Abstract
Atrial fibrillation (AF) is associated with increased risk for stroke, heart failure and mortality. The causality between worse prognosis and AF is not clear at this time and AF may just be expression of underlying heart disease that by itself is associated with increased morbidity and mortality. AF is characterized by progression from rare paroxysmal episodes to permanent AF. It has been well recognized that maintenance of sinus rhythm with either antiarrhythmic drugs or catheter ablation is easier to achieve if treatment is established early on. In addition to the established indication of symptomatic improvement, the focus of AF management is shifting to earlier intervention to prevent cardiovascular complications. This concept is currently under investigation in the ongoing EAST trial. Early treatment initiation is desirable from a pathophysiologic perspective. This includes consequent prevention and treatment of AF risk factors, efforts for early diagnosis, and stroke prevention according to the CHA2DS2-VASc score. As long as no data support prognostic advantages with “aggressive” rhythm control therapy it remains reserved for symptomatic patients, since both, medication and catheter ablation, convey a significant risk for complications.
Zusammenfassung
Vorhofflimmern ist mit einem erhöhten Risiko für Schlaganfall, Herzinsuffizienz und Mortalität assoziiert. Die Kausalität zwischen ungünstiger Prognose und Vorhofflimmern ist allerdings zum jetzigen Zeitpunkt nicht gesichert, die Arhythmie ist möglicherweise nur Ausdruck einer fortgeschrittenen Grunderkrankung, die ihrerseits mit erhöhter Morbidität und Mortalität einhergeht. Vorhofflimmern ist durch eine Progression von seltenen Anfällen bis hin zur permanenten Form gekennzeichnet. Dabei ist ein Erhalt des Sinusrhythmus sowohl mit Antiarrhythmika als auch mit der Katheterablation erfolgreicher, wenn die Therapie möglichst früh beginnt. Neben der etablierten Indikation einer rhythmuserhaltenden Therapie mit dem Ziel einer Symptomlinderung rückt deshalb zunehmend eine frühe antiarrhythmische Therapie mit dem Ziel einer Vermeidung kardiovaskulärer Komplikationen in den Mittelpunkt. Diese These wird aktuell u.a. in der EAST Studie untersucht.
Ein möglichst frühzeitiger Therapiebeginn ist aus pathophysiologischer Sicht sinnvoll. Dazu gehört eine konsequente Prävention und Behandlung der Risikofaktoren, das Bemühen um möglichst frühzeitige Diagnosestellung und die Schlaganfallprävention nach CHA2DS2-VASc score. So lange keine Daten einen günstigen Effekt der Vorhofflimmertherapie „mit allen Mitteln“ belegen, bleibt es bei der Empfehlung zur rhythmuserhaltenden Therapie lediglich bei symptomatischen Patienten, denn sowohl Medikamente als auch die Katheterablation sind mit eigenen Risiken behaftet, die es abzuwägen gilt.
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References
Camm AJ, Lip GY, De Caterina R, Savelieva I, Atar D, Hohnloser SH, Hindricks G, Kirchhof P, ESC Committee for Practice Guidelines-CPG, Document Reviewers (2012) 2012 focused update of the ESC Guidelines for the management of atrial fibrillation: an update of the 2010 ESC Guidelines for the management of atrial fibrillation—developed with the special contribution of the European Heart Rhythm Association. Europace 14:1385–1413
Wasmer K, Breithardt G, Eckardt L (2014) The young patient with asymptomatic atrial fibrillation—what is the evidence to leave the arrhythmia untreated. Eur Heart J 35:1439–1447
Van Gelder IC, Haegeli LM, Brandes A, Heidbuchel H, Aliot E, Kautzner J, Szumowski L, Mont L, Morgan J, Willems S, Themistoclakis S, Gulizia M, Elvan A, Smit MD, Kirchhof P (2011) Rationale and current perspective for early rhythm control therapy in atrial fibrillation. Europace 13:1517–1525
Nattel S, Guasch E, Saveliea I, Cosio FG, Valverde I, Halperin JL, Conroy JM, Al-Khatib SM, Hess PL, Kirchhof P, De Bono J, Lip GY, Banerjee A, Ruskin J, Blendea D, Camm AJ (2014) Early management of atrial fibrillation to prevent cardiovascular complications. Eur Heart J 35:1448–1456
Kirchhof P, Breithardt G, Camm AJ, Crijns HJ, Kuck KH, Vardas P, Wegscheider K (2013) Improving outcomes in patients with atrial fibrillation: rationale and design of the early treatment of atrial fibrillation for stroke prevention trial. Am Heart J 166:442–448
Weijs B, Pisters R, Nieuwlaat R, Breithardt G, Le Heuzey JY, Vardas PE, Limantoro I, Schotten U, Lip GY, Crijns HJ (2012) Idiopathic atrial fibrillation revisited in a large longitudinal clinical cohort. Europace 14:184–190
Wijffels MC, Kirchhof CJ, Dorland R, Allessie MA (1995) Atrial fibrillation begets atrial fibrillation. A study in awake chronically instrumented goats. Circulation 92:1954–1968
Voigt N, Li N, Wang Q, Wang W, Trafford AW, Abu-Taha I, Sun Q, Wieland T, Ravens U, Nattel S, Wehrens XH, Dobrev D (2012) Enhanced sarcoplasmic reticulum Ca2+ leak and increased Na+ -Ca2+ exchanger function underlie delayed after depolarizations in patients with chronic atrial fibrillation. Circulation 125:2059–70
Alings M, Smit MD, Moes ML, Crijns HJ, Tijssen JG, Brügemann J, Hillege HL, Lane DA, Lip GY, Smeets JR, Tieleman RG, Tukkie R, Willems FF, Vermond RA, Van Veldhuisen DJ, Van Gelder IC (2013) Routine versus aggressive upstream rhythm control for prevention of early atrial fibrillation in heart failure: background, aims and design of the RACE 3 study. Neth Heart J 21:354–363
Jahangir A, Lee V, Friedman PA, Trusty JM, Hodge DO, Kopecky SL, Packer DL, Hammill SC, Shen WK, Gersh BJ (2007) Long-term progression and outcomes with ageing in patients with lone atrial fibrillation: a 30-year follow-up study. Circulation 115: 3050–3056
Kato T, Yamashita T, Sagara K, Iinuma H, Fu LT (2004) Progressive nature of paroxysmal atrial fibrillation. Circ J 68: 568–572
Panzio JG, Perea J, Galan L, Jimenez S, Romero R, Ruiz M, Villanueva A, Hinojar R, Ruiz J, Cosio FG (2011) The first episode of atrial fibrillation: paroxysmal, persistent or uncertain? Pacing Clin Electrophysiol 34:1320 (Abstract 30)
Freemantle N, Lafuente-Lafuente C, Mitchell S, Eckert L, Reynolds M (2011) Mixed treatment comparison of dronedarone, amiodarone, sotalol, flecainide, and propafenone, for the management of atrial fibrillation. Europace 13:329–345
Wyse DG, Waldo AL, DiMarco JP, Domanski MJ, Rosenberg Y, Schron EB, Kellen JC, Greene HL, Mickel MC, Dalquist JE, Corley SD, Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) Investigators (2002) A comparison of rate control and rhythm control in patients with atrial fibrillation. N Engl J Med 347:1825–1833
Van Gelder IC, Hagens VE, Bosker HA, Kingma JH, Kamp O, Kingma T, Said SA, Darmanata JI, Timmermans AJ, Tijssen JG, Crijns HJ, Rate Control versus Electrical Cardioversion for Persistent Atrial Fibrillation Study Group (2002) A comparison of rate control and rhythm control in patients with recurrent persistent atrial fibrillation. N Engl J Med 347:1834–1840
Shinagawa K, Shiroshita-Takeshita A, Schram G, Nattel S (2003) Effects of antiarrhythmic drugs on fibrillation in the remodeled atrium: insights into the mechanism of the superior efficacy of amiodarone. Circulation 107:1440–1446
Wazni OM, Marrouche NF, Martin DO, Verma A, Bhargava M, Saliba W, Bash D, Schweikert R, Brachmann J, Gunther J, Gutleben K, Pisano E, Potenza D, Fanelli R, Raviele A, Themistoclakis S, Rossillo A, Bonso A, Natale A (2005) Radiofrequency ablation vs antiarrhythmic drugs as first-line treatment of symptomatic atrial fibrillation: a randomized trial. JAMA 293:2634–2640
Cosedis Nielsen J, Johannessen A, Raatikainen P, Hindricks G, Walfridsson H, Kongstad O, Pehrson S, Englund A, Hartikainen J, Mortensen LS, Hansen PS (2012) Radiofrequency ablation as initial therapy in paroxysmal atrial fibrillation. N Engl J Med 367:1587–1595
Leong-Sit P, Zado E, Callans DJ, Garcia F, Lin D, Dixit S, Bala R, Riley MP, Hutchinson MD, Cooper J, Gerstenfeld EP, Marchlinski FE (2010) Efficacy and risk of atrial fibrillation ablation before 45 years of age. Circ Arrhythm Electrophysiol 3:452–457
Zhang XD1, Gu J, Jiang WF, Zhao L, Wang YL, Liu YG, Zhou L, Gu JN, Wu SH, Xu K, Liu X (2013) The impact of age on the efficacy and safety of catheter ablation for long-standing persistent atrial fibrillation. Int J Cardiol 168:2693–2698
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Wasmer, K., Köbe, J. & Eckardt, L. Antiarrhythmic therapy of atrial fibrillation: are we treating too late?. Herzschr Elektrophys 25, 210–213 (2014). https://doi.org/10.1007/s00399-014-0331-9
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DOI: https://doi.org/10.1007/s00399-014-0331-9