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Atrial fibrillation 2009: contemporary therapies for the new epidemic

Atrial Fibrillation

The first presentation by Dr JR Ehrlich (Frankfurt, DE ) dealt with atrial remodelling and its application for therapy. There are 3 types of remodelling: Electrical, contractile and structural. Electrical remodelling refers to the atrial cellular response to rate increase which can be multiplied by 10 at the atrial level and is associated with calcium overload. This represents a threat to cell viability and involves a number of atrial currents which can represent potential targets to therapy. Contractile remodelling is demonstrated by the recovery of contraction which can be delayed after restoration of sinus rhythm. Structural remodelling involves inflammation, fibrosis and hypertrophy and may result in heterogeneity in conduction and anisotropy which promote AF. The renin-angiotensin system is involved and ACE inhibitors and ARBs have been reported to have a beneficial effect in the primary and secondary prevention of atrial fibrillation (AF). However, there is no convincing prospective trial supporting this use and the recent GISSI trial using an ARB was negative.

Pr Thomas Meinertz from Hamburg, DE, spoke about the future of antiarrhythmic therapy. He classified the perspectives into 3 groups: Atrial selective agents including vernakalant, amiodarone congeners and particularly dronedarone and others. The latter group represents gap junction blockers, serotonin receptor antagonists and muscarinic receptor blockers. Does dronedarone represent a progress in terms of efficacy and safety? Yes referring to the recent results of the ATHENA trial, which showed that dronedarone decreased cardiovascular hospitalisation by 26 per cent, the first AF related hospitalisation by 46 per cent, all AF related hospitalisation by 23per cent and reduction of the number of days of hospitalisation. This multichannel blocker without iodine is the first antiarrhythmic agent which reduced cardiovascular events and cardiovascular mortality.

Dr Carlo Pappone from Milan, IT presented the outcome and complications of AF ablation.  The difficulty of evaluating AF ablation comes - according to the lecturer – from the number of techniques used in ablation procedures. All the series comparing ablation to pharmacological therapy have shown that the percentage of patients treated with ablation in sinus rhythm is superior (64 per cent) to medical therapy (26 per cent); in their series, 89 per cent versus 23 per cent. The complications have an incidence which depends on the center and the experience of the operators. These complications concern the vascular access, the trans-septal puncture and the injury to the cardiac chambers. The risk of death during the procedure is reported to be around 0.1 per cent.

Dr Douglas Packer from the Mayo Clinic (Rochester, USA) found that the statement of international societies concerning AF ablation and ablation guidelines cannot include class A recommendation as prospective comparative randomized trials are not available. Registries such as the one conducted by Dr Cappato are useful but the long –term results are difficult to evaluate with a registry. The CABANA trial will cover this gap and will randomize recent onset paroxysmal AF to antiarrhythmic medications or to ablation, which will include pulmonary vein isolation as a minimum procedure. The primary endpoint will be mortality and secondary endpoints will include cardiovascular death, hospitalizations, heart failure, cost and quality of life.




Atrial fibrillation 2009: contemporary therapies for the new epidemic

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.