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Dr. Jean-Yves Le Heuzey,
This session devoted to medical treatment of atrial fibrillation showed that in the future, we will probably use new drugs, especially in the field of antithrombotic agents.
Regarding anti-arrhythmic drugs, as analysed by A. CAPUCCI (Piacenza, IT), amiodarone remains the drug which is, in most cases, used by cardiologists, mainly as a second choice after failure of another anti-arrhythmic drug firstly chosen. Adverse effects are now well established after so many years of therapeutic habits. In the future, dronedarone will probably find its place in the medical treatment of atrial fibrillation.
Treating atrial fibrillation implies that it is necessary to make a choice between rhythm and rate control strategies. If rate control is chosen, as emphasized by H. CRIJNS (Maastricht, NL), the choice of drugs that can be used to achieve proper rate control remains rather limited. Digitalis, slowing heart rate calcium blockers and beta-blockers are the only drugs which can be used. Clearly, digitalis is not able to achieve a good control during exercise in most patients and it is necessary to use calcium blockers or beta-blockers. Further studies have to be done to better define the ideal value of heart rate at rest and during exercise.
The future of antithrombotic therapy was described by R.WILLEMS (Leuven, BE). A lot of new drugs are currently under development, mainly antithrombin and anti Xa drugs. Dabigatran is, to date, the drug whose development seems to be the most advanced in atrial fibrillation. The RELY trial has completed its recruitment with more than 10,000 patients, and the final results will probably be known in 2010. Dabigatran is an antithrombin drug whereas rivaroxaban and apixaban are anti Xa drugs. Large trials are currently ongoing with these drugs, versus warfarin (ROCKET AF with rivaroxaban and ARISTOTLE with apixaban) or aspirin (AVERROES with apixaban). Finally, idraparinux is a drug that is also being developed in atrial fibrillation, under its biotylinated form. It can be used subcutaneously with one injection every week. It is being tested in a trial named BOREALIS AF.
Nowadays, so-called ”upstream” therapy is used more and more often to treat atrial fibrillation, as described by R. HATALA (Bratislava, SK). It mainly concerns renin angiotensin system blocking agents (ACE inhibitors and ARB), statins and polyunsaturated acids (PUFAs). There are many experimental arguments to think that agents blocking the renin angiotensin system could avoid electrophysiological remodeling following the occurrence of atrial fibrillation, mainly by limiting the development of fibrosis. Several post hoc analyses of subgroups coming from large trials and small randomized trials make it possible to draw this hypothesis of a beneficial effect, but we are still waiting for a definitive, evidence-based demonstration of this efficacy in a large trial directly designed with this goal.
In conclusion, medical treatment of atrial fibrillation remains a major challenge for cardiologists. The field of thrombo-embolic risk prevention is very promising with the development of competitive drugs trying to replace vitamin K antagonists with the goal of suppressing INR monitoring.
Medical treatment of atrial fibrillation
This congress report accompanies a presentation given at the ESC Congress 2008. Written by the author himself/herself, this report does not necessarily reflect the opinion of the European Society of Cardiology.
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