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Atrial Fibrillation: What’s Next?
For many years, we’ve lived with the concept that untreated atrial fibrillation (AFib) will ultimately result in multiple strokes or heart failure due to a tachycardia-induced cardiomyopathy.
The recent literature is replete with clinical trials and other studies on AFib. Yet it’s taken nearly 200 years, and the invention of electrocardiography by Einthoven, to gain a full understanding of this arrhythmia and how to treat it.
When warfarin was developed as an anticoagulant, around 1950, an organized method for anticoagulation and its reversal with vitamin K was established.
Most patients with AFib worldwide use warfarin. It’s incumbent on us to maintain appropriate therapeutic protocols for warfarin management.
The direct-acting oral anticoagulants (DOACs) have been available for about six years. The clinical trials comparing DOAC therapy with warfarin have provided firm data indicating that bleeding rates are lower with DOACs than with aspirin, and stroke rates are either lower or unchanged in the face of a lower rate of bleeding.
Some uncertainty remains regarding cessation of DOAC therapy for planned surgical procedures. Patients need to discuss stopping a DOAC with their physician before doing so. Most of us are now comfortable with using a DOAC for our patients with AFib. Aspirin has fallen out of favor due to its well-documented bleeding risk compared with a DOAC and lack of a substantial gain in stroke prevention compared with a DOAC.
Where do we go next?
Several technical advances designed to improve detection and follow-up of AFib are emerging.
- Smartphone rhythm monitoring is readily available and we’re seeing wrist watches that measure heart rate and rhythm as well as blood pressure.
Some clinical trials have demonstrated similar outcomes for chronic AFib compared with therapy aimed at maintaining sinus rhythm.
- More recent studies examining the use of left atrial ablation suggest that long-term sinus rhythm is in fact feasible after left atrial ablation. Most studies recommend continuous anticoagulation therapy even with sinus rhythm, and there’s still some uncertainty about stopping anticoagulation after some period of sinus rhythm.
Concern has arisen from long-term monitoring studies that demonstrate continued evidence of intermittent AFib that is often undetected, but still increases risk for a stroke.
- Ablation for AFib is a useful option that is beginning to show favorable long-term outcomes compared with persistent AFib for patients who are younger, symptomatic from the irregular rhythm or who have a persistent tachycardia on medications.
- For patients who cannot take an anticoagulant, we now have the option of occluding the left atrial appendage with an implanted device that excludes the left atrial appendage from the body of the left atrium. While this procedure does not eliminate the AFib, thrombus originating in the left atrial appendage is prevented from entering the circulation. This procedure has been shown to reduce the risk of stroke in patients who cannot be anticoagulated.
- We can also restore or maintain sinus rhythm in patients undergoing cardiac surgery with the Maze procedure. This procedure is often an add-on for many cardiac surgeons who are willing to spend a few minutes at the completion of a valvular or coronary procedure to disrupt the conduction pathways in the left atrium to prevent the reentrant rhythms that cause AFib. Some early studies suggest this could be an initial therapy for many patients whose AFib is difficult to manage or who are intolerant to anticoagulation.
Unlike the 1950s when our only option for oral anticoagulation was warfarin, we now have a menu of therapeutic options for patients with AFib that can be tailored to individual patient needs, which in many cases will leave the patient in sinus rhythm.
