Editorial

Evolving perspectives for personalised management of patients with atrial fibrillation Paulus Kirchhof1,2 This editorial introduces a series of review articles on different diagnostic modalities that can help to personalise the treatment of atrial fibrillation. The editorial outlines the current best evidence-based management of atrial fibrillation, and highlights the huge clinical need to improve outcomes in patients with atrial fibrillation further. It appears that understanding the causes of atrial fibrillation in individual patients would allow to design, test and validate better and personalised strategies for the treatment of this common threat to healthy ageing. This issue of Heart inaugurates a series of review articles on atrial fibrillation. The reviews will explore different ways to apply existing diagnostic tests to personalise the management of patients with atrial fibrillation. Atrial fibrillation has received a lot of attention by researchers, clinicians, journals and the wider public in recent years, and there are good reasons to think and talk about this common arrhythmia: Assuming that the average reader of Heart is around 40 years old, every fourth of us will suffer from atrial fibrillation in his or her life.1 Those of us who will work in clinical medicine for another 20 years or 30 years will be faced with double or triple the amount of patients with atrial fibrillation that they see today.2 Furthermore, atrial fibrillation, while rarely acutely life-threatening, bears severe consequences for patients and societies: Atrial fibrillation causes approximately every fourth stroke, patients with atrial fibrillation are at increased risk for cardiovascular death, are frequently and urgently admitted to hospital, and suffer from reduced quality of life, cognitive dysfunction and loss of autonomy. After the breakthrough demonstration that oral anticoagulation by dose-adjusted 1

University of Birmingham Center for Cardiovascular Sciences, School of Clinical and Experimental Medicine, and SWBH NHS Trust, Birmingham, UK; 2Department of Cardiovascular Medicine, Hospital of the University of Muenster, Muenster, Germany Correspondence to Dr Paulus Kirchhof, University of Birmingham Centre for Cardiovascular Sciences, School of Clinical and Experimental Medicine and SWBH NHS trust, IBR, 1st Floor, Birmingham B15 2TT, UK; [email protected]

Kirchhof P. Heart July 2014 Vol 100 No 14

warfarin can prevent strokes in patients with atrial fibrillation,3 the last decade has seen further improvements in stroke prevention: While the first studies were done in patients at extremely high stroke risk, we now have good data to support the use of oral anticoagulation in all patients with atrial fibrillation and cardiovascular risk factors.4 As valid alternatives to vitamin K antagonists, five novel, fixeddose direct oral anticoagulants have been compared with warfarin in large controlled clinical trials: They are equally effective or slightly more effective than vitamin K antagonists and are less likely to cause intracranial haemorrhages.5 Dabigatran, rivaroxaban and apixaban have been approved for use in patients with atrial fibrillation, and edoxaban is currently evaluated by the European Medicines Agency (EMA), the US Food and Drug Administration (FDA), and other regulatory agencies. Ximelagatran is no longer used due to non-cardiac side effects. Hence, we have a choice of different anticoagulants that will allow healthcare professionals to offer anticoagulation to all patients with atrial fibrillation at risk for stroke. But even when patients with atrial fibrillation receive adequate rate control and oral anticoagulation therapy, they still die prematurely, often from heart failure or sudden death,6 and many are admitted to hospital every year. Furthermore, cognitive dysfunction, loss of autonomy and depression are associated with atrial fibrillation. Indeed, our current evidence-based management—including anticoagulation and rate control in all patients with atrial fibrillation, and rhythm control therapy in

Table 1

those with persistent symptoms—does not sufficiently lower the increased mortality associated with atrial fibrillation: Even in trials, patients with atrial fibrillation die at a rate of 3.5–4% per year, 1.5% per year suffer strokes even in anticoagulation trials, and 3–5% need unplanned hospitalisations per year.5 Importantly, and possibly contributing to this remaining morbidity and mortality, all available treatments for AF can cause severe, albeit uncommon side effects (table 1). Recent insights into the molecular7 8 and genetic9 pathophysiology of atrial fibrillation open perspectives for better, personalised approaches to the management of atrial fibrillation.10 11 These insights may enable prevention and treatment of atrial fibrillation in the future by countering the root causes of the arrhythmia. This reads a bit like science fiction today, and we definitely need tools to identify and characterise the causes of atrial fibrillation in individual patients to let our pathophysiological insights come to fruition for patients. The review series on atrial fibrillation that inaugurates in this issue of Heart reviews some of the techniques that are already available to us, to understand the different causes and types of atrial fibrillation a bit better. The authors of the individual review articles, all experts in their field, comprise physiologists, engineers, cardiologists with expertise in imaging and arrhythmia management, and stroke physicians, illustrating the interdisciplinary approaches that seem required to successfully improve management of patients with AF in the future. In this issue of Heart, Ulrich Schotten and Theo Lankveld discuss how the ECG is already used to detect AF,12 and how detailed analyses of the ECG can be used to improve therapeutic decisions in patients with atrial fibrillation. Thereafter, Karl Georg Häusler and Daniel Werring will review the information that can be extracted from brain imaging in patients with atrial fibrillation to identify those at risk for cognitive decline and those at risk

Therapeutic modalities in atrial fibrillation and their main complications

Therapeutic modality

Main therapeutic benefit

Main side effect

Anticoagulants Rate control agents

prevention of strokes prevention of palpitations and heart failure prevention of atrial fibrillation and symptomatic improvement prevention of atrial fibrillation and symptomatic improvement

bleeding Syncope and other bradycardia-related events Proarrhythmia, sudden death

Antiarrhythmic drugs Catheter ablation of atrial fibrillation

stroke, tamponade and access site complications

1071

Editorial for intracerebral bleeding. Dres Delgado and Bax will be describing the current role of cardiac imaging in the management of atrial fibrillation. There are other important developments that we did not cover in this review series, such as the emerging role of blood-based biomarkers including miRNAs to identify causes of atrial fibrillation in patients, or how a genetic predisposition to atrial fibrillation may alter treatment response. Time, experience, and translational research efforts will tell whether this information can become useful to improve prevention, diagnosis and therapy of atrial fibrillation in the future. If atrial fibrillation conveys all these adverse outcomes, why do we not restore and maintain sinus rhythm to improve outcomes in patients with AF? Pointing at this elephant in the atrial fibrillation room, Hindricks et al will end this series of review articles discussing the current and emerging role of rhythm control therapy to improve outcomes in patients with atrial fibrillation. The editorial team of Heart believes that this series of reviews highlights some of the potentially useful roads to improve outcomes in patients with atrial fibrillation through individualised therapy concepts based on a better understanding of the arrhythmia. The editors of Heart wish that these review articles increase your appetite to find better treatments for patients with atrial fibrillation in your practice, and that they suggest some of the

1072

cutlery needed to feed that appetite. There is a huge unmet clinical need, and I sincerely hope that this decade will be used to translate our wealth of knowledge about mechanisms of atrial fibrillation into better treatments for patients with atrial fibrillation.

3

4

Funding European Union FP7 EUTRAF and British Heart Foundation (FS/13/32/30324). Competing interests None. Provenance and peer review Commissioned; internally peer reviewed.

To cite Kirchhof P. Heart 2014;100:1071–1072.

5

6

Received 10 March 2014 Accepted 11 March 2014 7

▸ http://dx.doi.org/10.1136/heartjnl-2013-305149 ▸ http://dx.doi.org/10.1136/heartjnl-2013-305151

8

9

Heart 2014;100:1071–1072. doi:10.1136/heartjnl-2013-305146

10

REFERENCES 1

2

Lloyd-Jones DM, Wang TJ, Leip EP, et al. Lifetime risk for development of atrial fibrillation: the Framingham heart study. Circulation 2004;110: 1042–6. Heeringa J, van der Kuip DA, Hofman A, et al. Prevalence, incidence and lifetime risk of atrial fibrillation: the Rotterdam study. Eur Heart J 2006;27:949–53.

11

12

Hylek EM, Go AS, Chang Y, et al. Effect of intensity of oral anticoagulation on stroke severity and mortality in atrial fibrillation. N Engl J Med 2003;349:1019–26. Kirchhof P, Curtis AB, Skanes AC, et al. Atrial fibrillation guidelines across the Atlantic: a comparison of the current recommendations of the European Society of Cardiology/European Heart Rhythm Association/European Association of Cardiothoracic Surgeons, the American College of Cardiology Foundation/American Heart Association/ Heart Rhythm Society, and the Canadian Cardiovascular Society. Eur Heart J 2013;34: 1471–4. Ruff CT, Giugliano RP, Braunwald E, et al. Comparison of the efficacy and safety of new oral anticoagulants with warfarin in patients with atrial fibrillation: a meta-analysis of randomised trials. Lancet 2013. Published Online First: Epub Date. doi:10.1016/S0140-6736(13)62343-0 Marijon E, Le Heuzey JY, Connolly S, et al. Causes of death and influencing factors in patients with atrial fibrillation: a competing risk analysis from the randomized evaluation of long-term anticoagulant therapy study. Circulation 2013;128:2192–201. Schotten U, Verheule S, Kirchhof P, et al. Pathophysiological mechanisms of atrial fibrillation: a translational appraisal. Physiol Rev 2011;91:265–325. Wakili R, Voigt N, Kaab S, et al. Recent advances in the molecular pathophysiology of atrial fibrillation. J Clin Invest 2011;121:2955–68. Ellinor PT, Lunetta KL, Albert CM, et al. Meta-analysis identifies six new susceptibility loci for atrial fibrillation. Nat Genet 2012;44:670–5. Van Gelder IC, Haegeli LM, Brandes A, et al. Rationale and current perspective for early rhythm control therapy in atrial fibrillation. Europace 2011;13: 1517–25. Nattel S, Guasch E, Savelieva I, et al. Early management of atrial fibrillation to prevent cardiovascular complications. Eur Heart J 2014. Published Online First: Epub Date. doi:10.1093/eurheartj/ehu028. Lankveld TAR, Zeemering S, Crijns HJGM, et al. The ECG as a tool to determine atrial fibrillation complexity. Heart 2014;100:1077–84.

Kirchhof P. Heart July 2014 Vol 100 No 14

Evolving perspectives for personalised management of patients with atrial fibrillation.

Evolving perspectives for personalised management of patients with atrial fibrillation. - PDF Download Free
396KB Sizes 3 Downloads 3 Views