Atrial fibrillation is emerging as the new epidemic in cardiovascular disease, according to a joint report by the German Competence Network on Atrial Fibrillation (AFNET) and the European Heart Rhythm Association (EHRA). The report, which was presented at the recent EHRA-Europace Congress (26–29 June, Madrid, Spain), states that the rate of mortality and morbidity associated with the condition remain “unacceptably high” despite recent advances in treatment. It sets out several key steps for improving the situation: detection and better management of risk factors, good clinical use of new antithrombotic therapies, early detection of any new arrhythmia, and timely rhythm control treatment.
The report identifies several well-known risk factors for atrial fibrillation, such as age, hypertension, and heart failure, and also lists emerging risk factors that are less well known (eg. height, with relative risk increasing markedly with 10cm increments). It recommends that the analysis of several cardiac biomarkers, particularly natriuretic peptides, can help to assess the risk of the condition. Genetic biomarkers may also be useful (genetic factors are most closely associated with younger patients with atrial fibrillation). However, the report recognises that many risk factors still have not been indentified and, thus, it says there is a “clear and unmet need to identify and characterise factors associated with progression of AF.”
Stroke, of course, is the major complication of atrial fibrillation but preventing it can be a challenge as the blood-clot reducing benefits of traditional treatments such as warfarin need to be balanced against the risk of bleeding associated with these treatments. The need for monitoring and problems of food and drug interactions can cause further challenges. Therefore, the new report welcomes the introduction of new anticoagulants (such as dabigatran, rivaroxaban, apixaban, and edoxaban) but calls for more information about them and for careful monitoring of their efficacy in clinical practice.
The risk of stroke, according to the report, remains “unacceptably high” even if a patient receives optimal anticoagulation: in controlled trials, the rate of stroke among patients who receive optimal anticoagulation was still 1.5%. Therefore, a comprehensive approach using rate and/or rhythm control therapies, particularly when these are used early, may help to further improve outcomes.
Paulus Kirchhof, one of the organisers of EHRA-Europace 2011, said: “The management of atrial fibrillation is undergoing remarkable changes – new antithrombotic drugs, catheter ablation, and new insights into its mechanism. Our consensus report provides initial guidance in the good use of these news – and at times costly – therapeutic options.”