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Background Guideline recommendations are the accepted reference for selection of therapies for rhythm control of atrial fibrillation (AF). This study was designed to understand physicians’ treatment practices and adherence to guidelines. Methods and Results The AIM‐AF (Antiarrhythmic Medication for Atrial Fibrillation) study was an online survey of clinical cardiologists and electrophysiologists that was conducted in the United States and Europe (N=629). Respondents actively treated ≥30 patients with AF who received drug therapy, and had received or were referred for ablation every 3 months. The survey comprised 96 questions on physician demographics, AF types, and treatment practices. Overall, 54% of respondents considered guidelines to be the most important nonpatient factor influencing treatment choice. Across most queried comorbidities, amiodarone was selected by 60% to 80% of respondents. Other nonadherent usage included sotalol by 21% in patients with renal impairment; dofetilide initiation (16%, United States only) outside of hospital; class Ic agents by 6% in coronary artery disease; and dronedarone by 8% in patients with heart failure with reduced ejection fraction. Additionally, rhythm control strategies were frequently chosen in asymptomatic AF (antiarrhythmic drugs [AADs], 35%; ablation, 8%) and subclinical AF (AADs, 38%; ablation, 13%). Despite guideline algorithms emphasizing safety first, efficacy (48%) was selected as the most important consideration for AAD choice, followed by safety (34%). Conclusions Despite surveyed clinicians recognizing the importance of guidelines, nonadherence was frequently observed. While deviation may be reasonable in selected patients, in general, nonadherence has the potential to compromise patient safety. These findings highlight an underappreciation of the safe use of AADs, emphasizing the need for interventions to support optimal AAD selection.

Abstract  Implantable cardioverter defibrillator (ICD) trials were initially limited to survivors of sudden death. The focus of defibrillator trials in the last decade has been in prophylactic implantation of the device in high risk populations for the prevention of sudden cardiac death. It is the contention in this review that the new focus for implantable defibrillator trials in 2008 and beyond will be on more selective and focused use of this therapy. This could be achieved by selecting ICD patients based on their pathophysiologic and genetic risk. Increasing effort will also be placed on using the device for prevention of spontaneous malignant ventricular tachyarrhythmias and the index clinical sudden death event. Finally, implantable defibrillators will be used in combination in a “hybrid” therapy approach. ICDs will be increasingly combined either with ventricular tachycardia ablation or ventricular fibrillation ablation using catheter techniques. With the addition of cardiac resynchronization therapy in these devices, new clinical trials that use cardiac resynchronization therapy as an early intervention in specific high risk heart failure populations and refinement of the CRT technique to improved optimal results are in progress. Finally, combining ICD devices and regenerative medicine approaches to myocardial replacement therapy are being explored. [ABSTRACT FROM AUTHOR]

Abstract Background: The effects of atrial pacing mode on atrial and ventricular function in patients with atrial fibrillation (AF) and bradycardia have not been evaluated. We evaluated atrial and ventricular function during randomization to support pacing (SP), high right atrial pacing (HRA), and dual site right atrial pacing (DAP). [ABSTRACT FROM AUTHOR]

Rhythm control methods have not shown superior outcomes to rate control strategies in atrial fibrillation. Newer approaches to rhythm control employ “hybrid” therapies combining pharmacologic and non pharmacologic interventions. Pathophysiologic insights into mechanisms of atrial fibrillation (AF) suggest that arrhythmogenesis is due to interactions of multiple triggering rhythms and a complex electrophysiologic substrate resulting in the emergence of multiple tachyarrhythmias, often in disparate locations that may coexist in time. Thus, an “hybrid” therapy prescription is more likely to address several of the etiologic factors culminating in clinical AF. Results of pilot clinical studies of hybrid therapy are encouraging and involve drugs, devices and ablation techniques in varying permutations. Hybrid therapy algorithms using right heart procedures can improve efficacy with potentially lower risk. Considerations in implementation of these algorithms include staged or simultaneous interventions and a right versus left heart strategy. The parallel with the current coronary disease management paradigm is obvious and relevant. [ABSTRACT FROM AUTHOR]

The article focuses on health care systems in the United States. There has been a quiet but growing negative reaction to managed medical care. Its genesis rests in patients who feel they have been under-served, and physicians who find themselves blocked from providing what they consider to be timely, appropriate care, or excluded from managed care plans without any apparent cause. A medical care system that does not assure access for all is no longer acceptable. A system that is inherently inflationary also is no longer acceptable. Managed care has been the main alternative to a government administered health care system.