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Atrial fibrillation: medical therapy, anticoagulation and device therapy

Latest update 2013 December

Atrial Fibrillation

2012 focused update of the ESC Guidelines for the management of atrial fibrillation: an update of the 2010 ESC Guidelines for the management of atrial fibrillation. Developed with the special contribution of the European Heart Rhythm Association.

Camm AJ, Lip GY, De Caterina R, Savelieva I, Atar D, Hohnloser SH, Hindricks G, Kirchhof P; ESC Committee for Practice Guidelines (CPG), Bax JJ, Baumgartner H, Ceconi C, Dean V, Deaton C, Fagard R, Funck-Brentano C, Hasdai D, Hoes A, Kirchhof P, Knuuti J, Kolh P, McDonagh T, Moulin C, Popescu BA, Reiner Z, Sechtem U, Sirnes PA, Tendera M, Torbicki A, Vahanian A, Windecker S; Document Reviewers, Vardas P, Al-Attar N, Alfieri O, Angelini A, Blömstrom-Lundqvist C, Colonna P, De Sutter J, Ernst S, Goette A, Gorenek B, Hatala R, Heidbüchel H, Heldal M, Kristensen SD, Kolh P, Le Heuzey JY, Mavrakis H, Mont L, Filardi PP, Ponikowski P, Prendergast B, Rutten FH, Schotten U, Van Gelder IC, Verheugt FW. Eur Heart J. 2012 Nov;33(21):2719-47.

This document is an update to the 2010 ESC Guidelines on the management of AF.

Stroke prevention in atrial fibrillation: managing the risks in light of new oral anticoagulants.

Strobeck JE.
Cardiovasc Drugs Ther (2012) 26:331–338.

In this review of the literature, results of the clinical trials involving these new
agents are discussed and compared, with a focus on the balance between efficacy and

Prevention of stroke in patients with atrial fibrillation: anticoagulant and antiplatelet options.

Varughese CJ, Halperin JL. J Interv Card Electrophysiol. 2012 Oct;35(1):19-27.

This review provides an update on recent advancements in antithrombotic therapy for stroke prevention in patients with AF.

EHRA practical guide on the use of new oral anticoagulants in patients with non-valvular atrial fibrillation: executive summary.

Heidbuchel H, Verhamme P, Alings M, Antz M, Hacke W, Oldgren J, Sinnaeve P,Camm AJ, Kirchhof P. Eur Heart J. 2013 Jul;34(27):2094-106.

Latest practical guidelines on using NOACs in patients with AF.

Antiarrhythmic drug therapy for atrial fibrillation.

Zimetbaum P. Circulation. 2012 Jan 17;125(2):381-9.

This review focuses primarily on antiarrhythmic drug use in patients with AF in the absence of significant structural heart disease or congestive heart failure.

Medical treatment of atrial fibrillation.

Camm AJ, Camm CF, Savelieva I. J Cardiovasc Med (Hagerstown). 2012 Feb;13(2):97-107

This review provides a contemporary evidence-based insight into the medical management of atrial fibrillation in the modern era.

Novel anti-arrhythmic medications in the treatment of atrial fibrillation.

Saklani P, Skanes A. Curr Cardiol Rev. 2012 Nov;8(4):302-9. Review. 

„This review summarizes the main anti-arrhythmic clinical trials, early phase trials involving novel agents and examines the conflicting data relating to Dronedarone”

Rhythm control versus rate control for atrial fibrillation and heart failure.

Roy D, Talajic M, Nattel S, Wyse DG, Dorian P, Lee KL, Bourassa MG, Arnold JM, Buxton AE, Camm AJ, Connolly SJ, Dubuc M, Ducharme A, Guerra PG, Hohnloser SH, Lambert J, Le Heuzey JY, O'Hara G, Pedersen OD, Rouleau JL, Singh BN, Stevenson LW, Stevenson WG, Thibault B, Waldo AL. N Engl J Med 2008;358:2667-2677.

Whereas the ACC/AHA/ESC 2006 guidelines (see above) incorporated data from many trials on rate vs. rhythm control in AF patients, no specific data exist on the best treatment option specifically in heart failure patients, although it is well-known that atrial fibrillation is a predictor of death in patients with heart failure. This multicenter, randomized AF-CHF trial compared the maintenance of sinus rhythm (rhythm control) with control of the ventricular rate (rate control) in patients with a LVEF of ≤35%, symptoms of congestive heart failure, and a history of atrial fibrillation. The primary outcome was the time to death from cardiovascular causes. A total of 1376 patients were enrolled (682 in the rhythm-control group and 694 in the rate-control group) and were followed for a mean of 37 months. The hazard ratio for death from cardiovascular causes in the rhythm-control group was 1.06 (95% confidence interval, 0.86 to 1.30; P=0.59 by the log-rank test). Also secondary outcomes were similar in the two groups, including death from any cause (32% in the rhythm-control group and 33% in the rate-control group), stroke (3% and 4%, respectively), worsening heart failure (28% and 31%), and the composite of death from cardiovascular causes, stroke, or worsening heart failure (43% and 46%). There were also no significant differences favoring either strategy in any predefined subgroup.

Role of permanent pacing to prevent atrial fibrillation

Science advisory from the American Heart Association Council on Clinical Cardiology (Subcommittee on Electrocardiography and Arrhythmias) and the Quality of Care and Outcomes Research Interdisciplinary Working Group, in collaboration with the Heart Rhythm Society. Knight BP, Gersh BJ, Carlson MD, Friedman PA, McNamara RL, Strickberger SA, Tse HF, Waldo AL. Circulation 2005;111:240-243.

Extensive overview on studies concerning pacing modalities and algorithms used to prevent and terminate atrial fibrillation (AF). Based on these data, recommendations are made concerning the type of pacemaker, site of pacing and the use of specific algorithms to prevent or treat AF.

Minimizing ventricular pacing to reduce atrial fibrillation in sinus-node disease.

Sweeney MO, Bank AJ, Nsah E, Koullick M, Zeng QC, Hettrick D, Sheldon T, Lamas GA.
N Engl J Med 2007;357:1000-1008.

This prospectively randomized ‘SAVE PACe’ trial in 1065 patients with sinus-node disease, intact atrioventricular conduction, and a normal QRS interval showed that algorithms in dual-chamber pacemakers intended to minimize ventricular pacing can achieve that goal effectively (from 99% to 9.1%, P<0.001). Such pacing resulted in a moderate but significantly lower rate of developing persistent atrial fibrillation (7.9% vs. 12.7%, hazard ratio 0.60, 95% confidence interval, 0.41 to 0.88; P=0.009). The mortality rate was similar in the two groups.

Percutaneous left atrial appendage closure for stroke prevention in patients with atrial fibrillation: an assessment of net clinical benefit.

Gangireddy SR, Halperin JL, Fuster V, Reddy VY. Eur Heart J. 2012 Nov;33(21):2700-8.

This post hoc analysis describes the net clinical benefit of percutaneous left atrial appendage closure for stroke prevention in patients with atrial fibrillation.

Left atrial appendage closure: a percutaneous transcatheter approach for stroke prevention in atrial fibrillation. 

Landmesser U, Holmes DR Jr. Eur Heart J. 2012 Mar;33(6):698-704.

For several reasons, device-based therapies are currently being developed for stroke prevention in non-valvular atrial fibrillation and potentially offer an alternative approach for stroke prevention in these patients which will be the focus of this excellent review article.

For prevention of stroke in patients with atrial fibrillation: a randomised non-inferiority trial.

Holmes DR, Reddy VY, Turi ZG, Doshi SK, Sievert H, Buchbinder M, Mullin CM, Sick P; PROTECT AF Investigators.Lancet. 2009 Aug 15;374(9689):534-42.

A randomized trial of an LAA occlusion device compared with Warfarin. This suggests non-inferiority for LAA occlusion on an intention to treat analysis. Importantly patients were left on Warfarin for 45 days after the occlusion procedure so the use of this device has not been tested in patients with absolute contraindications to Warfarin.