Challenges and Opportunities for Atrial Fibrillation Management

Abstract

Atrial fibrillation (AF) is the most common sustained arrhythmia worldwide and is associated with poor clinical outcomes and a huge economic burden on healthcare systems. Optimized anticoagulation, better symptom control via rhythm or rate control, and comprehensive comorbidity/risk factor management are 3 essential pillars of current AF management, where much progress has been made during the past decades. However, numerous challenges in AF management remain at the disease, patient, and population levels, including an incomplete understanding of basic mechanisms that can be clinically targeted; heterogenous progressive natural history; poor correlation between rhythm and symptoms/outcomes; as well as suboptimal detection methods and treatment options. Recent advances in disease perception in combination with modern monitoring devices, state-of-the art computational models, and novel antiarrhythmic drugs and ablation strategies can contribute to addressing these issues, ultimately leading to a paradigm shift in AF diagnosis, classification, and treatment. This narrative review summarizes these key challenges and future opportunities in the field of AF management.

Keywords: Anticoagulation; Atrial fibrillation; Pathophysiology; Precision medicine; Rhythm control; Translational challenges.

Figure 1

Interactive disease-level, patient-level, and population-level challenges in current AF management. Black boxes represent current challenges, and red boxes represent clinical observations. Black and red solid arrows represent the relationship between challenges and corresponding clinical observations. Dotted red lines represent the interaction between different clinical observations. AADs: Antiarrhythmic drugs; AF: Atrial fibrillation; CA: Catheter ablation; ECV: Electrical cardioversion; OAC: Oral anticoagulation; SCAF: Subclinical AF.

Figure 2

Conceptual model describing the association among risk factors for ACM, AF, and stroke. In this model, ACM-promoting factors can produce the abnormal atrial substrates and cause ACM. Meanwhile, ACM is associated with higher risks of stroke and AF. Once AF occurs and continues for a period, the AF-induced electrical remodeling, atrial enlargement, and fibrosis can further stimulate the accumulation of atrial substrates, which increases the susceptibility to stroke and sustained AF. Except for ACM-caused stroke without the presence of AF, stroke may also be the result of extra stroke-promoting risk factors outside of the atrium and typical AF-induced hypercoagulability. Reversely, it is unclear if the post-stroke inflammation and altered activity of the autonomous nerve system may promote AF occurrence (dotted blue line). Finally, AF may also be the consequence of other AF-promoting risk factors. These ACM/stroke/AF-promoting risk factors may share common cardiovascular risk factors and comorbidities. ACM: Atrial cardiomyopathy; AF: Atrial fibrillation.