Prevalence of Asymptomatic Recurrences of Atrial Fibrillation After Successful Radiofrequency Catheter Ablation

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/72183/1/j.1540-8167.2004.04055.x.pd

Chapter 5: Guideline Recommendations: Which AAD and for Whom?

This chapter discusses the American College of Cardiology/American Heart Association/ Heart Rhythm Society (AHA/ACC/HRS) and European Society of Cardiology (ESC) guidelines for atrial fibrillation (AF) management with particular focus on antiarrhythmic drug (AAD) selection and the identification of individuals for whom AAD treatment is appropriate. Discussion includes AAD indications, when to start an AAD, choosing among AADs, how to minimize proarrhythmic risk, how to determine efficacy, and the use of adjuvant interventions. The indications for all AADs are based on safety; the current AHA/ACC/HRS and ESC guidelines state that the choice of AAD is based on the presence or absence of structural heart disease (SHD), coronary artery disease, or heart failure (HF), with further recommendations in the ESC guidelines based on HF type (e.g., HF with reduced ejection fraction [HFrEF] versus HF with preserved ejection fraction [HFpEF]). The chapter closes with a discussion of the lack of consistent use of guideline-directed care, with a review of supportive data from the recently reported AIM-AF survey-a multinational survey on AF management that involved both cardiologists and electrophysiologists. In AIM-AF, inappropriate drug selection in terms of suitable candidate selection and drug choice occurred with all types of drugs and in most patient groups. Most notable was the overuse of amiodarone in patients without SHD, and the widespread use of sotalol, including its use in patients with HFrEF. Chapter 5 is summarized as follows

Chapter 3: Evidence for the Use of Early Rhythm Control to Prevent Atrial Fibrillation Progression

This chapter reviews atrial fibrillation (AF) progression and its associated mechanisms, including comorbidities and AF as contributors to atrial myopathy, and atrial myopathy as a contributing factor to AF progression. In addition, the chapter discusses the concept of comorbidities and atrial myopathy as synergistic contributors to adverse outcomes, the notion of AF begets AF, and the consequences of AF burden if left untreated. Clinical trials evaluating outcomes with antiarrhythmic drugs (AADs) compared with placebo have demonstrated efficacy, but also reveal a possible proarrhythmic and mortality risk if AAD selection is not appropriate and patients are not correctly identified based on risk factors and comorbidities. Data from ATHENA, the first and only trial to demonstrate that an AAD (dronedarone) can reduce cardiovascular (CV) hospitalizations in people with AF, are reviewed, along with studies reporting on the use of catheter ablation versus AADs for AF rhythm control. Finally, recent data showing a reduction in major adverse outcomes if rhythm control is initiated early are summarized, including results from the EAST-AFNET 4 trial, as well as confirmatory results from several large real-world trials. Chapter 3 is summarized as follows

Introduction: Early Diagnosis and Appropriate Treatment of Atrial Fibrillation

Atrial fibrillation (AF), the most common sustained arrhythmia, represents a significant burden to patients and healthcare systems. Many patients with AF are asymptomatic and often undiagnosed. Improved detection methods and surveillance have resulted in recognition of asymptomatic and subclinical AF, providing earlier diagnosis. The recent EAST-AFNET 4 and Korean studies have demonstrated early rhythm control (ERC) with antiarrhythmic drugs (AADs) or ablation in patients with AF improves outcomes. The EARLY AF and STOP AF First studies have shown that ERC using ablation can slow AF progression. In the following videos, the authors discuss the evolving AF landscape, with an emphasis on the benefits of early diagnosis and treatment. Historic rate versus rhythm control studies and their limitations are reviewed, followed by recent studies that support the use of ERC alongside usual care including rate control. Discussion of ERC treatment includes the selection of appropriate AADs based on safety, when to choose ablation as first-line therapy, and the complementary use of ablation and AADs. The authors summarize the current guidelines for the use of AADs to treat AF, highlighting the importance of concordance with those guidelines. Patient cases are used to relate the contents of the videos to clinical practice and are supplemented with discussion of the importance of shared decision-making involving the patient in treatment decisions. It is anticipated that this digital publication will enable cardiologists and primary care providers to recognize when early treatment of AF will improve patient outcomes, and to empower them to initiate that treatment accordingly

Chapter 2: Rate Versus Rhythm Control

Atrial fibrillation (AF) is a potentially serious health risk, both because of its symptoms and because of its association with an increased risk for heart failure, hospitalization, thromboembolism, and death. Chapter 2 discusses selection of appropriate treatments and when to initiate these therapies. Older trials focused on comparing rate versus rhythm control treatment options for AF. It is now recognized that both rate and rhythm control are important and can be used together. This chapter reviews the historical, pivotal rate versus rhythm control trials that failed to show any overall survival benefit of rhythm over rate control, as well as the trials\u27 now-recognized limitations with respect to modern therapy. In addition, an in-depth discussion of the more recent trials of antiarrhythmic drugs (AAD) and ablation techniques (which have become available since the original rate versus rhythm trials were performed) is included. These updated trials show that when applied to patient- and disease-specific situations, rhythm control can reduce the risk for mortality and hospitalization. The chapter also reviews the guidelines that have been developed to achieve these goals. Chapter 2 is summarized as follows: (1) Rate control is needed (at rest and during exertion) to reduce rate-related symptoms when rhythm control is ineffective or incomplete and to prevent a tachycardia-induced cardiomyopathy. (2) Previous trials with pharmacological therapy alone comparing rate versus rhythm control using the AADs available at that time failed to show any overall survival benefit of rhythm control over rate control. (3) These earlier trials had many methodological limitations and enrolled participants who did not have access to modern therapies. (4) Newer therapies, including those for stroke prevention, dronedarone (the latest approved AAD), and AF ablation, have improved the safety and efficacy of rhythm control strategies

Chapter 1: The Evolving Atrial Fibrillation Landscape: Importance of Early Diagnosis and Treatment

Chapter 1 begins with data that show the rising prevalence of atrial fibrillation (AF), which is increasing in tandem with the growing number of older adults, increased survival of people who have cardiovascular (CV) disorders, and the expanding use of wearable and insertable/implantable devices capable of detection. Together, these increases will result in healthcare providers seeing more patients with AF who present at earlier stages of the disease. The panel discussion covers information regarding symptoms that are common to patients with AF as well as information about the important adverse outcomes that may occur in patients with AF, including heart failure, hospitalization, thromboembolism, and death. Notably, these events may reflect either the comorbidities commonly underlying AF, AF itself, or a combination of these conditions. The chapter also introduces the four pillars of therapy- upstream therapy, rate control, rhythm control, and embolic prevention-with an emphasis on early rhythm control as being optimal. Chapter 1 is summarized as follows

Chapter 4: Evidence for the Early Use of Ablation and AADs Post-Ablation

Both catheter ablation and antiarrhythmic drugs (AADs) are effective treatments for atrial fibrillation (AF) and can be used individually or as complementary treatments. This chapter discusses the use of ablation for early rhythm control in AF, and the use of AADs post-ablation. Decisions on which therapeutic approach to pursue should be based on shared decision-making with the patient. The chapter reviews data from the CABANA trial, in which the intent-to-treat (ITT) analysis failed to show superiority for ablation versus AADs. Statistical significance was achieved, however, when using the pre-specified per-protocol and pre-treatment analyses. The discussion addresses the fact that data analysis was complicated by several factors: (1) not all members of the group assigned to ablation actually received ablation; (2) the AAD arm included rate control treatment without the use of AADs; (3) there were a large number of crossovers from the AAD arm to the ablation arm; and (4) many ablation-treated participants also used AADs. Results from the CABANA trial showed that ablation was better at preventing AF recurrence than AADs alone. Data from the STOP AF and EARLY AF trials that support the observation of ablation being superior to AADs alone for the reduction of recurrent AF are also reviewed. Many patients who undergo catheter ablation for AF either continue to use or need to restart AADs following ablation. This combination therapy is used by up to 40-50% of people at 1-year post ablation, as is clearly demonstrated by the results from the trials discussed above, in addition to those from the 5A trial, the POWDER AF trial, the AMIO-CAT trial, and a substantial meta-analysis. All these trials are reviewed in this chapter, noting that a variety of differences exist between the randomized clinical trials, including in ablation procedures, follow-up periods, physician experience, and AADs. Chapter 4 is summarized as follows

Chapter 6: AAD Use in Different Patient Populations, and a Patient-Centric Approach to Optimal Patient Management

Associated with longer life expectancy, greater survival of patients with cardiovascular disorders, and increased use of wearable and insertable/implantable devices capable of detection, the frequency of atrial fibrillation (AF) diagnosis is increasing. This chapter describes two representative patient cases that were used to enable a discussion of the evaluation and management of AF in different scenarios. One patient is young and healthy with paroxysmal AF but no major comorbidities (though there is a family history of AF). The other is older with multiple complicating comorbidities. These cases sparked an active discussion among the panelists that demonstrated not only the multitude of considerations when choosing the optimal therapy for each individual, but also the individualistic differences in biases and styles that can exist between experts in the field. The results of these discussions revealed agreement that

Outcomes of out of hospital sudden cardiac arrest in India: A review and proposed reforms

Background: Bystander cardiopulmonary resuscitation (CPR) is the cornerstone in managing out-of-hospital cardiac arrest (OHCA). However, India lacks a formal sudden cardiac arrest (SCA) registry and the infrastructure for a robust emergency medical services (EMS) response system. Also, there exists an opportunity to improve widespread health literacy and awareness regarding SCA. Other confounding variables, including religious, societal, and cultural sentiments hindering timely intervention, need to be considered for better SCA outcomes. Objectives: We highlight the current trends and practices of managing OHCA in India and lay the groundwork for improving the awareness, education, and infrastructure regarding the management of SCA. Conclusion: Effective management of OHCA in India needs collaborative grassroots reformation. Establishing a large-scale SCA registry and creating official and societal guidelines will be pivotal for transforming OHCA patient outcomes