Stone G, Teirstein P, Rubenstein R, et al: A prospective, multicenter, randomized trial Risk Factors

of percutaneous transmyocardial laser revascularization in patients with nonreca- Men are approximately 4 times more likely than women to develop
nalizable chronic total occlusions, J Am Coll Cardiol 39:1581–1587, 2002.
Stone NJ, Robinson J, Lichtenstein AH, et al: 2013 ACC/AHA guideline on the treat- an abdominal aortic aneurysm. Clearly, older persons, particularly
ment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: A those older than 60 years, are at higher risk. Tobacco use is prob-
report of the American College of Cardiology/American Heart Association Task ably the strongest preventable risk factor, with tobacco users being
Force on Practice Guidelines, Circulation 2013. approximately eight times more likely to be affected than non-
Weber MA, Schiffrin EL, White WB, et al: Clinical practice guidelines for the manage-
ment of hypertension in the community, J Clin Hypertens 16:14–26, 2014. smokers. Hypertension is present in approximately 40% of
Wenger NK: Cardiac Rehabilitation: A Guide to Practice in the 21st Century, patients with abdominal aortic aneurysms. Family history also
New York, 1999, Marcel Dekker. plays a significant role. In fact, men who have first-degree female
Whooley MA, Jonge P, Vittinghoff E, et al: Depressive symptoms, health behaviors, relatives who had aneurysms are approximately 18 times more
and risk of cardiovascular events in patients with coronary heart disease, JAMA
300:2379–2388, 2008. likely than the general population to develop an abdominal aortic
aneurysm. There is also a strong correlation between abdominal
aortic aneurysms and other peripheral artery aneurysms. Patients
with bilateral popliteal artery aneurysms have an approximately
AORTIC DISEASE: ANEURYSM AND DISSECTION 50% to 60% risk of having an abdominal aortic aneurysm.
Method of
David G. Neschis, MD Pathophysiology
An aneurysm is a dilatation of a blood vessel that could occur in
any blood vessel in the body, even in the veins. Most commonly
it is defined as a dilatation of approximately 1.5 to 2 times at that
CURRENT DIAGNOSIS diameter of the adjacent normal vessel.
The definition of a pseudoaneurysm is often misunderstood. The
• Because the majority of patients with abdominal aortic
attempt to describe a pseudoaneurysm in terms of the number of
layers of the artery wall involved does nothing to help resolve this
aneurysms are asymptomatic, the majority of abdominal aortic
confusion. A pseudoaneurysm is a walled-off defect in the artery
aneurysms are detected on imaging studies performed for other
wall. A circular shell of adventitial and surrounding connective tis-
indications.
• Patients older than 50 years who present with abdominal or
sue contains the blood, preventing free hemorrhage. However,
there remains continued flow out and back into the arterial lumen,
back pain of unclear etiology should be considered for evalua-
III The Cardiovascular System

resulting in a classic to-and-fro pattern on duplex ultrasound. The

tion of possible abdominal aortic aneurysm.
• Asymptomatic men older than 65 years who have ever smoked
most common cause of a pseudoaneurysm is iatrogenic, from nee-
dle puncture, but it also can be caused by trauma or focal rupture of
are eligible for abdominal aortic aneurysm screening.
• All patients older than 60 years who have a strong family history
the artery at the site of an atherosclerotic ulcer.
The etiology of true aneurysms is not clear, although in the past
of abdominal aortic aneurysms should be considered for
these have been attributed to atherosclerosis. However, it is well
screening.
• Patients presenting with sudden onset of chest or back pain
known that the majority of patients with abdominal aortic aneu-
rysms do not have associated significant occlusive disease. Bio-
without clear etiology should be evaluated for dissection.
• Dissection can mimic numerous other conditions.
chemical studies have demonstrated decreased quantities of
elastin and collagen in the walls of aneurysmal aortas. It is believed
that a family of enzymes known as matrix metalloproteinase
(MMP), particularly those that have collagenase and elastase activ-
ity, are likely involved in development of arterial aneurysms. The
CURRENT THERAPY propensity for growth and rupture is based on Laplace’s law,
94 T ¼ PR, where T represents wall tension (or in other words the pro-
Indications for Repair of Aneurysm pensity to rupture), P is the transmitted pressure, and R is the
• Fusiform abdominal aortic aneurysms greater than 5.5 cm in radius. This explains why patients with hypertension and those
maximum diameter with larger aneurysms are at higher risk for aortic rupture.
• Most saccular aneurysms and pseudoaneurysms
• Thoracic and thoracoabdominal aortic aneurysms of greater Prevention
than 6 cm in maximal diameter Currently the most effective means to prevent aneurysm rupture is
• Aneurysms that are symptomatic or are rapidly enlarging early detection and elective repair. Avoidance of smoking and
aggressive control of blood pressure would likely be helpful in pre-
Indications for Repair of Aortic Dissection
venting aneurysmal development and growth. Patients with known
• Dissections involving the ascending aorta
abdominal aortic aneurysms that are relatively small and at low risk
• Dissections involving only the descending aorta are usually
for rupture are generally serially followed with imaging studies over
managed medically unless complicated by the following:
time. These patients are advised to avoid straining (e.g., heavy lift-
unrelenting pain, end organ ischemia, or significant aneurysmal
ing), avoid smoking, and keep their blood pressure well controlled.
degeneration to greater than 6 cm in maximal diameter
Investigation is ongoing in efforts to develop a medication that
may be helpful in slowing the growth of abdominal aortic aneu-
Abdominal Aortic Aneurysms rysms. It has been known since 1985 that tetracycline antibiotics
Epidemiology have activity against MMPs. There had been several animal studies
A ruptured abdominal aortic aneurysm is a devastating event lead- and at least one small human study suggesting that doxycycline
ing to approximately 15,000 deaths per year, and it is the 13th (Vibramycin)1 may be effective at slowing the growth of abdominal
leading cause of death in the United States. It is the 10th leading aortic aneurysms. Currently, larger human studies are ongoing. At
cause of death in men. Once rupture occurs, there is an 85% chance this point, there are no formal recommendations regarding the use
of death overall and approximately 50% mortality in the patients of doxycycline for the purpose of slowing aneurysmal growth.
who make it to the hospital alive. Clearly, the goal is to identify this Clinical Manifestations
life-threatening lesion and repair prior to rupture. Abdominal aor- Approximately 75% of abdominal aortic aneurysms are asymp-
tic aneurysms are approximately four times more prevalent in men tomatic and discovered incidentally. Unfortunately, physical
than in women. The overall incidence in persons older than 60 years
is approximately 3% to 4%, with incidence as high as 10% to 12%
1
in an elderly hypertensive population. Not FDA approved for this indication.

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examination is an unreliable method for detecting aneurysms or
determining aneurysm size. In heavier patients it may be simply
impossible to adequately palpate the aorta. The majority of aneu-
rysms are incidental findings identified on imaging studies per-
formed for other reasons. Occasionally, an aneurysm is first
detected upon operation for another condition.
Unfortunately, when an aneurysm becomes symptomatic, this is
usually a sign of impending rupture. Symptoms related to abdom-
inal aortic aneurysms can include abdominal or back pain. The
classic triad of findings in the setting of abdominal aortic aneurysm
rupture includes abdominal pain, hypotension, and a pulsatile
abdominal mass. This triad, however, occurs in only approxi-
mately 20% of the patients. Often a high index of suspicion needs
to be maintained.
The episode of hypotension associated with aneurysm rupture
may be manifested as an episode of syncope or near-syncope before
the patient arrives at the hospital. It is quite possible for the patient
to have a contained rupture of the abdominal aorta and appear
quite stable with a normal blood pressure in the emergency depart-
ment. Although uncommon, a primary fistula between the aneu- Figure 2 Classic image of a ruptured abdominal aortic aneurysm, which in
rysm and gastrointestinal tract can occur and manifest as this case can be seen even without the use of intravascular contrast. Note the
gastrointestinal bleeding. lack of symmetry and obliteration of tissue planes in the retroperitoneum on
the left.
Diagnosis

Aortic Disease: Aneurysm and Dissection

Several imaging modalities are available that can accurately diag-
nose and measure abdominal aortic aneurysms. Real-time B-mode versus the risk of operative repair. Historically, open repair can be
ultrasound scanning has the advantage of being almost universally performed with less than 5% in-hospital mortality. Based on his-
available, relatively inexpensive, and essentially risk free. The torical studies it was estimated that the risk of rupture for an
major disadvantage, however, is that it is technician dependent. approximately 5-cm aneurysm was about 1% per year, which
Computed tomography (CT) scans can provide a very accurate rep- increased dramatically to 6.6% for aneurysms between 6 and
resentation of the aorta in a very short study time (Figures 1 and 2). 7 cm. It has been fairly well established for years that aneurysms
The use of iodinated contrast is not necessary to obtain a gross size larger than 5.5 cm are generally recommended for repair and those
measurement of the aorta. The contrast, however, helps delineate less than 4 cm are generally observed over time. There remains a
the flow lumen more clearly, and it is quite valuable in planning gray area for moderate aneurysms in the 4- to 5.5-cm category.
repair. Disadvantages include the use of ionizing radiation and Two large prospective randomized trials were developed to
the use of iodinated contrast material. MRI is also accurate in answer this question. These include the United Kingdom Small
determining the size of the aneurysm; however, study times are lon- Aneurysm Trial and the Department of Veterans Affairs Aneurysm
ger, equipment is less widely available, and the expense is consid- Detection and Management (ADAM) trial. Both these studies ran-
erable. Angiography, while excellent for evaluating the status of domized patients with moderately sized aneurysms to observation
important aortic branches and for evaluating occlusive disease, is versus open repair. Results of both trials were fairly similar. The
not an accurate study for the purpose of determining maximal rupture rate for aneurysms under observation was 0.5% to 1%
diameter of the aneurysm. Often aneurysms are filled with lami- per year, and neither trial showed a difference in long-term sur-
nated thrombus, and the flow lumen, which was seen on aortogra- vival. Both studies concluded that it was relatively safe to observe 95
phy, is not representative of the true aneurysm size. patients with aneurysms less than 5.5 cm in diameter, particularly
in men who would be compliant with the follow-up regimen. The
Treatment diameter of the aneurysm, however, should not be the only data
The decision on when to intervene in an abdominal aortic aneu- point used for a decision on whether to repair.
rysm is based on a careful analysis of the patient’s risk for rupture Women seem to have a higher rupture rate for a particular aneu-
rysm diameter than men, perhaps because they are starting with
smaller aortas to begin with. Patients with COPD may be at higher
risk for rupture as well. Saccular or eccentric-shaped aneurysms
may also have a higher propensity to rupture and should not be
subject to diameter recommendations for fusiform aneurysms
(Figures 3 and 4). Additionally, rapidly growing aneurysms—
growing at a rate faster than approximately 0.5 cm per year—
should be considered for repair.
Once it has been determined that repair is indicated, a number of
options are available. Traditional open repair involves a relatively
large abdominal incision, cross clamping of the aorta, and replace-
ment of the aneurysmal segment with a graft of polyethylene tere-
phthalate (Dacron) or polytetrafluoroethylene (PTFE; Teflon).
Often the iliac arteries are involved, and in these cases a bifurcated
graft is placed. Open repair is quite durable and very effective at
preventing aneurysm-related deaths. Long-term complications
are rare, and patients following open repair generally enjoy 95%
freedom from issues related to the repair over the course of their
lifetime. Disadvantages, however, include the large incision and
an approximate 1-week hospital stay. Recovery to a relatively nor-
Figure 1 Large abdominal aortic aneurysm. Notice how the majority of mal level of function occasionally takes months. In the past, many
this aneurysm is filled with laminated thrombus. The flow lumen is only patients were deemed too old or frail to be expected to undergo
mildly dilated, and this aneurysm could be missed on angiography alone. open surgery.

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III The Cardiovascular System

Figure 3 Axial CT slice and reconstructed images of a saccular abdominal aortic aneurysm. This lesion could also be described as a pseudoaneurysm. For
these, treatment is recommended because it is thought that the risk of rupture is higher than for a similarly sized fusiform abdominal aortic aneurysm.

Figure 4 Angiogram of patient in Figure 3, demonstrating

aneurysm before and after deployment of an endograft,
which successfully excluded the lesion from the circulation.

96

Endograft repair has revolutionized the practice of vascular sur- has allowed treatment of older and frailer patients who previously
gery. Using small incisions placed at the groin and performing the were denied treatment due to concerns of operative risk.
procedure under fluoroscopic guidance, devices can now be Endograft repair, however, is clearly not without its disadvan-
advanced into the aorta from the femoral artery. Using angiogra- tages. Currently, the durability of endograft repair is unknown,
phy as a guide, the graft typically is deployed below the renal arter- and these patients are subject to frequent serial imaging. Also, there
ies and effectively excludes the aneurysm from the circulation. is a higher incidence of graft-related complications, which can
Advantages include small incisions and very short hospital stays. occur in up to 35% of patients. These include the development
Patients are typically discharged on the first or second day after of leaks of blood into the aneurysm sac outside the graft device,
aneurysm repair. Recovery to normal activity is also quite issues related to graft failure and migration, and graft limb throm-
rapid, taking approximately 1 to 2 weeks. Use of this modality bosis. These grafts are also quite expensive.

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 Two major prospective randomized trials studying traditional Thoracic Aortic Dissection
open versus endograft repair are often cited. These include the Thoracic aortic dissection is the most common aortic emergency,
United Kingdom–based EVAR-1 trial (first Endovascular Aneu- even more common than ruptured abdominal aortic aneurysm.
rysm Repair trail) and the Dutch-based DREAM trial (Diabetes This potentially fatal condition is rare in patients younger than
REduction Assessment with ramipril and rosiglitazone Medication 50 years and is approximately two times more common in men
trial). Both studies randomized patients who were believed to be than women. Patients at risk include patients with a history of con-
good risks for open repair to endograft versus traditional open nective tissue disorders and patients with severe, poorly controlled
repair. The results of both of these studies were relatively similar hypertension.
in that both studies demonstrated a clear early survival benefit for An aortic dissection occurs when there is loss of integrity of the
patients in the endograft group. However, this came at a cost of intima and blood dissects into the media. Once in the media, there
an increased incidence of graft-related complications in the endo- is a natural plane through which dissection is quite easy.
graft group and a higher cost for the endograft group. Additionally, Although there are various classification systems for aortic dis-
at 2 to 4 years, there was no clear difference in long-term survival in section, the Stanford classification is perhaps the most widely used
either group. and the most useful. In this classification, any dissection that
Ultimately, the decision about whether to proceed with open or involves the ascending aorta, whether it involves the ascending
endograft repair is a decision between surgeon and patient based aorta alone or both the ascending and descending thoracoabdom-
on the patient’s aortic anatomy, overall health, and the patient’s inal aorta, are classified as type A. Dissections that do not involve
and physician’s preference. It would appear, however, that older the ascending aorta are classified as type B. This classification is
and frail patients with good anatomy should be strongly consid- useful because type A dissections require urgent surgery. Type B
ered for endograft repair. dissections are typically managed medically unless they are associ-
ated with complications such as unremitting pain, aneurysmal
Monitoring expansion, and end-organ ischemia. By convention, aortic dissec-
Patients with abdominal aortic aneurysms should be evaluated tions that are evaluated within 14 days after the onset of symptoms

Aortic Disease: Aneurysm and Dissection

for the presence of femoral and popliteal aneurysms (particularly are considered acute, and those evaluated beyond 14 days are con-
in men) and for thoracic aortic aneurysms. After open repair, a sidered chronic.
follow-up CT scan with contrast should be considered approxi- Helical CAT scanners with the use of contrast are excellent at
mately 5 years out to evaluate for the integrity of the graft (i.e., pseu- defining the location and extent of aortic dissection. However,
doaneurysms), as well as development of new aneurysms. Patients being alert to the potential for this diagnosis requires a high index
who have undergone endograft repair require more-intensive of suspicion. Aortic dissection can mimic a variety of common con-
monitoring. Typical regimens include a contrast-enhanced CT scan ditions based on the extent of the dissection and the aortic branches
approximately 2 weeks after repair, then 6 months after repair, and involved (Table 1). Uncomplicated type B dissections are typically
then based on the perceived stability of the graft, approximately managed medically. This is usually performed in an intensive care
yearly thereafter. Some centers have used duplex ultrasonography setting with the use of intravenous medications to control contrac-
for evaluating patients after endograft repair in efforts to reduce tility and, if necessary, hypertension.
the amount of ionizing radiation the patients receive. However, it In the past, due to the friability of dissected aortic tissue, the
should be remembered that duplex ultrasound is highly technician results of operative repair for type B dissections have been partic-
dependent, and follow-up of patients with endograft repairs using ularly poor. Currently, endograft repair with the purpose of
only duplex ultrasound should be performed in experienced centers. excluding the entry point of dissection and reestablishing flow to
the true lumen is gaining popularity in the treatment of complex
Thoracic Aortic Aneurysms dissection. This at times may be supplemented by stenting of
Thoracic aortic aneurysms (TAAs) are limited to the chest cavity. affected aortic side branches and fenestration to establish a connec-
Although they are less common than infrarenal abdominal aortic tion between the true and false lumen to restore perfusion to certain
aneurysms, they share similar risk factors. The male-to-female ratio organs. Once the acute phase has passed and medically treated 97
incidence of the TAA is approximately 1:1. patients are under good hypertensive control, these patients are
In the past, the threshold for repair was at a diameter greater then converted to an oral medication regimen and transferred
than 6 cm. This threshold was chosen due to the higher operative out of the intensive care setting. Patients need to be followed up
risks associated with repair of the thoracic aorta. Now with the with serial CT imaging after discharge to evaluate for aneurysmal
availability of endograft, patients with good anatomy are generally
recommended for repair at a diameter similar to those for the
infrarenal aorta.
Open repair involves performing a thoracotomy and cross- TABLE 1 Dissection: The Great Mimic
clamping the aorta. Repair in this location is often performed with TERRITORY INVOLVED OR AFFECTED
the addition of extracorporeal bypass to maintain perfusion to the BY DISSECTION MIMICS
viscera and spinal cord drain performance of the repair. Although
Rupture into pericardial sac Cardiac tamponade
the risk of paraplegia in the treatment of infrarenal aortic is exceed-
ingly low, the risk of paraplegia from a repair of an isolated TAA is Dissection through aortic valve Acute aortic insufficiency
approximately 6%. Endograft devices for repair of TAA are now
Dissection occluding coronary arteries Myocardial infarction
widely available and have reduced the incidence of paraplegia to
approximately 3%. Involvement of cerebral vessels Stroke
Involvement of subclavian arteries Upper extremity ischemia
Thoracoabdominal Aortic Aneurysms (cold arm)
By definition, thoracoabdominal aortic aneurysms require
entrance to both the thoracic and abdominal cavity to perform Dissection running down descending Severe back pain and
repair. These lesions are usually true aneurysms of the aorta and thoracic aorta paralysis
should not be confused with dissection. Repair of thoracoabdom- Mesenteric artery obstruction Mesenteric ischemia
inal aortic aneurysms is quite complex and carries risks of death
and paraplegia as high as 20% in some settings. These procedures Renal artery obstruction Oliguria and acute renal
are generally performed at larger institutions with considerable failure
experience with this condition. Unfortunately, endograft devices Iliac artery occlusion Lower extremity ischemia
for the repair of thoracoabdominal aortic aneurysms are limited (cold leg)
to a handful of centers in the United States.

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 degeneration of the false lumen. This evaluation should occur every Epidemiology
6 months until the patient is stable and then yearly thereafter. AF is the most common sustained arrhythmia in the adult general
In cases where the total aortic diameter grows to greater than population. Globally, the estimated number of individuals with AF
6 cm, repair for the purpose of preventing rupture is indicated, in 2010 was 33.5 million. Between 1990 and 2010, the global esti-
although this is often technically more complicated than treating mated age-adjusted prevalence rate of AF increased from 569.5 to
a fusiform aneurysm in the absence of a previous dissection. 596.2 per 100,000 men and from 359.9 to 373.1 per 100,000
Patients should strictly adhere to their blood pressure medication women. This increase in prevalence was accompanied by a sub-
regimen for life. stantial increase in health burden: disability-adjusted life-years
increased by 18.8% in men and 18.9% in women from 1990 to
References 2010. Finally, the lifetime risk for development of AF in adults
Blankensteijn JD, de Jong SE, Prinssen M, et al: Two-year outcomes after conventional at age 40 is 1 in 4.
or endovascular repair of abdominal aortic aneurysms, N Engl J Med 352
(23):2398–2405, 2005.
Crawford ES, Crawford JL, Safi HJ, et al: Thoracoabdominal aortic aneurysms: Pre- Risk Factors and Pathophysiology
operative and intraoperative factors determining immediate and long-term results
of operations in 605 patients, J Vasc Surg 3(3):389–404, 1986. Table 1 shows the known risk factors of AF; many of these are also
Daily PO, Trueblood HW, Stinson EB, et al: Management of acute aortic dissections, risk factors for atherosclerotic disease. Traditional cardiovascular
Ann Thorac Surg 10(3):237–247, 1970. risk factors such as diabetes, hypertension, and obesity can lead to
EVAR Trial Participants: Endovascular aneurysm repair versus open repair in patients AF via the following pathway: Cardiovascular risk factors ! left
with abdominal aortic aneurysm (EVAR trial 1): Randomised controlled trial,
Lancet 365(9478):2179–2186, 2005. ventricular diastolic dysfunction ! structural and functional alter-
EVAR Trial Participants: Endovascular aneurysm repair and outcome in patients unfit ations in the atria (enlargement, impaired function, fibrosis, etc.)
for open repair of abdominal aortic aneurysm (EVAR trial 2): Randomised con- ! AF. The aforementioned pathway creates the substrate for AF;
trolled trial, Lancet 365(9478):2187–2192, 2005. premature atrial contractions and supraventricular ectopic beats
Lederle FA, Wilson SE, Johnson GR, et al: Immediate repair compared with surveil-
lance of small abdominal aortic aneurysms, N Engl J Med 346(19):1437–1444, are the trigger for AF. Other pathophysiological pathways include
2002. inflammation and increased oxidative stress leading to electrical
Lee ES, Pickett E, Hedayati N, et al: Implementation of an aortic screening program in remodeling, and, consequently, AF.
clinical practice: Implications for the Screen For Abdominal Aortic Aneurysms
Very Efficiently (SAAAVE) Act, J Vasc Surg 49(5):1107–1111, 2009.
Nevitt MP, Ballard DJ, Hallett JW Jr: Prognosis of abdominal aortic aneurysms. Clinical Manifestations
A population-based study, N Engl J Med 321(15):1009–1014, 1989. Common symptoms of AF include palpitations, irregular heart
III The Cardiovascular System

Nienaber CA, Rousseau H, Eggebrecht H, et al: Randomized comparison of strategies

for type B aortic dissection: The INvestigation of STEnt Grafts in Aortic Dissection beat sensation, lightheadedness, dyspnea, chest discomfort, and
(INSTEAD) trial, Circulation 120(25):2519–2528, 2009. fatigue. Some patients may have no symptoms at rest but report
Rentschler M, Baxter BT: Pharmacological approaches to prevent abdominal aortic poor stamina or easy fatigability with physical activity. Other
aneurysm enlargement and rupture, Ann N Y Acad Sci 1085:39–46, 2006. patients, particularly in the elderly, may be asymptomatic.

Diagnosis
ATRIAL FIBRILLATION The absence of distinct P waves with irregularly irregular RR
Method of interval on the ECG are the sine qua non for diagnosing AF.
Lin Yee Chen, MD, MS; and Samuel C. Dudley, Jr., MD, PhD Rhythm documentation can be obtained via the standard
12-lead ECG, Holter monitors that can record up to 48 hours,
leadless patch monitors that can record up to 2 weeks, or
implantable loop recorders. Newer wearable technologies that
can diagnose AF include smart watches and smart phones with
CURRENT DIAGNOSIS specialized apps.
98
• History taking and physical examination for atrial fibrillation
(AF) should be focused on determining symptom severity (to
decide on treatment strategy), risk of thromboembolic stroke,
and associated cardiovascular risk factors.
• Symptoms include palpitations, chest discomfort, shortness of TABLE 1 Risk Factors of Atrial Fibrillation
breath, and reduced exercise capacity. Some patients are Cardiovascular risk factors
symptom free. Older age
• Investigations include 12-lead electrocardiogram (ECG) for Male sex
confirmation, transthoracic echocardiogram to evaluate left Diabetes mellitus
atrial size, left ventricular ejection fraction, and rule out valvular Overweight and obesity
abnormalities, and blood tests for thyroid, renal, and hepatic Hypertension
function. Chronic kidney disease
Structural heart disease
Valvular heart disease
Cardiomyopathy (dilated, restrictive, and hypertrophic)
CURRENT THERAPY Congenital heart disease
Coronary heart disease
• Rate control: Achieve average ventricular rate of less than 110 Left ventricular diastolic dysfunction
beats/min by using atrioventricular node (AVN) blockers or Left atrial enlargement
catheter ablation of AVN Family history
• Rhythm control: Prevent AF recurrence by using antiarrhythmic Genetics (polygenic and monogenic inheritance)
drugs or catheter ablation (pulmonary vein isolation) Inflammation
• Stroke prophylaxis: Risk stratification and stroke prevention by Low serum magnesium
oral anticoagulation or left atrial appendage closure Heavy alcohol consumption
• Risk factor management or lifestyle modification: Prevent AF by Poor cardiorespiratory fitness
weight management, intensive blood pressure lowering, and Low physical activity
exercise training Premature atrial contractions or supraventricular ectopy

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