Managing atrial fibrillation in the global community: The European perspective

Abstract

Atrial fibrillation is a common, global problem, with great personal, economic and social burdens. As populations age it increases in prevalence and becomes another condition that requires careful chronic management to ensure its effects are minimised. Assessment of the risk of stroke using well established risk prediction models is being aided by modern computerised databases and the choice of drugs to prevent strokes is ever expanding to try and improve the major cause of morbidity in AF. In addition, newer drugs for controlling rhythm are available and guidelines are constantly changing to reflect this. As well as medications, modern techniques of electrophysiology are becoming more widely embraced worldwide to provide more targeted treatment for the underlying pathophysiology. In this review we consider these factors to concisely describe how AF can be successfully managed.

Figure 1.

Transoesphageal echocardiogram demonstrating a 1.8 cm (“1”) by 0.8 cm (“2”) thrombus in the left atrial appendage of a 57-year-old male with longstanding atrial fibrillation, despite being on warfarin but with subtherapeutic INR.

Figure 2.

European Society of Cardiology guidelines for assessing need for oral anticoagulant (OAC) therapy in AF. Camm et al. ^aComprised of 1 point for congestive cardiac failure, hypertension, diabetes mellitus, age 65–74, female sex and vascular disease, and 2 points for previous stroke/TIA/thromboembolism or age 75 years or greater.

Figure 3.

ESC guidelines for antiarrhythmic drug selection in AF. Adapted from Camm J et al. . HHD – hypertensive heart disease; CHD – coronary heart disease; HF – heart failure; LVH – left ventricular hypertrophy.

Figure 4.

Summary of outcomes in PALLAS and ATHENA trials. In PALLAS, there was an increased incidence in the first coprimary outcome of stroke, myocardial infarction, systemic embolism or CV death for dronedarone compared to placebo and an increased incidence in the second coprimary outcome unplanned cardiovascular hospitalisation or death for dronedarone compared to placebo. As a result dronedarone should not be used in this permanent high risk AF patient population. Standard therapy may have included rate control agents (beta-blockers, and/or Ca-antagonist and/or digoxin) and/or anti-thrombotic therapy (Vit. K antagonists and /or aspirin and other antiplatelets therapy) and/or other cardiovascular agents such as ACEIs/ARBs and statins. Source: Adapted from Hohnloser et al. ; Connolly et al.