title: Early management of atrial fibrillation to prevent cardiovascular complications.
abstract: Atrial fibrillation (AF) is generally considered a progressive disease, typically evolving from paroxysmal through persistent to 'permanent' forms, a process attributed to electrical and structural remodelling related to both the underlying disease and AF itself. Medical treatment has yet to demonstrate clinical efficacy in preventing progression. Large clinical trials performed to date have failed to show benefit of rhythm control compared with rate control, but these trials primarily included patients at late stages in the disease process. One possible explanation is that intervention at only an early stage of progression may improve prognosis. Evolving observations about the progressive nature of AF, along with the occurrences of major complications such as strokes upon AF presentation, led to the notion that earlier and more active approaches to AF detection, rhythm-reversion, and maintenance of sinus rhythm may be a useful strategy in AF management. Approaches to early and sustained rhythm control include measures that prevent development of the AF substrate, earlier catheter ablation, and novel antiarrhythmic drugs. Improved classifications of AF mechanism, pathogenesis, and remodelling may be helpful to enable patient-specific pathophysiological diagnosis and therapy. Potential novel therapeutic options under development include microRNA-modulation, heatshock protein inducers, agents that influence Ca(2+) handling, vagal stimulators, and more aggressive mechanism-based ablation strategies. In this review, of research into the basis and management of AF in acute and early settings, it is proposed that progression from paroxysmal to persistent AF can be interrupted, with potentially favourable prognostic impact.
authors.affiliation: Montreal Heart Institute, Montreal, QC, Canada.
authors.forename: Stanley
authors.initials: S
authors.lastname: Nattel
authors.affiliation: Montreal Heart Institute, Montreal, QC, Canada.
authors.forename: Eduard
authors.initials: E
authors.lastname: Guasch
authors.affiliation: Division of Clinical Sciences, Cardiovascular Science, St George's University of London, Cranmer Terrace, London, SW17 0RE, UK.
authors.forename: Irina
authors.initials: I
authors.lastname: Savelieva
authors.affiliation: Cardiología Department, Hospital Universitario de Getafe, Madrid, Spain.
authors.forename: Francisco G
authors.initials: FG
authors.lastname: Cosio
authors.affiliation: Cardiología Department, Hospital Universitario de Getafe, Madrid, Spain.
authors.forename: Irene
authors.initials: I
authors.lastname: Valverde
authors.affiliation: Zena and Michael A. Wiener Cardiovascular Institute, Mount Sinai School of Medicine, New York, NY, USA.
authors.forename: Jonathan L
authors.initials: JL
authors.lastname: Halperin
authors.affiliation: Zena and Michael A. Wiener Cardiovascular Institute, Mount Sinai School of Medicine, New York, NY, USA.
authors.forename: Jennifer M
authors.initials: JM
authors.lastname: Conroy
authors.affiliation: Cardiology Division, Department of Medicine, Duke University Medical Center, Durham, NC, USA.
authors.forename: Sana M
authors.initials: SM
authors.lastname: Al-Khatib
authors.affiliation: Cardiology Division, Department of Medicine, Duke University Medical Center, Durham, NC, USA.
authors.forename: Paul L
authors.initials: PL
authors.lastname: Hess
authors.affiliation: University of Birmingham Centre for Cardiovascular Sciences, University of Birmingham and Sandwell and West Birmingham NHS Trust, Birmingham, UK Department of Cardiology and Angiology, Hospital of the University of Münster, Münster, Germany German Atrial Fibrillation Competence NETwork (AFNET), Münster, Germany.
authors.forename: Paulus
authors.initials: P
authors.lastname: Kirchhof
authors.affiliation: University Hospitals Birmingham NHS Trust, Birmingham, UK.
authors.forename: Joseph
authors.initials: J
authors.lastname: De Bono
authors.affiliation: University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham, UK.
authors.forename: Gregory Y H
authors.initials: GY
authors.lastname: Lip
authors.affiliation: University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham, UK.
authors.forename: Amitava
authors.initials: A
authors.lastname: Banerjee
authors.affiliation: Department of Medicine, Massachusetts General Hospital, Boston, MA, USA.
authors.forename: Jeremy
authors.initials: J
authors.lastname: Ruskin
authors.affiliation: Department of Medicine, Massachusetts General Hospital, Boston, MA, USA.
authors.forename: Dan
authors.initials: D
authors.lastname: Blendea
authors.affiliation: Division of Clinical Sciences, Cardiovascular Science, St George's University of London, Cranmer Terrace, London, SW17 0RE, UK jcamm@sgul.ac.uk.
authors.forename: A John
authors.initials: AJ
authors.lastname: Camm
mesh_terms: D000368:Aged; D000889:Anti-Arrhythmia Agents / Q000627:therapeutic use; D001281:Atrial Fibrillation / Q000209:etiology / Q000628:therapy*; D064752:Atrial Remodeling / Q000502:physiology; D002318:Cardiovascular Diseases / Q000517:prevention & control; D017115:Catheter Ablation / Q000379:methods; D018450:Disease Progression; D042241:Early Diagnosis; D006801:Humans; D008875:Middle Aged; D016032:Randomized Controlled Trials as Topic; D012307:Risk Factors
chemical_list: D000889:Anti-Arrhythmia Agents
keywords: Anticoagulation; Atrial fibrillation; Atrial remodelling; Integrated care pathways; Natural history; Post-operative AF; Rhythm control