Personalized management of atrial fibrillation: Proceedings from the fourth Atrial Fibrillation competence NETwork/European Heart Rhythm Association consensus conference

Abstract

The management of atrial fibrillation (AF) has seen marked changes in past years, with the introduction of new oral anticoagulants, new antiarrhythmic drugs, and the emergence of catheter ablation as a common intervention for rhythm control. Furthermore, new technologies enhance our ability to detect AF. Most clinical management decisions in AF patients can be based on validated parameters that encompass type of presentation, clinical factors, electrocardiogram analysis, and cardiac imaging. Despite these advances, patients with AF are still at increased risk for death, stroke, heart failure, and hospitalizations. During the fourth Atrial Fibrillation competence NETwork/European Heart Rhythm Association (AFNET/EHRA) consensus conference, we identified the following opportunities to personalize management of AF in a better manner with a view to improve outcomes by integrating atrial morphology and damage, brain imaging, information on genetic predisposition, systemic or local inflammation, and markers for cardiac strain. Each of these promising avenues requires validation in the context of existing risk factors in patients. More importantly, a new taxonomy of AF may be needed based on the pathophysiological type of AF to allow personalized management of AF to come to full fruition. Continued translational research efforts are needed to personalize management of this prevalent disease in a better manner. All the efforts are expected to improve the management of patients with AF based on personalized therapy.

2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS

“…Warianty genetyczne mogłyby w przyszłości stać się użyteczne podczas doboru pacjentów do strategii kontroli rytmu serca lub kontroli częstości rytmu komór [71][72][73][74]. Choć analizy genomiczne mogą w przyszłości stworzyć możliwości postępu w rozpoznawaniu i leczeniu AF [75,76], obecnie nie można zalecić rutynowych badań genetycznych w celu wykrywania częstych wariantów genetycznych związanych z AF [77].…”

“…Uzyskano pewne dowody wskazujące na to, że nasilenie AF może wpływać na ryzyko udaru mózgu [44,124,164] i mogłoby modyfikować odpowiedź na leczenie w celu kontroli rytmu serca [76,165]. Przemawiające za tym dowody są jednak słabe.…”

“…włóknienie [171][172][173] lub elektrokardiograficzne parametry złożoności AF [174]) bądź podłoża genetycznego. W tabeli 6 przedstawiono taką taksonomię opartą na opinii ekspertów [76,120,175], ale nie ma zbyt wielu dowodów potwierdzających zasadność Właściwe rozróżnienie między napadowym a przetrwałym AF często nie jest możliwe bez dostępu do długoterminowego monitorowania [163]. Sama ta klasyfikacja jest więc często niewystarczająca do wyboru określonego leczenia.…”

Defining the major health modifiers causing atrial fibrillation: a roadmap to underpin personalized prevention and treatment

“…Delegates at the 4 th AFNET/EHRA consensus conference proposed a classification of AF that reflected the different disease mechanisms. The proposed AF types were: monogenic AF, focally induced AF, postoperative AF, valvular AF, AF in the elderly, polygenic AF, and unclassified AF 45,46 . Unfortunately, however, prospective validation of such a classification is currently lacking, resulting in many patients being classified as 'other' .…”

“…Such personal ized concepts will add to the existing practice of cardio vascular risk reduction. These interventions will comprise targeted treatment of reversible health modifiers, such as antifibrotic treatment in patients prone to atrial fibrosis, weight reduction in patients with atrial fat-cell infiltration, or selection of antiarrhythmic drugs on the basis of the atrial electrical function as determined by age or genetic predisposition 36,45 . Although a complex network of arrhythmogenic processes is likely to culminate in AF, a balance between simpli city and the integration of the major mechanisms of AF is essential.…”