General introduction 9 Cardiac electrophysiology is a rapidly evolving subspecialty of cardiology. Its main focus is to treat cardiac arrhythmias and prevent sudden cardiac death. Within the Erasmus MC there is a dedicated team of cardiac electrophysiologists, fellows, nurse practitioners, nurses, technicians and researchers who are actively involved in the care and cure of patients with a heart rhythm disorder. Over the last decades the treatment of heart rhythm disorders has evolved from exclusive anti-arrhythmic drug therapy to a broad spectrum of invasive and noninvasive therapies. The invasive treatment arsenal includes pacemakers, implantable cardioverter-defibrillators (ICDs), and catheter ablation of cardiac arrhythmias (1). Furthermore, patient centred care with emphasis on shared decision making has entered the clinical arena. Currently, there is an enhanced emphasis on risk factor management, which inherently optimizes therapy outcomes and as such is the underlying principle of this thesis. 1.1 Evaluation of complications in atrial fibrillation Atrial fibrillation (AF) is a supraventricular tachyarrhythmia with uncoordinated atrial electrical activation (2). It is the most common cardiac arrhythmia in adults and constitutes a significant burden to patients, communal health and health economy. The lifetime risk of AF in Europe is as high as 40% (2). In 2021 approximately 123,400 newly diagnosed AF cases were documented in the Netherlands (3). In recent years a paradigm shift in the management of AF was observed with a change from prescribing anti-arrhythmic drugs and electrical cardioversions (ECVs) to comprehensive AF care (1). Comprehensive AF care includes a focus on patient engagement, participation, and shared decision making in a treatment plan and involves a combination of lifestyle management, risk factor management, antiarrhythmic drugs, ECV and AF catheter ablation (1). Currently, the first aim is to improve lifestyle management and initiate a more aggressive risk factor management. Secondly, a choice will be made between rate or rhythm control depending on patient preferences, symptoms, comorbidity, and anticipated benefits and risks of invasive catheter ablation. Rate control is achieved using atrioventricular blocking agents (i.e., betablockers, digoxin, verapamil) or a “pace and ablate” strategy. Rhythm control is achieved using a combination of anti-arrhythmic drugs, ECVs, and AF catheter ablation. Inherent to every medical procedure, there are 1
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