atrial debulking (Maze) and catheter ablation (eg, pulmonary PVI). No difference has been found in rates of successful cardioversion or in the risk of thromboembolism and stroke between electrical cardioversion (ECV) and PCV as the initial treatment strategy (Valencia et al 2002). In prolonged cases of AF, ECV is the preferred option based on clinical experience and current clinical practice, whereas within 48 hours of onset, either pharmacological or electrical cardioversion could be performed. Whilst ini- tial cardioversion is successful in achieving sinus rhythm in the majority, approximately 50% of patients are back in AF by one year (Lim et al 2004). Patients considered most likely to successfully cardiovert and maintain sinus rhythm are those with persistent AF of shorter duration (onset <12 months), those without underlying structural heart disease or AF secondary to a precipitant (eg, treated thyroid disease, fever) that has been treated. Hence, careful consideration should be made for the presence of coexist- ing factors that inﬂuence success. For example, a history of recurrent AF (Dmochowska-Perz et al 2002), chronic- obstructive pulmonary disease (Okcun et al 2002), heart failure (Okcun et al 2002) and cardiomegaly (Galperin et al 2003) has been found to be associated with reduced cardioversion success. The maintenance of sinus rhythm post cardioversion is notoriously difﬁcult and the treatments consistently inﬂuenc- ing procedural success are limited. Consensus favors initial beta-blocker therapy followed by sotalol or ﬂecanide in resistant cases (after ensuring good left ventricular function) and amiodarone as the ﬁnal resort for patients that require antiarrythmic drugs post cardioversion. Management strategies Since atrial ﬁbrillation is classiﬁed according its duration of onset, management strategies will differ based on the time- span of existence of AF. It can be seen from above that in general, patients who have AF of less than 1 year duration can be considered for cardioversion and have the highest chance of remission, in contrast to patients whose AF has lasted more than 1 year. The aim of treatment in these patients is to minimize symptoms and achieve adequate rate control. Digoxin has traditionally been used for rate control; however it is has limited efﬁcacy in hyperadrenergic states and with exercise (David et al 1979). Beta-blockers (Farshi et al 1999) and calcium antagonists (Maragno et al 1988) control exertional heart rate much more efﬁciently. Where required a combination treatment with atenolol and digoxin appears to be more effective than beta-blocker alone. Thus, Vascular Health and Risk Management 2007:3(1) Atrial ﬁbrillation evidence suggests that in patients requiring rate control, the ﬁrst line of treatment should be beta-blockers or calcium antagonists with digoxin reserved for use in more sedentary patients (Li-Saw-Hee et al 1998). When atrial ﬁbrillation is paroxysmal, its management can be quite challenging. The aim of treatment is to reduce AF frequency, prevent complications and alleviate symptoms during the paroxysm itself. The ratio of asymptomatic versus symptomatic episodes can be highly variable and may be as high as 12:1 (Page et al 1994). Hence, treatment needs to be highly tailored to the individual patient and may vary depend- ing on the frequency of paroxysms. Studies have evaluated different regimes of pharmacological therapy for PAF and found comparative efﬁcacy with standard beta-blockers and sotalol (Steeds et al 1999). Amiodarone (Roy et al 2000; Ko- chiadakis et al 2004), in has been shown to be superior to all other agents (including class 1c agents); however, its efﬁcacy is offset by its side- effect proﬁle. Selected patients may be suitable for domiciliary self-treatment, using the so-called “pill in the pocket approach (Alboni et al 2004). Selection for this approach is critically important: these patients should be generally well educated, without evidence of coexistent left- ventricular dysfunction, valvular or ischemic heart disease and have infrequent episodes of paroxysmal AF. For the hemodynamically compromised AF patient, treat- ment strategies should be in accordance with resuscitation council guidelines with the aim being to re-establish circula- tion while acknowledging the potential risks of inadequate thromboprophylaxis. ECV is indicated irrespective of the duration of AF (Michael et al 1999). Intravenous amiodarone may be used where delays in ECV are expected. Importantly, in patients with known Wolf-Parkinson-White syndrome, AV nodal blocking drugs should be avoided. AF is an important postoperative complication as it signiﬁ- cantly increases both morbidity (eg, longer hospitalization) and mortality (Almassi et al 1997). It occurs in approximately 33% of patients post-coronary heart surgery (Vecht et al 1980). One major meta-analysis (Crystal et al 2003) helped clarify the util- ity of varying medical treatments, and found that for patients undergoing cardiothoracic surgery, prophylactic administra- tion of amiodarone, standard beta-blockers and sotalol were all justiﬁed in preventing post-operative AF in high-risk patients. Evidence in favor of the rate-limiting calcium antagonist dil- tiazem was extracted from additional studies (Seitelberger et al 1994). Indeed, rhythm control has been shown to be superior to rate control in maintenance of sinus rhythm and decreas- ing length of hospital stay among patients with postoperative AF (Lee et al 2003). Where AF occurs post operatively with 111