The Future of Atrial Fibrillation Treatment

We have seen a remarkable evolution in the therapy of atrial fibrillation in the last 2 decades. Once regarded as a nuisance arrhythmia by electrophysiologists, AF has taken center stage in modern clinical practice, attracting attention of physicians from all specialties.

This increased attention is appropriate. By far the most prevalent arrhythmia in clinical practice, AF accounts for more hospitalizations than all other arrhythmia diagnoses combined. And these hospitalizations are protracted, costly and complicated.

AF is important to patients for two reasons. First, it causes severe symptoms that dramatically reduce quality of life, and second, it is responsible for stroke. Thus, treatment of some nature is required for virtually every patient, and therapy is likely to be chronic.

Clinicians clamor for effective therapies, but currently available treatments are limited. Since we don’t have a complete understanding of the pathophysiology of the disease, our treatments are largely broad spectrum, meaning some patients are destined to not respond or to respond poorly while being exposed to potential complications. Yet it is amazing how successful physicians have been in restoring patients to reasonable functionality while preventing the most devastating consequences of the disease.

In this issue, several internationally renowned experts review the state of the art. We have asked each of them to consider, in particular, stroke prevention. Several interesting things emerge. Clearly, not all patients with AF require anticoagulation. So how do we identify those patients for whom the benefit outweighs the risk? We hope that with the advent of new anticoagulants, we will be able to protect patients more efficiently, even those whose stroke risk may not be high. Emerging data from dabigatran trials suggest that we are succeeding.

We are also learning that patients and physicians are uncertain about the need for continuing anticoagulation after patients are treated with rhythm control measures. This issue has been brought into bold relief in the catheter ablation literature, where close monitoring of patients post procedure suggests that at least some patients remain free of recurrence at least for several months. Will anticoagulants with short times to onset and offset set the stage for intermittent therapy? Might we also be able to use drugs selectively, only when frequent arrhythmias have been observed? Such an approach will require sophisticated patient monitoring. Fortunately, devices to accomplish that are rapidly evolving.

So the future of AF treatment is bright, but the path forward will not be easy. We need to take into account the cost implications and the risk of every new intervention, and to do that, large, controlled, randomized trials will be mandated. Using publications such as this, we hope to keep our physician public properly briefed to optimize the care they render to patients with AF.