ESC Congress FA eBook 2016 - 17

ESC CONGRESS 2016
IN REVIEW

FOCUS ON ARRHYTHMIAS
SELECTED UPDATES

Reducing the Burden of
Atrial Fibrillation Through
Prevention and Treatment
Written by Maria Vinall

Speakers in this symposium presented highlights from three papers published in a Special
Edition of The Lancet that focused on the priorities for prevention and best clinical management
of atrial fibrillation (AF). Gregory Y. H. Lip, MD, University of Birmingham, Birmingham, United
Kingdom, spoke on stroke prevention in patients with AF; Laurent Fauchier, MD, Universitaire
Trousseau et Faculté de Médecine, Université François Rabelais, Tours, France, discussed
rhythm control in patients with AF; and Isabelle C. Van Gelder, MD, University Medical Center
Groningen, The Netherlands, discussed rate control in AF.
About one-third of all ischemic strokes are associated with AF. Prof Lip noted that most of
these could be prevented through proper risk assessment and use of the appropriate therapy
based on a patient's risk factors. There is growing evidence that even a single stroke risk factor confers an excess risk of thromboembolism and mortality in patients with AF and that these
patients can benefit from treatment with oral anticoagulants (OACs) [Fauchier L et al. Stroke.
2016]. Accordingly, the 2016 ESC guidelines for the management of AF [Kirchhof P et al. Europace.
2016] now state that OACs should be considered for men with a CHA2DS2-VASc ≥ 1 and women
with a score ≥ 2, balancing the expected stroke reduction and bleeding risk, and taking into
account patient preference. Prof Lip suggested that given the availability of four non-vitamin K
OACs in addition to the vitamin K antagonists, it is possible and beneficial to fit the drug to the
patient's profile. Clinical considerations include abnormally low weight (consider a dose reduction); bleeding risk, especially previous or recent gastrointestinal bleeding; renal function; potential drug interactions; and elderly age (again potential dose reduction).
Prof Lip suggested the following approach: and Step 1, identify low-risk patients using their
CHA2DS2-VASc; Step 2, use OACs in all patients with ≥ 1 risk factors; and Step 3, decide on the
type and approach to anticoagulant treatment. Finally, patients need support to ensure adherence to and persistence with treatment in the long term.
According to Prof Van Gelder, rate control is indicated to prevent the symptoms of AF and the
induction or progression of HF; however, the optimal heart rate target in patients with AF is unclear.
The RACE II trial, which compared lenient vs strict rate control in patients with AF showed that over
3 years, lenient rate control was not inferior to strict rate control for preventing cardiovascular morbidity and mortality in patients with permanent AF and was easier to achieve. Fewer drugs, lower
doses, and fewer hospital visits were needed (Figure 1) [Van Gelder et al. N Engl J Med. 2010].
Prof Van Gelder noted that the rate control guidelines in the 2016 ESC guidelines for the
management of AF remained the same as those in the 2010 guidelines (ie, lenient rate control
is acceptable unless symptoms call for stricter rate control). The recommendation to consider
atrial ablation also remained unchanged [Kirchhof P et al. Europace. 2016]. Before choosing a
rate control strategy, Prof Van Gelder suggests observing the patient's heart rate to assess for
underlying comorbidities. Rate control drugs include: ß-blockers, non-dihydropyridine calciumchannel antagonists, digoxin, and amiodarone. There are no large randomized trials comparing
the different types of drugs but there are two good older, smaller studies. The first compared several drug combinations in 12 patients. The most effective treatment for achieving the lowest heart
rate over a 24-hour period was atenolol plus digoxin [Farshi R et al. J Am Coll Cardiol. 1999]. The
second study compared several individual drugs in 60 symptomatic permanent AF patients. The
most effective drugs for reducing symptoms were verapamil and diltiazem; whereas, ß-blockers
reduced exercise tolerance and increased NT-proBNP [Ulimoen SR et al. Am J Cardiol. 2013; Eur
Heart J. 2014].

Official Peer-Reviewed
Highlights From

Official Peer-Reviewed Highlights From ESC Congress 2016

Table of Contents for the Digital Edition of ESC Congress FA eBook 2016