Upstream Treatments for Atrial Fibrillation

Atrial Fibrillation: Is Rhythm Control Required, and If So, How, and What Is the Internist's Role?

Atrial fibrillation-no primary care physician can escape it! Atrial fibrillation is the most common tachyarrhythmia encountered in clinical practice-whether family practice, internal medicine, cardiology, pulmonology medicine, etc. Moreover, with growth of the older segment of our population and better survival of patients with cardiovascular disorders, the incidence and prevalence of atrial fibrillation are both increasing progressively. Currently, a review of major guidelines shows that the treatment approach to atrial fibrillation involves 4 "pillars"-treatment of contributory comorbidities ("upstream therapy"), control of the ventricular response to the rapid atrial rates during atrial fibrillation, prevention of thromboembolism with oral anticoagulation or left atrial appendage occlusion (except in the minority of patients at too low a thromboembolic risk), and rhythm control in those patients who require it. The latter is the most complex of the 4, and many, if not most, primary care physicians currently prefer to leave this "pillar" to the care of a cardiologist or electrophysiologist. Nonetheless, it is important for the primary care physician to be familiar with the rhythm treatment components and choices (both overall and, specifically, the ones in which they must participate) as they will impact many interactions with their patients in multiple ways. This review details for the primary care physician the components of care regarding rhythm control of atrial fibrillation and the areas in which the primary care physician/internist must be knowledgeable and proactively involved.