ESC Congress FA eBook 2016 - 19

ESC CONGRESS 2016
IN REVIEW

FOCUS ON ARRHYTHMIAS
SELECTED UPDATES

An Update on Atrial Fibrillation
in Clinical Practice
Written by Phil Vinall

Laurent Fauchier, MD, Universitaire Trousseau et Faculté de Médecine, Université François
Rabelais, Tours, France, opened this session on atrial fibrillation (AF) in clinical practice with a
discussion of the definitions of valvular and nonvalvular AF and how to use nonvitamin K antagonist oral anticoagulants (NOACs) to treat AF patients with valvular disease.
European and US guidelines define non-valvular AF as AF in the absence of rheumatic mitral
stenosis, a mechanical or bioprosthetic heart valve [Camm AJ et al. Eur Heart J. 2012], or mitral
valve repair [January CT et al. J Am Coll Cardiol. 2014]. Prof Fauchier noted that these are not
mechanistic definitions. Rather, they evolved from the somewhat inconsistent inclusion and
exclusion criteria used in the NOAC trials [Breithardt G, Baumgartner H. Eur Heart J. 2015].
Suggesting that patients with some types of valvular disease should not be restricted from NOAC
therapy [Fauchier L et al. Arch Cardiovascu Dis. 2015], Prof Fauchier used several recent trials to provide a perspective on the thromboembolic risk in AF with different types of valve disease. The ROCKET
AF trial compared the use of rivaroxaban and warfarin in patients with and without significant valvular
disease (SVD; none with mitral stenosis or artificial valve prostheses). Efficacy for both groups was similar, but the risk of bleeding among patients with SVD was higher with rivaroxaban (the risk was similar
for those without SVD) [Breithardt G et al. Eur Heart J. 2014]. In the ARISTOTLE trial, apixaban and
warfarin had similar effects on stroke and systemic embolism and bleeding in patients with and without valvular heart disease [Avezum A et al. Circulation. 2015]. A third trial, in patients with mechanical
heart values, showed dabigatran to be associated with significantly increased rates of thromboembolic
and bleeding complications, compared with warfarin [Eikelboom JW et al. N Engl J Med. 2013]. With
respect to bioprostheses, a 2016 trial showed these AF patients to have a non-significantly higher risk
of stroke/thromboembolic events compared to patients with non-valvular AF, according to the older
definition [Philippart R et al. Thromb Haemost. 2016]. There is no longer a definition of valvular AF
in the guidelines. Prof Fauchier recommends classifying patients based on the type of valvular defect
(Table 1).
The onset of AF and heart failure (HF) often coincide. In clinical practice, however, the diagnosis of
both conditions is often delayed because therapy has concealed their onset (ie, diuretics can conceal
HF and ß-blockers can conceal AF). John Cleland, MD, PhD, University of Glasgow and National Heart
and Lung Institute, Imperial College, London, United Kingdom, discussed the relationship between
these 2 conditions.
The prevalence of AF in patients with HF is high (about 20% to 40%), while the incidence (4% to 6%) is
relatively low. Given the competing risk between incident AF and death among patients with HF, the
incidence rate for AF is too low to account for its prevalence. Investigations into this paradox indicate
that the temporal relationship between the conditions has prognostic significance [Shelton RJ et al.
Congest Heart Fail. 2010]. Specifically, the development of AF in patients with HF confers a worse
prognosis [Zakeri R et al. Circulation. 2013] while cardiovascular hospitalization and all-cause mortality occur less often in patients who develop AF first (49.6% vs 77.7% of patients; P = .001; Figure 1)
[Smit MD et al. Eur J Heart Fail. 2012].
Prevention should be considered in these patients, especially strategies involving neuro-endocrine inhibition.
With regards to stroke prevention, in the 2016 guidelines, the European Society of Cardiology
stated that NOACs can prevent the majority of ischemic strokes in patients with AF and is superior
to no treatment or treatment with aspirin. The Guidelines go on to suggest that NOACs should be
used in most patients with AF, with the exception of those with very low stroke risk [Kirchhof P et
al. Eur Heart J. 2016].

Official Peer-Reviewed
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Official Peer-Reviewed Highlights From ESC Congress 2016

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