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

EP Europace, Jan 2008

Atrial fibrillation (AF) is associated with impaired functional capacity and quality of life and significant morbidity and mortality. The current management approach fails to maintain stable sinus rhythm (SR) in the majority of patients. For many years, guidelines have recommended antiarrhythmic treatment of a first AF episode only if the AF is poorly tolerated, a position that has been reinforced by studies showing no mortality or morbidity advantage of rhythm control over rate control. During the last decade, research has shown mechanisms of self-perpetuation of AF based on electrophysiological and structural remodelling induced by AF itself. There is mounting evidence that ‘ lone ’ AF is because of a host of factors, some of which may be easily treatable, such as hypertension, sleep apnoea, and obesity, thus allowing secondary prevention at the time of the first episode of AF. According to these concepts, lack of early intervention could be one of the reasons for long-term failure of maintenance of SR. In this position paper, we propose testing the working hypothesis that if an SR maintenance strategy is selected, treatment of AF should commence at the first-detected episode and should be based on a double strategy of SR restoration and aggressive treatment of associated conditions that promote atrial remodelling.

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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 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 Francisco G. Cosio 1 Etienne Aliot 2 Giovanni Luca Botto 3 Hein Heidbu?chel 4 Christoph Johan Geller 5 Paulus Kirchhof 6 Jean-Claude De Haro 7 Robert Frank 8 Julian Perez Villacastin 9 Johan Vijgen 10 Harry Crijns 0 0 University Hospital Maastricht , The Netherlands 1 Hospital Universitario de Getafe , Carretera de Toledo, km 12,5 Getafe, 28905 Madrid , Spain 2 Ho?pital de Brabois , Nancy , France 3 Sant'Anna Hospital , Como , Italy 4 University Hospital Gasthuisberg , Leuven , Belgium 5 Zentralklinik Bad Berka , Germany 6 Kompetenznetz Vorhofflimmern und Medizinische Klinik und Poliklinik C, Kardiologie und Angiologie , Muenster , Germany 7 Ho?pital de La timone , Marseille , France 8 Ho?pital Pitie Salpetriere , Paris , France 9 University Hospital San Carlos , Madrid , Spain 10 Virga Jesse Hospital , Hasselt , Belgium * Corresponding author. Tel: ?34 91 683 0781; fax: ?34 91 683 9826. E-mail address: Published on behalf of the European Society of Cardiology. All rights reserved. & The Author 2007. For permissions please email: . The online version of this article has been published under an open access model. Users are entitled to use, reproduce, disseminate, or display the open access version of this article for non-commercial purposes provided that the original authorship is properly and fully attributed; the Journal, Learned Society and Oxford University Press are attributed as the original place of publication with correct citation details given; if an article is subsequently reproduced or disseminated not in its entirety but only in part or as a derivative work this must be clearly indicated. For commercial re-use, please contact journals.permissions&oxfordjournals.org. eol>First-detected atrial fibrillation; Antiarrhythmic; Angiotensin; Atrial remodelling - Atrial fibrillation (AF) is associated with impaired functional capacity and quality of life and significant morbidity and mortality. The current management approach fails to maintain stable sinus rhythm (SR) in the majority of patients. For many years, guidelines have recommended antiarrhythmic treatment of a first AF episode only if the AF is poorly tolerated, a position that has been reinforced by studies showing no mortality or morbidity advantage of rhythm control over rate control. During the last decade, research has shown mechanisms of self-perpetuation of AF based on electrophysiological and structural remodelling induced by AF itself. There is mounting evidence that ?lone? AF is because of a host of factors, some of which may be easily treatable, such as hypertension, sleep apnoea, and obesity, thus allowing secondary prevention at the time of the first episode of AF. According to these concepts, lack of early intervention could be one of the reasons for long-term failure of maintenance of SR. In this position paper, we propose testing the working hypothesis that if an SR maintenance strategy is selected, treatment of AF should commence at the first-detected episode and should be based on a double strategy of SR restoration and aggressive treatment of associated conditions that promote atrial remodelling. Introduction: atrial fibrillation, a growing clinical problem In developed countries, a progressively ageing population and better survival from chronic conditions such as hypertension and heart failure has led to a dramatic increase in the prevalence of atrial fibrillation (AF). It has been estimated that between 2.3 million and 10 and 12 million individuals in USA and European Union, respectively, have AF and it is expected that these numbers will increase 2.5- to 3-fold during the next 50 years (Figure 1).1?3 AF is particularly prevalent in patients with cardiac disease, but a proportion of AF patients have ?lone AF?, i.e. AF that is not associated with structural heart disease.4,5 AF also affects a significant proportion of younger individuals, with a prevalence of 0.7% in those aged 55?59 years.6 AF has a significant impact on morbidity, mortality, and quality of life (QoL),7 which may be worse in women than in men.7?9 This is reflected in the high rate of hospitalizations for AF.6 Patients with congestive heart failure (CHF) are at an increased risk of AF,10 and AF often worsens heart failure in these cases.11?14 AF is also associated with a risk of stroke of 5% per year, two to seven times than that of people without AF.11,15,16 Strokes are also more severe in patients with AF, and are more likely to result in permanent disability.17 AF often causes significant impairment in QoL that is frequently recognized by the patient only after sinus rhythm (SR) has been restored by cardioversion.18,19 Symptoms vary with ventricular rate, underlying heart condition, and the duration of AF.19 Importantly, a high percentage of AF epi (...truncated)


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Cosio, Francisco G., Aliot, Etienne, Botto, Giovanni Luca, Heidbüchel, Hein, Geller, Christoph Johan, Kirchhof, Paulus, De Haro, Jean-Claude, Frank, Robert, Villacastin, Julian Perez, Vijgen, Johan, Crijns, Harry. 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, EP Europace, 2008, pp. 21-27, Volume 10, Issue 1, DOI: 10.1093/europace/eum276