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Atrial fibrillation treatment in 2013

Atrial Fibrillation

During this session dedicated to atrial fibrillation (AF) treatment, an overview of both anti-arrhythmic and anticoagulation aspects was done by the 4 speakers.

Pharmacological or electrical cardioversion?

Luc Jordaens pointed out that the key question is the need or not for cardioversion. The answer should be based on the expected success rate, the expected clinical benefit and the estimated risk of recurrences whatever the strategy. The second key point is to schedule the cardioversion according to the anticoagulation.
The overall efficacy is higher when using electrical cardioversion (88%) as compared to pharmacological cardioversion (71%) with a lower adverse event rate (< 6% vs 10%). The success rate of pharmacological cardioversion and delay for sinus rhythm restoration is variable: 50-80% within 6 hours with class IC drugs, 50% within 90 minutes with ibutilide, 50% within 14 minutes with vernakalant and 80-90% within 24 hours with amiodarone. In the latest ESC guidelines, both methods, pharmacological or electrical cardioversion, may be performed according to patient status, and physician and patient preferences. The safety issue, based on contraindication of antiarrhythmic drugs, is a priority.

Antiarrhythmic drugs for sinus rhythm maintenance: are they safe enough?

Jean Yves le Heuzey summarized the expected benefit of rhythm control strategy. The negative results of the large trials on AF rhythm management may have been related to the proarrhythmic effect of the drugs. In all the trials, heart failure was clearly identified as the strongest predictive factor of death and major adverse events, including the recent studies with dronedarone.
The safety of amiodarone may also be questionable if we consider the results of SCD-HeFT, with an overall mortality higher under amiodarone as compared to placebo, even if this trial was not dedicated to AF patients. Nevertheless being in sinus rhythm is clearly associated with a better prognosis, leading to consider safer approaches, including development of new drugs with a better risk/benefit profile, for promoting rhythm control strategy. For clinical practice the drug selection should be based on the 2012 updated ESC guidelines.

Anticoagulants: which one for which patient?

For John Eikelboom, the clinical decision should be based on 3 questions.
First: is there a need for anticoagulation? Based on the 2012 updated guidelines, 90% of AF patients are candidates for anticoagulation therapy.
Second question: antivitamin K antagonist or new oral anticoagulant (NOAC)? Based on the results of the 3 published trials that demonstrated a clear global benefit of NOACs, warfarin should be considered only in valvular AF patients and patients with a contraindication to NOAC, mainly renal insufficiency or drug interaction.
Third question: which NOAC? All 3 available NOACs are highly effective and safe. In the absence of head to head comparisons, only indirect comparisons were performed on the basis of meta-analysis, with some risks of bias and misinterpretation. None of the 3 evaluated drugs may be identified as superior to the others. For any given patient, the choice has to be performed by considering the drug characteristics and the patient profile (moderate renal impairment, risk of gastro-intestinal bleeding, coronary disease, dyspepsia…).

Ablation: a first line therapy?

Gerhard Hindricks, as an author of the 2012 updated ESC guidelines, mentioned that the window is now open to consider ablation as a first line therapy. Nevertheless, the strong recommendation (Class I, level A) is to consider ablation only after failure of at least one antiarrhythmic drug. However, the potential better results of ablation when performed early and the low rate of major adverse events when performed in experienced centers lead to consider, in selected patients, ablation as a first line option. Such an approach is already observed in 10% of ablated patients. Based on the results of the MANTRA AF trial, a 50% reduction of AF recurrence and a significant improvement in quality of life may be expected.
The recommendation on ablation as a first line treatment is grade IIa, level of evidence B. The long term European registry on AF ablation will show us the impact of this recommendation on clinical practice. Despite the enthusiasm of the EP community, we have to await the results of ongoing prospective trials conducted on large populations to validate the risk/benefit ratio of ablation.
At that time, we may expect an upgrade of the level of recommendation.


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Session Title: Atrial fibrillation treatment in 2013

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.