Avoiding permanent atrial fibrillation: treatment approaches to prevent disease progression

Abstract

Atrial fibrillation (AF) is the most common sustained arrhythmia and a major global public health problem due to its associated morbidity, including stroke and heart failure, diminished quality of life, and increased mortality. AF often presents initially in a paroxysmal form and may progress to a more sustained form over time. Evidence from randomized controlled trials suggests that there may be no mortality benefit to using a rhythm control approach in comparison with rate control of AF. Nevertheless, sustained forms of AF may be associated with increased symptoms and cardiovascular morbidity, and consequently they remain an additional target for therapy. The present review evaluates the clinical correlates of arrhythmia progression and risk stratification techniques available to assess probability of AF progression. Further, currently available management options for arrhythmia control in AF are evaluated and their therapeutic effect and efficacy on disease progression are explored.

Keywords: atrial fibrillation; permanent; prevention; progression.

Figure 1

1-year incidence of progression of atrial fibrillation based on HATCH score (hypertension, age >75 years, transient ischemic attack or stroke, chronic obstructive pulmonary disease, and heart failure). Note: Reprinted from Journal of the American College of Cardiology, 55(8), de Vos CB, Pisters R, Nieuwlaat R, et al, Progression from paroxysmal to persistent atrial fibrillation clinical correlates and prognosis, 725–731, Copyright © 2010, with permission from Elsevier. Abbreviation: AF, atrial fibrillation.

Figure 2

Proposed algorithm for use of antiarrhythmic drugs in patients with paroxysmal or persistent atrial fibrillation. Note: Reproduced from Fuster V, Rydén LE, Cannom DS, et al, 2011 ACCF/AHA/HRS focused updates incorporated into the ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines, Circulation, 123(10):e269–e367, Copyright © 2011, with permission from Wolters Kluwer Health. Abbreviation: LVH, left ventricular hypertrophy.

Figure 3

Atrial fibrillation-related medication use at baseline and association with arrhythmia progression at 1 year. Note: Reprinted from American Heart Journal, 163(5), De Vos CB, Breithardt G, Camm AJ, et al, Progression of atrial fibrillation in the REgistry on Cardiac rhythm disORDers assessing the control of Atrial Fibrillation cohort: clinical correlates and the effect of rhythm-control therapy, 887–893, Copyright © 2012, with permission from Elsevier.

Figure 4

Rate of progression of atrial fibrillation. Probability for progression of atrial fibrillation was estimated to be 0.6% per year after radiofrequency catheter ablation (blue line) in comparison with a rate of 8.6% in the first year among patients treated with antiarrhythmic drug therapy. Note: Reprinted from Journal of Cardiovascular Electrophysiology, 23(1), Jongnarangsin K, Suwanagool A, Chugh A, et al, Effect of catheter ablation on progression of paroxysmal atrial fibrillation, 9–14, Copyright © 2012, with permission from John Wiley & Sons. Abbreviation: AF, atrial fibrillation.