Early management of atrial fibrillation to prevent cardiovascular complications

Abstract

Atrial fibrillation (AF) is generally considered a progressive disease, typically evolving from paroxysmal through persistent to 'permanent' forms, a process attributed to electrical and structural remodelling related to both the underlying disease and AF itself. Medical treatment has yet to demonstrate clinical efficacy in preventing progression. Large clinical trials performed to date have failed to show benefit of rhythm control compared with rate control, but these trials primarily included patients at late stages in the disease process. One possible explanation is that intervention at only an early stage of progression may improve prognosis. Evolving observations about the progressive nature of AF, along with the occurrences of major complications such as strokes upon AF presentation, led to the notion that earlier and more active approaches to AF detection, rhythm-reversion, and maintenance of sinus rhythm may be a useful strategy in AF management. Approaches to early and sustained rhythm control include measures that prevent development of the AF substrate, earlier catheter ablation, and novel antiarrhythmic drugs. Improved classifications of AF mechanism, pathogenesis, and remodelling may be helpful to enable patient-specific pathophysiological diagnosis and therapy. Potential novel therapeutic options under development include microRNA-modulation, heatshock protein inducers, agents that influence Ca(2+) handling, vagal stimulators, and more aggressive mechanism-based ablation strategies. In this review, of research into the basis and management of AF in acute and early settings, it is proposed that progression from paroxysmal to persistent AF can be interrupted, with potentially favourable prognostic impact.

EHRA/HRS/APHRS/SOLAECE expert consensus on atrial cardiomyopathies: definition, characterization, and clinical implication

“…It has been suggested that earlier aggressive intervention to maintain sinus rhythm, including AF ablation if needed, may aid to prevent 'chronicization' of AF and improve long-term outcomes. 501 A large-scale multicentre trial is presently testing this idea. 502 The true impact of atrial cardiomyopathies on the success of catheter ablation has not been elucidated.…”

Cellular and Molecular Electrophysiology of Atrial Fibrillation Initiation, Maintenance, and Progression

“…10,11 Each AF episode requires initiation by a trigger acting on a vulnerable substrate. This vulnerable substrate is at least partly determined by genetic factors.…”

“…15 About 5% of patients with pAF progress to persistent forms each year. 11 Further progression occurs at increasing rates, with 35% to 40% of patients with persistent AF developing permanent AF <1 year. 4 The progression rate is lowest in young patients without associated heart disease (lone AF), amounting to 1% to 3% per year.…”

“…In some cases, AF initially presents as persistent AF ( Figure 1C). 11 When AF is maintained, it causes atrial tachycardia-induced remodeling, increasing substrate vulnerability and promoting AF maintenance, progression, and stabilization. It must be recognized that Figure 1 is a schematic presentation of our present concepts of common forms of AF evolution, and that other clinical forms are possible, for example, recurrent paroxysmal AF that never becomes persistent, and initial presentation with persistent AF that is never terminated, whether because treating physicians decide that AF conversion is unnecessary or because successful conversion to sinus rhythm proves impossible.…”

Irregular rhythm and atrial metabolism are key for the evolution of proarrhythmic atrial remodeling in atrial fibrillation

“…AF is generally considered a progressive disease, with episodes increasing in frequency and/or duration over time, resulting in a transition from paroxysmal (lasting \7 days and spontaneously converting to sinus rhythm) AF (pAF) to persistent AF (lasting [7 days or requiring cardioversion), long-lasting persistent (chronic) AF (cAF), and permanent AF [12,20]. Although the current AF classification was not developed based on underlying pathophysiological mechanisms, there are important differences in the molecular and cellular electrophysiology of pAF and cAF patients [30,31].…”