Comprehensive risk reduction in patients with atrial fibrillation: Emerging diagnostic and therapeutic options

Summary

There are exciting new developments in several areas of atrial fibrillation (AF) management that carry the hope of improving outcomes in AF patients. This paper is an executive summary that summarises the proceedings from the 3^rd AFNET/EHRA consensus conference on atrial fibrillation, held in Sophia Antipolis from November 7^th to 9^th 2010, shortly after the release of the new ESC guidelines on AF. The conference was jointly organised by the German Atrial Fibrillation competence NETwork (AFNET) and the European Heart Rhythm Association (EHRA). This executive summary report covers four sections: 1. Risk factors and risk markers for AF, 2. Pathophysiological classification of AF, 3. Relevance of monitored AF duration for AF-related outcomes, and 4. Perspectives and needs for implementing better antithrombotic therapy.

Keywords

Acquired coagulation disorders - vitamin K-dependent factors - stroke / prevention - thrombin - atrial fibrillation

^* Full version in Europace 2011; published online July 26th, 2011 http://europace.oxfordjournals.org/content/early/2011/07/26/europace.eur241.full.pdf+html.

• References

• 1 Kirchhof P, Auricchio A, Bax J. et al. Outcome parameters for trials in atrial fibrillation: executive summary: Recommendations from a consensus conference organized by the German Atrial Fibrillation Competence NETwork (AFNET) and the European Heart Rhythm Association (EHRA). Eur Heart J 2007; 28: 2803-2817.
• 2 Kirchhof P, Bax J, Blomstrom-Lundquist C. et al. Early and comprehensive management of atrial fibrillation: executive summary of the proceedings from the 2nd AFNET-EHRA consensus conference 'research perspectives in AF'. Eur Heart J 2009; 30: 2969-2977c.
• 3 Camm AJ, Kirchhof P, Lip GYH. et al. Guidelines for the management of atrial fibrillation. Eur Heart J 2010; 31: 2369-2429.
• 4 Benjamin EJ, Chen PS, Bild DE. et al. Prevention of atrial fibrillation: report from a national heart, lung, and blood institute workshop. Circulation 2009; 119: 606-618.
• 5 Shotan A, Garty M, Blondhein DS. et al. Atrial fibrillation and long-term prognosis in patients hospitalized for heart failure: results from heart failure survey in Israel (HFSIS). Eur Heart J 2010; 31: 309-317.
• 6 Ducharme A, Swedberg K, Pfeffer MA. et al. Prevention of atrial fibrillation in patients with symptomatic chronic heart failure by candesartan in the Candesartan in Heart failure: Assessment of Reduction in Mortality and morbidity (CHARM) program. Am Heart J 2006; 152: 86-92.
• 7 Olsson LG, Swedberg K, Ducharme A. et al. Atrial fibrillation and risk of clinical events in chronic heart failure with and without left ventricular systolic dysfunction: results from the Candesartan in Heart failure-Assessment of Reduction in Mortality and morbidity (CHARM) program. J Am Coll Cardiol 2006; 47: 1997-2004.
• 8 Tsang TS, Gersh BJ, Appleton CP. et al. Left ventricular diastolic dysfunction as a predictor of the first diagnosed nonvalvular atrial fibrillation in 840 elderly men and women. J Am Coll Cardiol 2002; 40: 1636-1644.
• 9 Cosio FG, Aliot E, Botto GL. et al. Delayed rhythm control of atrial fibrillation may be a cause of failure to prevent recurrences: reasons for change to active antiarrhythmic treatment at the time of the first detected episode. Europace 2008; 10: 21-27.
• 10 Benjamin EJ, Levy D, Vaziri SM. et al. Independent risk factors for atrial fibrillation in a population-based cohort. The Framingham Heart Study. J Am Med Assoc 1994; 271: 840-844.
• 11 Psaty BM, Manolio TA, Kuller LH. et al. Incidence of and risk factors for atrial fibrillation in older adults. Circulation 1997; 96: 2455-2461.
• 12 Smith JG, Newton-Cheh C, Almgren P. et al. Assessment of conventional cardiovascular risk factors and multiple biomarkers for the prediction of incident heart failure and atrial fibrillation. J Am Coll Cardiol 2010; 56: 1712-1719.
• 13 Kannel WB, Abbott RD, Savage DD. et al. Epidemiologic features of chronic atrial fibrillation: the Framingham study. N Engl J Med 1982; 306: 1018-1022.
• 14 Marinigh R, Lip GY, Fiotti N. et al. Age as a risk factor for stroke in atrial fibrillation patients implications for thromboprophylaxis: Implications for thromboprophylaxis. J Am Coll Cardiol 2010; 56: 827-837.
• 15 Conen D, Tedrow UB, Koplan BA. et al. Influence of systolic and diastolic blood pressure on the risk of incident atrial fibrillation in women. Circulation 2009; 119: 2146-2152.
• 16 Thomas MC, Dublin S, Kaplan RC. et al. Blood pressure control and risk of incident atrial fibrillation. Am J Hypertens 2008; 21: 1111-1116.
• 17 Chamberlain AM, Agarwal SK, Folsom AR. et al. A clinical risk score for atrial fibrillation in a biracial prospective cohort (from the Atherosclerosis Risk in Communities [ARIC] study). Am J Cardiol 2011; 107: 85-91.
• 18 Wang TJ, Larson MG, Levy D. et al. Temporal relations of atrial fibrillation and congestive heart failure and their joint influence on mortality: the Framingham Heart Study. Circulation 2003; 107: 2920-2925.
• 19 Schotten U, Verheule S, Kirchhof P. et al. Pathophysiological mechanisms of atrial fibrillation: a translational appraisal. Physiol Rev 2011; 91: 265-325.
• 20 Wann LS, Curtis AB, January CT. et al. 2011 ACCF/AHA/HRS focused update on the management of patients with atrial fibrillation (updating the 2006 guideline): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 2011; 123: 104-123.
• 21 Dorian P, Guerra PG, Kerr CR. et al. Validation of a new simple scale to measure symptoms in atrial fibrillation: the Canadian Cardiovascular Society Severity in Atrial Fibrillation scale. Circ Arrhythm Electrophysiol 2009; 2: 218-224.
• 22 Kirchhof P, Bax J, Blomstrom-Lundquist C. et al. Early and comprehensive management of atrial fibrillation: Proceedings from the 2nd AFNET/EHRA consensus conference on atrial fibrillation entitled 'research perspectives in atrial fibrillation'. Europace 2009; 11: 860-885.
• 23 Israel CW, Gronefeld G, Ehrlich JR. et al. Long-term risk of recurrent atrial fibrillation as documented by an implantable monitoring device: implications for optimal patient care. J Am Coll Cardiol 2004; 43: 47-52.
• 24 Kirchhof P, Auricchio A, Bax J. et al. Outcome parameters for trials in atrial fibrillation: Recommendations from a consensus conference organized by the German Atrial Fibrillation Competence NETwork and the European Heart Rhythm Association. Europace 2007; 9: 1006-1023.
• 25 Capucci A, Santini M, Padeletti L. et al. Monitored atrial fibrillation duration predicts arterial embolic events in patients suffering from bradycardia and atrial fibrillation implanted with antitachycardia pacemakers. J Am Coll Cardiol 2005; 46: 1913-1920.
• 26 Sinha AM, Diener HC, Morillo CA. et al. Cryptogenic Stroke and underlying Atrial Fibrillation (CRYSTAL AF): design and rationale. Am Heart J 2010; 160: 36-41 e1.
• 27 Glotzer TV, Hellkamp AS, Zimmerman J. et al. Atrial high rate episodes detected by pacemaker diagnostics predict death and stroke: report of the Atrial Diagnostics Ancillary Study of the MOde Selection Trial (MOST). Circulation 2003; 107: 1614-1619.
• 28 Glotzer TV, Daoud EG, Wyse DG. et al. The relationship between daily atrial tachyarrhythmia burden from implantable device diagnostics and stroke risk: the TRENDS study. Circ Arrhythm Electrophysiol 2009; 2: 474-480.
• 29 Ziegler PD, Glotzer TV, Daoud EG. et al. Incidence of newly detected atrial arrhythmias via implantable devices in patients with a history of thromboembolic events. Stroke 2010; 41: 256-260.
• 30 Hindricks G, Pokushalov E, Urban L. et al. Performance of a new leadless implantable cardiac monitor in detecting and quantifying atrial fibrillation - results of the XPECT trial. Circ Arrhythm Electrophysiol 2010; 3: 141-147.
• 31 Pisters R, Lane DA, Nieuwlaat R. et al. A novel user-friendly score (HAS-BLED) to assess 1-year risk of major bleeding in patients with atrial fibrillation: the Euro Heart Survey. Chest 2010; 138: 1093-1100.
• 32 Lip GY, Frison L, Halperin JL. et al. Comparative Validation of a Novel Risk Score for Predicting Bleeding Risk in Anticoagulated Patients With Atrial Fibrillation The HAS-BLED (Hypertension, Abnormal Renal/Liver Function, Stroke, Bleeding History or Predisposition, Labile INR, Elderly, Drugs/Alcohol Concomitantly) Score. J Am Coll Cardiol 2011; 57: 173-180.
• 33 Hughes M, Lip GY. Risk factors for anticoagulation-related bleeding complications in patients with atrial fibrillation: a systematic review. QJM 2007; 100: 599-607.
• 34 O'Donnell HC, Rosand J, Knudsen KA. et al. Apolipoprotein E genotype and the risk of recurrent lobar intracerebral hemorrhage. N Engl J Med 2000; 342: 240-245.
• 35 Rosand J, Hylek EM, O'Donnell HC. et al. Warfarin-associated hemorrhage and cerebral amyloid angiopathy: a genetic and pathologic study. Neurology 2000; 55: 947-951.
• 36 Rosand J, Greenberg SM. Beyond hypertension: unraveling the causes of intracerebral hemorrhage. Stroke 2002; 33: 1195-1196.
• 37 Kimberly WT, Gilson A, Rost NS. et al. Silent ischemic infarcts are associated with hemorrhage burden in cerebral amyloid angiopathy. Neurology 2009; 72: 1230-1235.
• 38 Smith EE, Gurol ME, Eng JA. et al. White matter lesions, cognition, and recurrent hemorrhage in lobar intracerebral hemorrhage. Neurology 2004; 63: 1606-1612.
• 39 Eckman MH, Wong LK, Soo YO. et al. Patient-specific decision-making for warfarin therapy in nonvalvular atrial fibrillation: how will screening with genetics and imaging help?. Stroke 2008; 39: 3308-3315.
• 40 Devereaux PJ, Anderson DR, Gardner MJ. et al. Differences between perspectives of physicians and patients on anticoagulation in patients with atrial fibrillation: observational study. Br Med J 2001; 323: 1218-1222.
• 41 Holmes DR, Reddy VY, Turi ZG. et al. Percutaneous closure of the left atrial appendage versus warfarin therapy for prevention of stroke in patients with atrial fibrillation: a randomised non-inferiority trial. Lancet 2009; 374: 534-542.
• 42 Connolly SJ, Ezekowitz MD, Yusuf S. et al. Dabigatran versus warfarin in patients with atrial fibrillation. N Engl J Med 2009; 361: 1139-1151.
• 43 Patel MR, Mahaffey KW, Garg I J. et al. ROCKET AF Investigators. Rivaroxaban versus warfarin in nonvalvular atrial fibrillation. New Engl J Med 2011; 365: 883-891.
• 44 Hart RG, Pearce LA, Aguilar I M. Adjusted-dose warfarin versus aspirin for preventing stroke in patients with atrial fibrillation. Ann Intern Med 2007; 147: 590-592.
• 45 Connolly SJ, Crijns HJ, Torp-Pedersen C. et al. Analysis of stroke in ATHENA: a placebo-controlled, double-blind, parallel-arm trial to assess the efficacy of dronedarone 400 mg BID for the prevention of cardiovascular hospitalization or death from any cause in patients with atrial fibrillation/atrial flutter. Circulation 2009; 120: 1174-1180.
• 46 Kirchhof P, Lip GYH, van Gelder IC. et al. Comprehensive risk reduction in patients with atrial fibrillation: Emerging diagnostic and therapeutic options. A report from the 3rd AFNET/EHRA consensus conference. Europace. 2011 published online July 26th, 2011 http://europace.oxfordjournals.org/content/early/2011/07/26/europace.eur241.full.pdf+html