Primary Prevention of Atrial Fibrillation where are we in 2012?
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ABSTRACT:
SUBMITTER: Imazio M
PROVIDER: S-EPMC5153126 | biostudies-literature | 2012 Aug-Sep
REPOSITORIES: biostudies-literature
Publications
Primary Prevention of Atrial Fibrillation where are we in 2012?
Journal of atrial fibrillation 20120820 2
Drugs to alter or delay myocardial remodelling associated with heart failure, hypertension, or inflammation in the post-operative setting, may prevent the development of atrial fibrillation. Current experimental and clinical evidences support specific treatments for defined patient population (i.e. ACE-inhibitors and ARB for chronic heart failure and hypertension expecially with LV hypertrophy; statins, corticosteroids and possibly colchicine after cardiac surgery). ...[more]
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Project description:Atrial fibrillation (AF), is the most common sustained cardiac arrhythmia. It was once thought to be benign as long as the ventricular rate was controlled, however, AF is associated with significant cardiac morbidity and mortality. Increasing life expectancy driven by improved health care and decreased fertility rates has, in most of the world, resulted in the population aged ≥65 years growing more rapidly than the overall population. As the population ages, projections suggest that the burden of AF may increase more than 60% by 2050. Although considerable progress has been made in the treatment and management of AF, primary prevention, secondary prevention, and prevention of thromboembolic complications remain a work in progress. This narrative review was facilitated by a MEDLINE search to identify peer-reviewed clinical trials, randomized controlled trials, meta-analyses, and other clinically relevant studies. The search was limited to English-language reports published between 1950 and 2021. Atrial fibrillation was searched via the terms primary prevention, hyperthyroidism, Wolff-Parkinson-White syndrome, catheter ablation, surgical ablation, hybrid ablation, stroke prevention, anticoagulation, left atrial occlusion and atrial excision. Google and Google scholar as well as bibliographies of identified articles were reviewed for additional references. In these two manuscripts, we discuss the current strategies available to prevent AF, then compare noninvasive and invasive treatment strategies to diminish AF recurrence. In addition, we examine the pharmacological, percutaneous device and surgical approaches to prevent stroke as well as other types of thromboembolic events.
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Project description:Atrial fibrillation (AF) and obstructive sleep apnea (OSA) are very prevalent diseases in modern society. Recent years have seen the emergence of a wide body of literature suggesting an important association between these two diseases. This review will provide a summary of this evidence as it currently exists. First, it will review the literature suggesting an association between AF and OSA by highlighting the prevalence of AF in OSA, the correlation of AF prevalence with OSA severity and the trend towards increased AF recurrence in patients with OSA after treatment for AF. Second, it will identify the possible pathophysiologic mechanisms for this association. In doing so, it will discuss the investigated effects of intrathoracic pressure changes, autonomic instability and atrial remodeling. Finally, it will review the evidence of the effect of treatment of OSA on AF, highlighting the role of continuous positive airway pressure (CPAP) in the treatment of OSA and its impact on AF prevalence and recurrence.
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Project description:Stroke prevention is central to the management of patients with atrial fibrillation (AF) which has moved towards a more holistic or integrative care approach. The published evidence suggests that management of AF patients following such a holistic approach based on the Atrial fibrillation Better Care (ABC) pathway is associated with a lower risk of stroke and adverse events. Risk assessment, re-assessment and use of direct oral anticoagulants (DOACs) are important for stroke prevention in AF. The stroke and bleeding risks of AF patients are not static and should be re-assessed regularly. Bleeding risk assessment is to address and mitigate modifiable bleeding risk factors, and to identify high bleeding risk patients for early review and follow-up. Well-controlled comorbidities and healthy lifestyles also play an important role to achieve a better clinical outcome. Digital health solutions are increasingly relevant in the diagnosis and management of patients with AF, with the potential to improve stroke prevention. In this review, we provide an update on stroke prevention in AF, including importance of holistic management, risk assessment/re-assessment, and stroke prevention for special AF populations. Evidence-based and structured management of AF patients would reduce the risk of stroke and other adverse events.
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Project description:Atrial fibrillation (AF) is the commonest cardiac rhythm disorder worldwide, affecting 1% of the general population. It is estimated that up to 16 million people in the US will suffer from the arrhythmia by 2050. AF is an independent stroke risk factor and associated with more severe strokes. For six decades, warfarin has been the only truly effective therapy to protect against stroke for patients with atrial fibrillation. Despite the proven worth of warfarin, its limitations have seen reluctance amongst physicians and patients to utilise this efficacious agent. This has meant that substantial numbers of patients are either unprotected against stroke or suboptimally protected with antiplatelet therapy. Contemporary well-validated stroke risk factor schemes (CHA(2)DS(2)-VASc) now permit rapid but comprehensive evaluation of a patient's risk for thromboembolism, allowing better identification of low-risk patients who do not require antithrombotic therapy, and whilst for those with ?1 stroke risk factors require formal oral anticoagulation. Aspirin has been proven to be inferior to anticoagulation, and is not free of bleeding risk. We also have simple scores to easily evaluate a patient's risk of haemorrhage (e.g. HAS-BLED). The emergence of new oral anticoagulants should further improve stroke prevention in AF, and they successfully negotiate many of the hurdles to oral anticoagulation generated by warfarin's limitations. Monitoring, reversal, and perioperative management are areas which require further investigation to enhance our ability to safely and effectively utilise the new agents.
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Project description:Atrial fibrillation (AF) complicating cardiac surgery continues to be a major problem that increases the postoperative risk of stroke, myocardial infarction, heart failure and costs and can affect long-term survival. The incidence of AF after surgery has not significantly changed over the last two decades, despite improvement in medical and surgical techniques. The mechanism and pathophysiology underlying postoperative AF (PoAF) is incompletely understood and results from a combination of acute and chronic factors, superimposed on an underlying abnormal atrial substrate with increased interstitial fibrosis. Several anti-arrhythmic and non-anti-arrhythmic medications have been used for the prevention of PoAF, but the effectiveness of these strategies has been limited due to a poor understanding of the basis for the increased susceptibility of the atria to AF in the postoperative setting. In this review, we summarize the pathophysiology underlying the development of PoAF and evidence behind pharmacological approaches used for its prevention in the postoperative setting.
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Project description:ObjectiveTo do an indirect comparison analysis of apixaban against dabigatran etexilate (2 doses) and rivaroxaban (1 dose), as well as of rivaroxaban against dabigatranetexilate (2 doses), for their relative efficacy and safety against each other, with particular focus on the secondary prevention population for stroke prevention in atrial fibrillation. A secondary objective was to do the same analysis in the primary prevention cohort.DesignIndirect treatment comparisons of phase III clinical trials of stroke prevention in atrial fibrillation, with a focus on the secondary prevention cohorts. A secondary analysis was done on the primary prevention cohort.Data sourcesMedline and Central (up to June 2012), clinical trials registers, conference proceedings, and websites of regulatory agencies.Study selectionRandomised controlled trials of rivaroxaban, dabigatran, or apixaban compared with warfarin for stroke prevention in atrial fibrillation.ResultsIn the secondary prevention (previous stroke) subgroup, when apixaban was compared with dabigatran (110 mg and 150 mg twice daily) for efficacy and safety endpoints, the only significant difference seen was less myocardial infarction (hazard ratio 0.39, 95% confidence interval 0.16 to 0.95) with apixaban compared with dabigatran 150 mg twice daily. No significant differences were seen in efficacy and most safety endpoints between apixaban or dabigatran 150 mg twice daily versus rivaroxaban. Less haemorrhagic stroke (hazard ratio 0.15, 0.03 to 0.66), vascular death (0.64, 0.42 to 0.99), major bleeding (0.68, 0.47 to 0.99), and intracranial bleeding (0.27, 0.10 to 0.73) were seen with dabigatran 110 mg twice daily versus rivaroxaban. In the primary prevention (no previous stroke) subgroup, apixaban was superior to dabigatran 110 mg twice daily for disabling or fatal stroke (hazard ratio 0.59, 0.36 to 0.97). Compared with dabigatran 150 mg twice daily, apixaban was associated with more stroke (hazard ratio 1.45, 1.01 to 2.08) and with less major bleeding (0.75, 0.60 to 0.94), gastrointestinal bleeding (0.61, 0.42 to 0.89), and other location bleeding (0.74, 0.58 to 0.94). Compared with rivaroxaban, dabigatran 110 mg twice daily was associated with more myocardial infarction events. No significant differences were seen for the main efficacy and safety endpoints between dabigatran 150 mg twice daily and rivaroxaban, or in efficacy endpoints between apixaban and rivaroxaban. Apixaban was associated with less major bleeding (hazard ratio 0.61, 0.48 to 0.78) than rivaroxaban.ConclusionsFor secondary prevention, apixaban, rivaroxaban, and dabigatran had broadly similar efficacy for the main endpoints, although the endpoints of haemorrhagic stroke, vascular death, major bleeding, and intracranial bleeding were less common with dabigatran 110 mg twice daily than with rivaroxaban. For primary prevention, the three drugs showed some differences in relation to efficacy and bleeding. These results are hypothesis generating and should be confirmed in a head to head randomised trial.
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