Elsevier

The Lancet

Volume 390, Issue 10105, 21–27 October 2017, Pages 1873-1887
The Lancet

Seminar
The future of atrial fibrillation management: integrated care and stratified therapy

https://doi.org/10.1016/S0140-6736(17)31072-3Get rights and content

Summary

Atrial fibrillation is one of the major cardiovascular health problems: it is a common, chronic condition, affecting 2–3% of the population in Europe and the USA and requiring 1–3% of health-care expenditure as a result of stroke, sudden death, heart failure, unplanned hospital admissions, and other complications. Early diagnosis of atrial fibrillation, ideally before the first complication occurs, remains a challenge, as shown by patients who are only diagnosed with the condition when admitted to hospital for acute cardiac decompensation or stroke. Once diagnosed, atrial fibrillation requires chronic, multidimensional management in five domains (acute management, treatment of underlying and concomitant cardiovascular conditions, stroke prevention therapy, rate control, and rhythm control). The consistent provision of these treatment options to all patients with atrial fibrillation is difficult, despite recent improvements in organisation of care, knowledge about atrial fibrillation, and treatment options. Integrated care models that provide patient-centred care in, or close to, the patient's community while maintaining access to all specialist treatment options, emerge as the best approach to achieve consistent delivery of these chronic treatments to all patients with atrial fibrillation. Ongoing research efforts will establish when to initiate oral anticoagulation in patients with device-detected atrial high-rate episodes, quantify the prognostic effect of early and comprehensive rhythm control therapy, including atrial fibrillation ablation, and delineate optimum methods to reduce bleeding complications in patients treated with anticoagulation. Additionally, research efforts are needed to define different types of atrial fibrillation on the basis of the main causes of atrial fibrillation to pave the way for the clinical development of stratified atrial fibrillation therapy.

Section snippets

The atrial fibrillation epidemic

Atrial fibrillation affects 2–3% of the populations in Europe,1, 2, 3 and more than 1% of Europe's health-care expenditure is spent on atrial fibrillation management.4, 5 Less than one in 200 people younger than 50 years, but more than one in ten people in populations aged 80 years or older, have atrial fibrillation.1, 2, 3 8% of the world population,6 and 13–21% of the European population are aged 65 years or older,7 and the worldwide population is living ever longer. The projected population

Clinical presentation and atrial fibrillation-associated symptoms

Atrial fibrillation is a common cause of ischaemic stroke.2 In patients with atrial fibrillation on oral anticoagulation, stroke is relatively infrequent (1·5% of anticoagulated patients with atrial fibrillation will have a stroke per year),10, 11 but worsening of heart failure and sudden death remain common even in adequately treated patients.12, 13 Common symptoms in patients with atrial fibrillation are fatigue or shortness of breath, palpitations,14, 15, 16, 17, 18, 19 anxiety,20 and a

ECG screening in populations to diagnose silent atrial fibrillation

Unfortunately, atrial fibrillation is often not diagnosed before the first stroke. About 5% of unselected patients who are admitted to stroke units present with overt (usually chronic) atrial fibrillation on admission.30 The identification of atrial fibrillation before the first stroke should therefore be a public and individual health priority. Opportunistic screening for atrial fibrillation (ie, pulse palpation followed by ECG in individuals with an irregular pulse35) is recommended by atrial

ECG screening in stroke survivors

ECG screening for silent atrial fibrillation has been extensively studied in survivors of a stroke or transient ischaemic attack. ECG monitoring for 2·5–4 days identifies silent atrial fibrillation in an additional 5% of unselected patients admitted to stroke units.30, 39 Longer ECG monitoring for a few weeks or months identifies even more patients with atrial fibrillation,30, 31, 40 especially in patients with cryptogenic stroke39, 41, 42 or embolic stroke of unknown source.43 ECG monitoring

Management of patients with atrial fibrillation identified by ECG screening

Identification of silent atrial fibrillation has immediate consequences for antithrombotic therapy. Most patients with incidentally diagnosed atrial fibrillation, or with atrial fibrillation identified by systematic ECG screening, will have stroke risk factors that make them eligible for oral anticoagulation.2, 33, 35 Patients with silent atrial fibrillation should also be investigated for concomitant cardiovascular conditions that require therapy.2 Rhythm control therapy is not required in

Management of patients with atrial high-rate episodes identified by implanted devices

All atrial fibrillation therapies have been assessed in patients with ECG-documented atrial fibrillation. Thus, atrial arrhythmias identified by other methods (eg, an irregular pulse detected by blood pressure machines or by an optical device), or atrial high-rate episodes identified by a pacemaker, require verification of atrial fibrillation by ECG before the start of atrial fibrillation therapy.2 Importantly, not all atrial high-rate episodes detected by implanted devices are atrial

Five domains of atrial fibrillation management

Five domains of management are available for atrial fibrillation, in which each treatment component targets different sections of the heart (figure 1). The five domains of atrial fibrillation management are acute stabilisation of patients who present with atrial fibrillation complications or haemodynamic compromise, detection and treatment of underlying and accompanying cardiovascular conditions, stroke risk assessment and oral anticoagulation for stroke prevention, rate control, and rhythm

Cardiovascular examination

The presence of atrial fibrillation strongly indicates that other cardiovascular conditions might exist. To identify such conditions, a careful cardiovascular examination and an echocardiogram should be done in all patients with atrial fibrillation at the time of diagnosis. In young patients with atrial fibrillation, the ECG should be examined for signs of inherited arrhyhthmogenic diseases. Comprehensive diagnosis and treatment of cardiovascular risk factors and concomitant diseases2, 53

Oral anticoagulation for stroke prevention

The combination of a local prothrombotic milieu in the left atrium, systemic activation of coagulation, blood stasis in the atria, and expression of prothrombotic factors on the atrial endothelium all contribute to clot formation and cerebral ischaemia in patients with atrial fibrillation.70, 71, 72 The annual stroke risk in patients with atrial fibrillation without anticoagulation treatment varies between <1% and >10%, depending on stroke risk factors (table 2).71, 72 Oral anticoagulation

Rate control therapy

During atrial fibrillation, each part of the atrial myocardium is stimulated at a rate of 300–400 activations per min. The rapid reactivation of atrial myocardium leads to atrial contractile standstill in most patients and results in rapid and irregular ventricular rates. Most patients with atrial fibrillation who are symptomatic present with high ventricular rates, and control of ventricular rate is used to improve left ventricular function and atrial fibrillation-associated symptoms. Rate

Rhythm control therapy

Restoration and maintenance of sinus rhythm in patients with atrial fibrillation can improve atrial fibrillation-associated symptoms. No evidence suggests that rhythm control therapy improves outcomes in patients with atrial fibrillation. Cardioversion, anti-arrhythmic drugs, and catheter or surgical atrial fibrillation ablation are available for this type of therapy. Current controlled studies such as CABANA (NCT00911508) and EAST-AFNET 4109 will investigate whether modern rhythm control

Integration and stratification of atrial fibrillation management

Implementation of advances in atrial fibrillation management (eg, access to medications that require specialist initiation or interventional and surgical therapy options) is not universal, as shown by the variable use of evidence-based treatments in observational data sets. 13, 16, 17, 77, 142 Furthermore, atrial fibrillation requires chronic management in a large population of patients, including provision of specialist treatment options when needed. Integrated, patient-centred approaches to

Conclusion

Screening for silent atrial fibrillation emerges as an important opportunity to prevent atrial fibrillation-associated complications. All patients with atrial fibrillation should receive long-term treatment in five domains (figure 2): acute haemodynamic stabilisation, detection and treatment of concomitant cardiovascular diseases, assessment of stroke risk and (in most patients) oral anticoagulation, assessment of ventricular rate and (in most patients) rate control therapy, and assessment of

Search strategy and selection criteria

I searched the Cochrane Library, MEDLINE, and Embase, supplemented by publications known to me, for articles published between 1962 and 2017. I used the search terms “atrial fibrillation” combined with “stroke prevention”, “risk factor”, “rate control”, “rhythm control”, “anticoagulation”, “combination therapy”, “stroke”, “occluder”, “ablation”, or “surgery” when required. I largely selected publications in the past 6 years on the basis of novelty, citations, and relevance for this clinical

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