Elsevier

American Heart Journal

Volume 164, Issue 3, September 2012, Pages 292-302.e1
American Heart Journal

Curriculum in Cardiology
A proposal for new clinical concepts in the management of atrial fibrillation

https://doi.org/10.1016/j.ahj.2012.05.017Get rights and content

Atrial fibrillation (AF) represents a growing public health burden. It is a complex condition, involving a number of etiologic factors and arrhythmia mechanisms associated with atrial remodeling. Greater understanding of these mechanisms may improve therapy.

Current AF classification schemes are limited by simplicity. A number of risk factors predict AF onset, and additional factors are being evaluated in registry studies. Doppler imaging and Holter monitoring in high-risk patients to predict the onset of AF and progression from paroxysmal to permanent AF are promising. There is a need for a novel multifactorial classification model encompassing AF duration, symptoms, markers of atrial remodeling, and a risk score for AF onset, persistence, progression, and complications to guide treatment and prognostication.

Preventing AF onset with upstream therapy is of great interest, but current data are conflicting. More study is needed to optimize rhythm control with antiarrhythmic drugs and targeted ablation to specific patient populations at an earlier stage. There is little consensus on optimal rate control and no information relating to optimum rate control in specific populations.

This article highlights new concepts in AF and directions for future research.

Section snippets

Methods

The group is organized into a working group, which reviewed and collated available evidence, and a scientific committee, which highlighted areas where evidence is lacking and progress is needed. The AF Science Evolution group was formed with the aid of an unrestricted educational grant from Sanofi. Members of the scientific committee received an honorarium and travelling expenses to attend a meeting in July 2011. Members of the working group received an honorarium for their time during a number

Overview of mechanistic determinants of AF

The mechanisms underlying AF are multifactorial and challenging to pinpoint on an individual case basis.2 Figure 1A depicts the principal determinants of clinical AF as 3 concentric rings. The etiologic dimension (outermost ring) includes clinical promoters of AF. The second ring describes the atrial remodeling that underlies the electrophysiology responsible for AF. The inner ring encompasses basic arrhythmia mechanisms responsible for induction and maintenance of AF. These are further

Current classification systems for AF

The current classification system adopted by the American College of Cardiology/American Heart Association/European Society of Cardiology/Heart Rhythm Society (ACC/AHA/ESC/HRS) guidelines5 is based on the pattern and duration of AF. Arrhythmia is classified as paroxysmal (resolving spontaneously), persistent (≥ 7 days in duration), or permanent, and as “first-detected” or “recurrent.” Classification as permanent is based on the patient and physician deciding not to attempt to restore or maintain

Therapeutic options in achieving rhythm control

Potential advantages of a rhythm control strategy include improved cardiac function, symptom relief, improved quality of life, and avoidance of unfavorable atrial electrical and mechanical remodeling. There are 2 major options for achieving rhythm control in patients with AF: pharmacologic treatment and ablation.

Conclusions

This article highlights several new directions for research in AF. Further characterization of the mechanisms underlying AF and greater understanding of AF progression will lead to better application of preventive therapies and improve prognosis.

Disclosures

A John Camm, MD, is an advisor and speaker for Sanofi, Merck, Gilead, Menarini, Medtronic, and Boston Scientific.

Sana M Al-Khatib, MD, received research funding from Bristol Myers Squibb

Hugh J Calkins, MD, is a consultant to Biosense Webster, Medtronic, and Atricure, and Sanofi.

Jonathon L Halperin, MD, received consulting fees from Astellas Pharma, US, Atricure/Boston Biomedical Associates, AstraZeneca, Bayer AG HealthCare, Boehringer Ingelheim, Pharmaceuticals, Inc, Bristol Meyers-Squibb,

Acknowledgements

Logistical and editorial support was provided by Healthcare21 Communications Ltd and was paid for by an unrestricted grant from Sanofi.

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