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The future of atrial fibrillation therapy: the 2nd AFNET/EHRA consensus conference

Atrial Fibrillation


Atrial Fibrillation (AF) is a rising epidemic and progressive chronic disease. It affects several million people in Europe, and it causes morbidity and mortality on a population level, including deaths, strokes, and reduced quality of life. This harm associated with AF cannot yet be prevented by current therapies maintaining sinus rhythm. Experts therefore postulate an earlier and more comprehensive management of AF patients. This is the main conclusion of the 2nd AFNET-EHRA consensus conference on research perspectives in atrial fibrillation.

Over 70 experts from academia and industry met in October 2008 in order to set the agenda for urgent research in the field of AF. The international summit was organised by the German Competence Network on Atrial Fibrillation (AFNET) and the European Heart Rhythm Association (EHRA), and initiated by cardiologists: Günter Breithardt (Münster, Germany), John Camm (London, UK), Harry Crijns (Maastricht, NL), and Paulus Kirchhof (Münster, Germany). The results have been made available on line in Europace (full paper), (1) and in the European Heart Journal (executive summary) (2).

Three main areas in need of research were identified:

  1. Understanding the mechanisms of AF
  2. Improving rhythm control monitoring and management
  3. Validation and implementation of comprehensive cardiovascular risk management in AF patients

The expectation of the attendees of the conference was that, in the future, adequate therapy for AF will need to simultaneously address:

  • management of underlying and concomitant diseases,
  • early and comprehensive rhythm control therapy,
  • adequate control of ventricular rate and cardiac function,
  • continuous therapy to prevent AF-associated complications

During a session at the ESC Congress 2009 that was chaired by Prof. Günter Breithardt, Münster, Germany and Prof. John Camm, London, U.K., four speakers highlighted some important issues that had been discussed at the Consensus Conference in October 2008 and published in the meantime in the European Heart Journal (Executive Summary) and in Europace (Full text).

The role of so-called upstream therapy was discussed by Prof. Harry Crijns from Maastricht, the Netherlands. He portrayed the importance of the angiotensin-converting enzyme system in the development of atrial fibrillation and the potential benefits of ACE inhibitors or angiotensin receptor blockers in reducing the burden of atrial fibrillation, especially in recent onset atrial fibrillation. Also, statins seem to have a beneficial effect on the underlying process, most probably through an anti-inflammatory mechanism. However, more data are needed to confirm these results which have mostly emerged from post-hoc analyses. These data at least have moved the focus on the potential to influence the underlying pathophysiological process.

New anticoagulants with mechanisms of action that are different from vitamin K antagonists, were addressed by Prof. Freek Verheugt from Amsterdam. He described the novel factor IIa and Xa antagonists like dabigatran and rivaroxaban, their mechanism of action and presently available results. In this context, the favourable results of the RELY-Trial with dabigatran in comparison to warfarin in patients with atrial fibrillation that had just been reported in a Hot Line Session at the congress for the first time ever, were intriguing, since they suggest a superiority of the drug over warfarin in patients with atrial fibrillation. Read the Hotline Report on RELY here.

Radiofrequency catheter ablation of atrial fibrillation by pulmonary vein isolation has emerged as an important treatment modality. However, despite initial success, there is a substantial recurrence rate. The strategy in patients with recurrences was addressed by Dr. J.F.R. de Sousa, Portugal. In a high percentage, the reason for recurrence is that pulmonary vein isolation is not complete due to local recovery of conduction out of the pulmonary veins. Re-ablation is then the method of choice. In other cases, it might be important to change the underlying atrial substrate by identifying regions with continuous fractionated atrial electrograms which stand for regional fibrosis.

Finally, Prof. Paulus Kirchhof of Münster, Germany addressed the role of outcome parameters in atrial fibrillation. There has recently been a shift of concern from symptoms and rhythm to cardiac structure and function, to other end organ damage (e.g. in the brain), quality of life, and negative effects of the disease on global functioning and well-being. Adequate therapy of AF will need a comprehensive approach that simultaneously addresses the management of underlying and concomitant conditions, early and comprehensive rhythm control therapy, adequate control of ventricular rate and cardiac function, and continuous therapy to prevent AF-associated complications.

References


  1. Kirchhof P, Bax J, Blomstrom-Lundquist C, Calkins H, Camm AJ, Cappato R, Cosio F, Crijns H, Diener HC, Goette A, Israel CW, Kuck KH, Lip G, Nattel S, Page R, Ravens U, Schotten U, Steinbeck G, Vardas P, Waldo A, Wegscheider K, Willems S, Breithardt G. Early and comprehensive management of AF: Proceedings from the 2nd AFNET-EHRA consensus conference on atrial fibrillation entitled “research perspectives in AF”. Europace 2009; e-pub ahead of print
  2. Kirchhof P, Bax J, Blomstrom-Lundquist C, Calkins H, Camm AJ, Cappato R, Cosio F, Crijns H, Diener HC, Goette A, Israel CW, Kuck KH, Lip G, Nattel S, Page R, Ravens U, Schotten U, Steinbeck G, Vardas P, Waldo A, Wegscheider K, Willems S, Breithardt G. Early and comprehensive management of AF: Exectuvie summary of the proceedings from the 2nd AFNET-EHRA consensus conference “research perspectives in AF”. Eur Heart J 2009; e-pub ahead of print

This congress report accompanies a presentation given at the ESC Congress 2009. Written by the author himself/herself, this report does not necessarily reflect the opinion of the European Society of Cardiology.

SessionNumber:

107

SessionTitle:

The future of atrial fibrillation therapy: the 2nd AFNET/EHRA consensus conference

Notes to editor


EHRA

The European Heart Rhythm Association (EHRA), a branch of the European Society of Cardiology (ESC), is an association specialising in electrophysiology and was created from the merger of two former Working Groups on 'Cardiac Pacing' and on 'Arrhythmias’. Its ambition is to serve as the leading organisation in the field of arrhythmias and electrophysiology in Europe, and to attract all physicians from Europe and beyond to foster the development of this area of expertise. http://authors.escardio.org/EHRA

AFNET

The German Competence Network on Atrial Fibrillation (AFNET) is an interdisciplinary research network located in Germany. AFNET aims to improve care of patients with atrial fibrillation by promoting research, medical services and information in emerging diagnostic and therapeutic fields in atrial fibrillation. The network has been funded by the German Federal Ministry of Research and Education since 2003.
http://www.kompetenznetz-vorhofflimmern.de/

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.