Page 20 - ADD-ON ABLATION SURGERY IN PATIENTS WITH ATRIAL FIBRILLATION

Chapter 1
rate control < 80 bpm104. As lenient-rate control is generally more convenient, requiring fewer outpatient visits and examinations, it may be adopted as a reasonable strategy in patients with permanent AF.
Drugs commonly used for rate control are ß-blockers, nondihydropyridine calcium channel antagonists, and digitalis. Amiodarone may be suitable for some patients with otherwise refractory rate control86. Dronedarone is similar to amiodarone but lacks an iodine moiety. Possessing both rate- and rhythm-control properties, Dronedarone has proved safe and effective in preventing recurrence of AF in patients with persistent AF in the DAFNE (Dronedarone Atrial Fibrillation Study After Electrical Cardioversion) trial, the first prospective randomized trial to evaluate its efficacy and safety105. Nonetheless, the DIONYSOS study106 (Efficacy & Safety of Dronedarone Versus Amiodarone for the Maintenance of Sinus Rhythm in Patients with Persistent Atrial Fibrillation) suggests higher tolerability but fewer efficacies for Dronedarone than for amiodarone. In the ATHENA trial107, Dronedarone improved the composite endpoint of cardiovascular hospitalizations and all-cause mortality in a carefully selected, high-risk, nonpermanent AF population.The new ESC 2010 AF guidelines incorporate Dronedarone into the algorithm previously recommended for therapy to maintain SR in patients with recurrent paroxysmal or persistent AF86.
Recommendations for antithrombotic therapy should be based on the presence (or absence) of risk factors for stroke and thrombo-embolism. Unless contraindicated, chronic oral anticoagulation (OAC) therapy is recommended in patients with a CHADS2 [cardiac failure, hypertension, age, diabetes, stroke (doubled)] score ≥ 2 to achieve an international normalized ratio (INR) value of 2.0–3.0. In patients with CHADS2 0–1, the CHA2DS2-VASc [congestive heart failure, hypertension, age ≥ 75 (doubled), diabetes, stroke (doubled), vascular disease, age 65–74 and sex category (female)] score is recommended and OAC therapy is suggested if the CHA2DS2-VASc score > 286.
Moreover, the new AF guidelines emphasize the importance of bleeding risk assessment before starting anticoagulation. In this case the HAS-BLE [Hypertension, Abnormal renal and liver function, Stroke, Bleeding, Labile INRs, Elderly] bleeding risk score is recommended. A score of ≥ 3 is considered indicative of ‘high-risk’ patients who require caution and regular review after starting antithrombotic therapy86.
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