Réduire ou ralentir la fibrillation auriculaire : est-ce la bonne question en 2010 ?

RésuméPourquoi et comment traiter la fibrillation atriale ? Cette question a paru simple pendant de nombreuses années : la fibrillation atriale, trouble du rythme cardiaque, doit être traitée par des médicaments anti-arythmiques, tant qu’ils peuvent être efficaces. Les effets secondaires de ces médicaments, comme le bénéfice fréquemment apporté par un simple traitement bradycardisant a amené à discuter il y a une dizaine d’années deux stratégies thérapeutiques, réduire ou ralentir. Mais ce choix largement mis en avant dans les précédentes recommandations thérapeutiques, apparaît aujourd’hui réducteur. En 2010 on peut sans doute proposer deux objectifs thérapeutiques, traiter les symptômes et traiter le risque cardiovasculaire associée à la fibrillation. La gêne symptomatique entraînée par l’arythmie doit être toujours évaluée chez nos patients, volontiers selon la classification récente EHRA. Parallèlement la fibrillation fait partie du continuum cardiovasculaire, et constitue un marqueur de risque supplémentaire : il apparaît certain que le contrôle de ce risque supplémentaire associé à la fibrillation ne dépend pas uniquement du traitement de l’arythmie proprement dite.SummaryWhy and how to treat atrial fibrillation? This question seemed simple for many years: atrial fibrillation, a cardiac arrhythmia, should be treated with antiarrhythmic drugs, as long as they can be effective. Side effects of these drugs, as good benefit often provided by a simple bradycardic treatment led to discuss it some 10 years ago 2 therapeutic strategies: rhythm control or rate control. But this choice widely highlighted in the previous guidelines, now seems simplistic. In 2010 we can probably offer two therapeutic goals, treat symptoms and treat cardiovascular risk associated with atrial fibrillation. The discomfort caused by symptomatic arrhythmia should always be assessed in our patients, as by the recent EHRA classification. Meanwhile fibrillation is part of the cardiovascular continuum, and is a marker of an additional risk: it appears certain that the control of this additional risk does not depend solely on the treatment of the arrhythmia itself

Les effets pro-arythmiques des médicaments

RésuméLes effets pro-arythmiques des médicaments sont fréquents et graves, et sont associés à une surmortalité non négligeable. La polymédication augmente le nombre d’effets indésirables et d’interactions graves voire mortelles. Certains sont facilement évitables. Cependant, au-delà de l’allongement de l’intervalle QT, d’autres mécanismes peuvent avoir un rôle majeur comme les dysfonctions du RyR2, responsable d’arythmie calcium-dépendantes par surcharge calcique intracellulaire, avec apparition de post-dépolarisations tardives, sans modifications de l’intervalle QT. Les bloqueurs des canaux sodiques sont également un problème sérieux de part le risque de démasquer ou d’aggraver une dysfonction du canal sodique chez des patients atteints de syndrome de Brugada asymptomatique ou non. Leur dépistage à un stade précoce du développement des médicaments peut avoir un intérêt majeur.SummaryThe cardiac safety of new and marketed drugs is a major concern for public authorities, patients, physicians as well as pharmaceutical companies. Letal adverse drug reactions are indeed a leading cause of death worldwide and increase at a greater rate than the increase in total hospital admission. The increasing use of polypharmacy in current clinical practice is also associated to a growing number of side effects and interactions leading to fatal adverse events. Measurement of the QT interval is an established, albeit incomplete, approach to assess the proarrhythmic risk of a drug. Ventricular arrhythmia (VA) can be caused by a QT-prolonging drug inducing abnormal repolarization of the action potential (AP) of ventricular cardiomyocytes. Emerging evidence, derived from recent understanding of these mechanisms and of similar mechanisms reported for heart failure (HF), suggest that diastolic Ca2+ leak from the sarcoplasmic reticulum (SR) related to RyR2 dysfunction can induce Ca2+ dependent arrhythmia. In this report, we review mechanisms underlying drug-induced arrhythmogenic effects and Ca2+ dependent arrhythmia, and, for the latter, we discuss some of the issues associated to worsening of cardiac arrhythmias

Left ventricular endocardial pacing in cardiac resynchronisation therapy: Moving from bench to bedside

In cardiac resynchronisation therapy, failure to implant a left ventricular lead in a coronary sinus branch has been reported in up to 10% of cases. Although surgical insertion of epicardial leads is considered the standard alternative, this is not without morbidity and technical limitations. Endocardial left ventricular pacing can be an alternative as it has been associated with a favourable acute haemodynamic response compared with epicardial pacing in both animal and human studies. In this paper, we discuss left ventricular endocardial pacing and compare it with epicardial surgical implantation. Ease of application and procedural complications and morbidity compare favourably with epicardial surgical techniques. However, with limited experience, the most important concern is the still unknown long-term risk of thromboembolic complications. Therefore, for now endovascular implants should remain reserved for severely symptomatic heart failure patients and patients at high surgical risk of failed coronary sinus implantation

MACVIA-LR (Fighting Chronic Diseases for Active and Healthy Ageing in Languedoc-Roussillon): A Success Story of the European Innovation Partnership on Active and Healthy Ageing.

International audienceThe Région Languedoc Roussillon is the umbrella organisation for an interconnected and integrated project on active and healthy ageing (AHA). It covers the 3 pillars of the European Innovation Partnership on Active and Healthy Ageing (EIP on AHA): (A) Prevention and health promotion, (B) Care and cure, (C) and (D) Active and independent living of elderly people. All sub-activities (poly-pharmacy, falls prevention initiative, prevention of frailty, chronic respiratory diseases, chronic diseases with multimorbidities, chronic infectious diseases, active and independent living and disability) have been included in MACVIA-LR which has a strong political commitment and involves all stakeholders (public, private, patients, policy makers) including CARSAT-LR and the Eurobiomed cluster. It is a Reference Site of the EIP on AHA. The framework of MACVIA-LR has the vision that the prevention and management of chronic diseases is essential for the promotion of AHA and for the reduction of handicap. The main objectives of MACVIA-LR are: (i) to develop innovative solutions for a network of Living labs in order to reduce avoidable hospitalisations and loss of autonomy while improving quality of life, (ii) to disseminate the innovation. The three years of MACVIA-LR activities are reported in this paper

MACVIA-LR, Reference site of the European Innovation Partnership on Active and Healthy Ageing (EIP on AHA) in Languedoc Roussillon

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Introduction

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