The two principal goals of therapy in all patients with atrial fibrillation (AF) are the reduction of the risk of stroke and the alleviation of symptoms. To accomplish the former, most patients with AF will require oral anticoagulant. (See "Antithrombotic therapy to prevent embolization in atrial fibrillation".)
With regard to control of symptoms, a decision needs to be made regarding treatment with either a rhythm control or rate control strategy in most patients. Randomized trials such as AFFIRM and RACE have shown no significant difference in major outcomes (mortality and stroke) with rate control in minimally symptomatic or asymptomatic individuals with other stroke risk factors who are candidates for either approach. This finding may have been due, in part, to inadequate anticoagulation among patients whose rhythm was thought to be controlled with antiarrhythmic agents, but may in fact been having recurrences of asymptomatic AF. In addition, the findings of AFFIRM and RACE may reflect the limited efficacy of our current methods for restoring and maintaining sinus rhythm with antiarrhythmic agents, rather than equivalence between AF and sinus rhythm. (See "Rhythm control versus rate control in atrial fibrillation".)
Two limitations of antiarrhythmic drugs include inconsistent efficacy in maintaining sinus rhythm and frequent side effects. Because of these limitations, nonpharmacologic approaches have been evaluated to prevent recurrent AF. The two most common nonpharmacologic approaches are radiofrequency catheter ablation (RFA) and surgery. Additional nonpharmacologic therapies have been studied, including atrial pacing, and implantable atrial defibrillators, although neither of these is commonly used in current clinical practice. (See "The role of pacemakers in the prevention of atrial fibrillation" and "General principles of the implantable cardioverter-defibrillator", section on 'Atrial defibrillation'.)
Similar to surgical procedures, ablation procedures for preventing recurrent AF are directed at the following:
- Elimination of the triggers of AF – Triggers are usually eliminated by disrupting the conduction of electrical activity between the tissues that contain these arrhythmogenic triggers (most commonly the ostial portion of the pulmonary veins), and the atrial myocardium. Less commonly, triggers within the atrial myocardium can be directly ablated.
- Modifying the atrial substrate(s) responsible for the maintenance of AF.