Optimal treatment for atrial fibrillation

A number of issues in the management of patients with AF are discussed. Strokes can be caused by large artery (carotid or aortic) disease, small (cerebral) artery disease or be of cardiogenic origin, with about half of cardiogenic strokes associated with AF. The incidence of AF rises sharply with increasing age, and AF is likely to be especially thrombogenic in the elderly. Results using warfarin and aspirin to prevent stroke in AF are summarized, as are current data on risk stratification. Echocardiographic risk factors for thromboembolism in AF are discussed, particularly spontaneous echocardiographic contrast. In experimental studies, more in vitro stasis is associated with increasing echocardiographic density; echocardiographic density can be modified by changing fibrinogen levels, but it is not known whether this changes risk of clinical thromboembolism. Clinical guidelines are given for when to treat AF with warfarin. Controversies surrounding cardioversion from AF are touched upon, with a summary of modern data using TEE to guide management of cardioversion.