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Letter to the Editor

Quixotic Quest or Shared Decision?

doi: 10.1097/01.EEM.0000578672.94368.27
Letter to the Editor

Editor:

The column by Rory Spiegel, MD, gives an interesting perspective on the treatment and the natural history of atrial fibrillation. (“Quixotic Quest to Control Atrial Fibrillation,” EMN. 2019;41[6]:1: http://bit.ly/2ZsiIU7.)

The fact that there is no need for immediate cardioversion should not obscure the fact that patients are better off in sinus rhythm. Literature failing to show a benefit of rhythm control strategies reflects the ineffectiveness and adverse effects of antiarrhythmic medications. A study in the Journal of American College of Cardiology stated, “Quality of life is impaired in patients with AF compared with healthy controls. Treatment strategy does not affect QoL. Patients with complaints related to AF, however, may benefit from rhythm control if SR can be maintained.” (J Am Coll Cardiol. 2004;[2]:241; http://bit.ly/2RhWaCL.)

Patients are different. Some are oblivious to their AF while others are acutely uncomfortable. Some patients are averse to anticoagulation because it will require altering their work or recreation to reduce the chance of traumatic injury.

Rather than having our patients adjust to rate control and anticoagulation medications, we should give them a choice and include a plan to adjust known modifiable risk factors for atrial fibrillation: hypertension, obesity, sleep apnea, and alcohol consumption. (Arrhythm Electrophysiol Rev. 2018;7[2]:118; http://bit.ly/2wYzyO2.)

The ED management of AF provides an opportunity for patient education and shared decision-making. It is not a quixotic quest if we provide education on the modifiable risk factors for atrial fibrillation. We can proceed with cardioversion per patient preference.

Joel Pasternack, MD, PhD

Rochester, NY

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