) with persistent AF to rhythm- or rate-control .  The combined primary end point was a combination of death , cardiopulmonary resuscitation , cerebrovascular event , and systemic embolism . RESULTS After 19.6 + /- 8.9 months ( range 0 to 36 months ) there was no difference in the primary end point between rhythm-control ( 9/100 ; 5.54%/year ) and rate-control ( 10/100 ; 6.09%/year ; p = 0.99 ) . The percentage of patients in sinus rhythm in the rhythm-control group after up to four cardioversions during the follow-up period ( rate-control group ) was 23 % ( 0 % ) at 36 months . Eighteen primary end points occurred in atrial fibrillation ; only one occurred in sinus rhythm ( p = 0.049 ) . CONCLUSIONS The STAF pilot study showed no differences between the two treatment strategies in all end points except hospitalizations . These data suggest that there was no benefit in attempting rhythm-control in these patients with a high risk of arrhythmia recurrence . It remains unclear whether the results in the rhythm-control group would have been better if sinus rhythm had been maintained in a higher proportion of patients , as all but one end point occurred during AF AIMS Permanent atrial fibrillation develops in many patients after ablation and pacing therapy .  We compared a strategy that initially allowed patients to remain in atrial fibrillation with a strategy that initially attempted to restore and maintain sinus rhythm . METHODS AND RESULTS In this multicentre r and omized controlled trial , 68 patients affected by severely symptomatic paroxysmal atrial fibrillation were assigned , after successful atrioventricular junction ablation and pacing treatment  , to antiarrhythmic drug therapy with amiodarone , propafenone , flecainide or sotalol and were compared with 69 patients assigned , after successful AV junction ablation and pacing treatment , to no antiarrhythmic drug therapy . The patients were followed-up for 12 to 24 months ( mean 16+/-4 ) . The drug arm patients had a 57 % reduction in the risk of developing permanent atrial fibrillation ( 21 % vs 37 % , P=0.02 ) . Evaluation after 12 months revealed similar quality of life scores and echocardiographic parameters in the two groups , but the drug arm patients had more episodes of heart failure and hospitalizations ( P=0.05 ) . The outcome was similar between the 40 patients who developed permanent atrial fibrillation and the 97 who did not . CONCLUSION Conventional antiarrhythmic therapy reduces the risk of development of permanent atrial fibrillation after ablation and pacing therapy . The present data do not support the concept that the development of permanent atrial fibrillation is related to an adverse outcome when a perfect control of heart rate is obtained by ablation and pacing STUDY OBJECTIVES The relative risks and benefits of strategies of rate control vs rhythm control in patients with atrial fibrillation ( AF ) remain to be fully explored . DESIGN The How to Treat Chronic Atrial Fibrillation ( HOT CAFE ) Polish trial was design ed to evaluate in a r and omized , multicenter , and prospect i ve manner the feasibility and long-term outcomes of rate control vs rhythm control strategies in patients with persistent AF . PATIENTS Our study population comprised 205 patients ( 134 men and 71 women ; mean [ + /- SD ] age , 60.8 + /- 11.2 years ) with a mean AF duration of 273.7 + /- 112.4 days . The mean observation period was 1.7 + /- 0.4 years . One hundred one patients were r and omly assigned to the rate control group and received rate-slowing therapy guided by repeated 24-h Holter monitoring . Direct current cardioversion and atrioventricular junctional ablation with pacemaker placement were alternative nonpharmacologic strategies for patients with tachycardia that was resistant to medical therapy . One hundred four patients were r and omized to sinus rhythm restoration and maintenance using serial cardioversion supported by a predefined stepwise antiarrhythmic drug regimen ( ie , disopyramide , propafenone , sotalol , and amiodarone ) . In both groups , thromboembolic prophylaxis followed current guidelines . MEASUREMENTS AND RESULTS At the end of follow-up , 63.5 % of patients in the rhythm control arm remained in sinus rhythm . No significant differences in the composite end point ( ie , all-cause mortality , number of thromboembolic events , or major bleeding ) were found between the rate control group and the rhythm control group ( odds ratio , 1.98 ; 95 % confidence interval , 0.28 to 22.3 ; p > 0.71 ) . The incidence of hospital admissions was much lower in the rate control arm ( 12 % vs 74 % , respectively ; p < 0.001 ) . New York Heart Association functional class improved in both study groups , while mean exercise tolerance , as measured by the maximal treadmill workload , improved only in the rhythm control group ( 5.2 + /- 5.1 vs 7.6 + /- 3.3 metabolic equivalents , respectively ; p < 0.001 ) . The rhythm control strategy led to an increased mean left ventricular fractional shortening ( 29 + /- 7 % vs 31 + /- 7 % , respectively ; p < 0.01 ) . One episode of pulmonary embolism occurred in the rate control group despite oral anticoagulation therapy , while three patients in the rhythm control arm of the study experienced ischemic strokes ( not significant ) . CONCLUSIONS The Polish HOT CAFE study revealed no significant differences in major end points between the rate control group and the rhythm control group OBJECTIVES The study sought to evaluate clinical outcomes in clinical practice with rhythm control versus rate control strategy for management of atrial fibrillation ( AF ) . BACKGROUND R and omized trials have not demonstrated significant differences in stroke , heart failure , or mortality between rhythm and rate control strategies . The comparative outcomes in contemporary clinical practice are not well described . METHODS Patients managed with a rhythm control strategy targeting maintenance of sinus rhythm were retrospectively  compared with a strategy of rate control alone in a AF registry across various U.S. practice setting s. Unadjusted and adjusted ( inverse-propensity weighted ) outcomes were estimated . RESULTS The overall study population ( N = 6,988 ) had a median of 74 ( 65 to 81 ) years of age , 56 % were males , 77 % had first detected or paroxysmal AF , and 68 % had CHADS2 score ≥2 . In unadjusted analyses , rhythm control was associated with lower all-cause death , cardiovascular death , first stroke/non- central nervous system systemic embolization/transient ischemic attack , or first major bleeding event ( all p < 0.05 ) ; no difference in new onset heart failure ( p = 0.28 ) ; and more frequent cardiovascular hospitalizations ( p = 0.0006 ) . There was no difference in the incidence of pacemaker , defibrillator , or cardiac resynchronization device implantations ( p = 0.99 ) . In adjusted analyses , there were no statistical differences in clinical outcomes between rhythm control and rate control treated patients ( all p > 0.05 ) ; however , rhythm control was associated with more cardiovascular hospitalizations ( hazard ratio : 1.24 ; 95 % confidence interval : 1.10 to 1.39 ; p = 0.0003 ) . CONCLUSIONS Among patients with AF , rhythm control was not superior to rate control strategy for outcomes of stroke , heart failure , or mortality , but was associated with more cardiovascular hospitalizations BACKGROUND The ideal management of patients with newly diagnosed symptomatic atrial fibrillation ( AF ) remains unknown . Current practice guidelines recommend a trial of antiarrhythmic drugs ( AAD ) prior to considering an invasive ablation procedure . However , earlier ablation offers an opportunity to halt the progressive patho-anatomical changes associated with AF , as well as impart other important clinical benefits . OBJECTIVE The aim of this study is to determine the optimal initial management strategy for patients with newly diagnosed , symptomatic atrial fibrillation . METHODS / DESIGN The EARLY-AF study ( Clinical Trials.govNCT02825979 ) is a prospect i ve , open label , multicenter , r and omized trial with a blinded assessment of outcomes . A total of 298 patients will be r and omized in a 1:1 fashion to first-line AAD therapy , or first-line cryoballoon-based pulmonary vein isolation .  Patients with symptomatic treatment naïve AF will be included . Arrhythmia outcomes will be assessed by implantable cardiac monitor ( ICM ) . The primary outcome is time to first recurrence of AF , atrial flutter , or atrial tachycardia ( AF/AFL/AT ) between days 91 and 365 following AAD initiation or AF ablation . Secondary outcomes include arrhythmia burden , quality of life , and healthcare utilization . DISCUSSION The EARLY-AF study is a r and omized trial design ed to evaluate the optimal first management approach for patients with AF . We hypothesize that catheter ablation will be superior to drug therapy in prevention of AF recurrence Chronic atrial fibrillation ( AF ) is a common arrhythmia with significant morbidity and mortality . AF has been the subject of considerable attention and intensive clinical research in recent years . Current opinion on the management of AF favors the restoration and maintenance of normal ventricular rhythm . This has several potential benefits , including the alleviation of arrhythmia-associated symptoms and hemodynamic improvements . Maintenance of frequents normalization of ventricular rhythm ( NVR ) can be achieved with antiarrhythmic drug therapy or with AV node radiofrequency ablation ( RFA ) and permanent ventricular pacing . Recent interest has focused on the use of class III antiarrhythmic agents , such as amiodarone hydrochloride . This investigation compared amiodarone to AV node RFA and permanent pacing of the His-bundle area in maintaining NVR in patients with resistant chronic AF . After 12 months of treatment with amiodarone ( 200 to 400 mg/d ) 30 % of patients remained in NVR , 30 % were in transitional phase of improvement , and 40 % showed negative effect . Only a few patients in this group developed ocular or hepatic side effects . On one year follow-up was achieved in 100 % of cases without any clinical ly significant side effects being seen . In conclusion , analysis of the results of this study suggests that low-dose amiodarone is well tolerated in the management of chronic AF in a selected patient population . The more aggressive interventional radiofrequency ablation technique is significantly more effective and more reliable in the long-term clinical treatment of drug-resistant AF IMPORTANCE Atrial fibrillation ( AF ) is the most common rhythm disorder seen in clinical practice . Antiarrhythmic drugs are effective for reduction of recurrence in patients with symptomatic paroxysmal AF .  Radiofrequency ablation is an accepted therapy in patients for whom antiarrhythmic drugs have failed ; however , its role as a first-line therapy needs further investigation . OBJECTIVE To compare radiofrequency ablation with antiarrhythmic drugs ( st and ard therapy ) in treating patients with paroxysmal AF as a first-line therapy . DESIGN , SETTING , AND PATIENTS A r and omized clinical trial involving 127 treatment-naive patients with paroxysmal AF were r and omized at 16 centers in Europe and North America to received either antiarrhythmic therapy or ablation .  The first patient was enrolled July 27 , 2006 ; the last patient , January 29 , 2010 . The last follow-up was February 16 , 2012 . INTERVENTIONS Sixty-one patients in the antiarrhythmic drug group and 66 in the radiofrequency ablation group were followed up for 24 months . MAIN OUTCOMES AND MEASURES The time to the first documented atrial tachyarrhythmia of more than 30 seconds ( symptomatic or asymptomatic AF , atrial flutter , or atrial tachycardia ) , detected by either scheduled or unscheduled electrocardiogram , Holter , transtelephonic monitor , or rhythm strip , was the primary outcome . Secondary outcomes included symptomatic recurrences of atrial tachyarrhythmias and quality of life measures assessed by the EQ-5D tool . RESULTS Forty-four patients ( 72.1 % ) in the antiarrhythmic group and in 36 patients ( 54.5 % ) in the ablation group experienced the primary efficacy outcome ( hazard ratio [ HR ] , 0.56 [ 95 % CI , 0.35 - 0.90 ] ; P = .02 ) . For the secondary outcomes , 59 % in the drug group and 47 % in the ablation group experienced the first recurrence of symptomatic AF , atrial flutter , atrial tachycardia ( HR , 0.56 [ 95 % CI , 0.33 - 0.95 ] ; P = .03 ) . No deaths or strokes were reported in either group ; 4 cases of cardiac tamponade were reported in the ablation group . In the st and ard treatment group , 26 patients ( 43 % ) underwent ablation after 1-year . Quality of life was moderately impaired at baseline in both groups and improved at the 1 year follow-up . However , improvement was not significantly different among groups . CONCLUSIONS AND RELEVANCE Among patients with paroxysmal AF without previous antiarrhythmic drug treatment , radiofrequency ablation compared with antiarrhythmic drugs result ed in a lower rate of recurrent atrial tachyarrhythmias at 2 years . However , recurrence was frequent in both groups . TRIAL REGISTRATION clinical trials.gov Identifier : NCT00392054 BACKGROUND We prospect ively compared the efficacy , safety , and quality of life ( QoL ) impact of catheter ablation versus antiarrhythmic drugs ( AAD ) in elderly patients with persistent atrial fibrillation ( AF ) . METHODS AND RESULTS Four hundred and twelve consecutive patients , aged ≥ 70 years , underwent ablation ( Group A , 153 patients ) or AAD ( Group B , 259 patients ) . Study endpoints : treatment failure ( any AF/AT lasting > 30 seconds ) and treatment-related adverse events ( acute when ≤1 month of procedure and long term when > 1 month ) . At a follow-up of 60 ± 17 months , 43 % and 46 % patients in Group B versus 58 % and 76 % in Group A were in sinus rhythm ( SR ) , respectively , after one ( P = 0.003 ) and 2 procedures ( P < 0.001 ) . Fifteen acute adverse events occurred ( 6.7 % in Group A vs 1 % in Group B , P < 0.001 ) , mainly periprocedural cerebral thromboembolism ( 3.3 % in Group A vs 0.7 % in Group B , P = 0.058 ) . Previous TIA/stroke result ed the only independent predictor of periprocedural cerebrovascular accidents ( OR 1.2 , 95%IC 1.1 - 1.3 ) . At follow-up , 74 long-term adverse events occurred ( 7.7 % in Group A vs 23.9 % in Group B , P < 0.001 ) with Group B patients more often experiencing  AAD-related  adverse events ( 12.7 % vs 2.6 % , P < 0.001 ) . Group A and absence of AF/AT recurrences significantly improved QoL scores ( P < 0.001 ) . CONCLUSIONS In elderly persistent AF patients  , catheter ablation is more effective in maintaining SR and in improving QoL  than AAD but is affected by a higher risk of embolic complications , particularly in patients with previous TIA/stroke . Over time , Group A patients more likely discontinued AAD with a reduction of long-term adverse events Background —Atrial flutter ( AFL ) and atrial fibrillation ( AF ) frequently coexist in the same patient . Recently it has been demonstrated that the triggers for both AF and AFL may originate in the pulmonary veins ( PVs ) . We hypothesized that in patients with both AF and typical AFL , pulmonary vein – left atrial junction ( PV-LAJ ) disconnection may eliminate both arrhythmias . Methods and Results —Consecutive patients with documented symptomatic AF and typical AFL were r and omly assigned to have PV-LAJ disconnection combined with cavotricuspid isthmus ( CTI ) ablation ( group 1 , n=49 ) or PV-LAJ disconnection alone ( group 2 , n=59 ) . Within the first 8 weeks after ablation , 32 of the group 2 patients had typical AFL documented , whereas none was seen in group 1 . Twenty of these 32 converted to sinus rhythm after initiating antiarrhythmic drugs ( AADs ) . Twelve were cardioverted , and AADs were started . After 8 weeks , all AADS were stopped , and only 3 patients continued to have recurrent sustained typical AFL that was eliminated by CTI ablation . Beyond 8 weeks of follow-up , 7 patients in group 1 and 6 patients in group 2 ( 14 % and 11 % , respectively ) continued to have AF . Ten of these 13 patients underwent a repeat PV-LAJ disconnection procedure and were cured . The remaining 3 remained in normal sinus rhythm while taking AADs . Conclusions —In patients with both AFL and AF , PV-LAJ disconnection alone may be sufficient to control both arrhythmias . CTI block reduced early postablation recurrence of arrhythmias , which in the majority of patients reflects a short-term clinical problem OBJECTIVES This study sought to determine whether ablation of complex fractionated atrial electrograms ( CFAEs ) after antral pulmonary vein isolation ( APVI ) further improves the clinical outcome of APVI in patients with long-lasting persistent atrial fibrillation ( AF ) . BACKGROUND Ablation of CFAEs has been reported to eliminate persistent AF . However , residual pulmonary vein arrhythmogenicity is a common mechanism of recurrence . METHODS In this r and omized study , 119 consecutive patients ( mean age 60 + /- 9 years ) with long-lasting persistent AF underwent APVI with an irrigated-tip radiofrequency ablation catheter . Antral pulmonary vein isolation result ed in termination of AF in 19 of 119 patients ( Group A , 16 % ) . The remaining 100 patients who still were in AF were r and omized to no further ablation and underwent cardioversion ( Group B , n = 50 ) or to ablation of CFAEs in the left atrium or coronary sinus for up to 2 additional hours of procedure duration ( Group C , n = 50 ) . RESULTS Atrial fibrillation terminated during ablation of CFAEs in 9 of 50 patients ( 18 % ) in Group C. At 10 + /- 3 months after a single ablation procedure , 18 of 50 ( 36 % ) in Group B and 17 of 50 ( 34 % ) in Group C were in sinus rhythm without antiarrhythmic drugs ( p = 0.84 ) . In Group A , 15 of 19 patients ( 79 % ) were in sinus rhythm . A repeat ablation procedure was performed in 34 of 100 r and omized patients ( for AF in 30 and atrial flutter in 4 ) . At 9 + /- 4 months after the final procedure , 34 of 50 ( 68 % ) in Group B and 30 of 50 ( 60 % ) in Group C were in sinus rhythm without antiarrhythmic drugs ( p = 0.40 ) . CONCLUSIONS Up to 2 h of additional ablation of CFAEs after APVI does not appear to improve clinical outcomes in patients with long-lasting persistent AF BACKGROUND Catheter ablation is now an alternative approach to antiarrhythmic drug therapy for patients with symptomatic atrial fibrillation ( AF ) . We focused on younger patients in whom the prevalence of AF is low , and we sought clinical factors associated with unsuccessful ablation outcomes . METHODS AND RESULTS Among 1983 consecutive symptomatic patients who underwent AF ablation procedures , 95 patients ( 4.8 % ) , age ≤ 40 years , were prospect ively included . Of them , 64 had paroxysmal AF , and the remaining 31 had persistent AF . All patients underwent pulmonary vein isolation and cavotricuspid isthmus ablation . When AF recurred , redo ablations were performed if the patients desired . The mean number of ablation procedures was 1.3 ± 0.6 times per patient . During the follow-up of 40 [ 27.8 - 49.6 ] months , sinus rhythm was maintained in 86 patients ( 90.5 % ) without any antiarrhythmic drugs , but not in the remaining 9 patients ( 9.5 % ) . Low body mass index ( BMI ) and persistent AF were associated with unsuccessful ablation procedures . In multivariate logistic regression analysis , a low BMI had the most significant value , with an odds ratio of 7.33 ( p=0.022 ) . The receiver operating characteristic curve demonstrated a BMI cut point of 22.1 kg/m(2 ) , with an area under the curve of 0.773 . CONCLUSION In symptomatic younger AF patients , a low BMI was an independent clinical factor for unsuccessful AF ablation outcomes
This review article provides an overview on the published clinical risk scores related to outcomes of rhythm control strategy or AF progression
Patients with atrial fibrillation ( AF ) are commonly managed with rhythm control strategy , but the natural history of this common arrhythmia leads itself to progression from paroxysmal to persistent or permanent AF , and recurrences are evident despite rhythm control treatments using cardioversion or catheter ablation .
Numerous clinical factors have been associated with outcomes of rhythm control or arrhythmia progression in patients with AF .
The more common factors have been used to formulate risk stratification scores , to help predict the outcomes of rhythm control treatments  or AF progression .