Figure 2

Freedom from any Atrial Arrhythmia

The Numbers Keep Rising: What it Means to the Individual

More than two million Americans have been diagnosed with atrial brillation. While some present with symptoms such as palpitations and rapid heart action, others present more insidiouslydyspnea with exertion, decreased exercise tolerance, and fatigue, all of which are often ascribed to as getting older. Many others, however, have no symptoms, and are diagnosed during a routine examination. Based on the presence or absence of symptoms, the patient and physician must ultimately decide whether to pursue a rate or rhythm control strategy. Whether one has symptoms or not, each patient must be risk stratied for stroke. Ultimately, the mainstay of therapy for the treatment of atrial brillation has been medications. Antiarrhythmic drugs (ecainide, propafenone, sotalol, dofetilide, amiodarione, etc.) to maintain sinus rhythm and atrioventricular nodal blocking agents (beta blockers and calcium channel blockers) to control the rapid ventricular rates that accompany AF are commonly prescribed. In addition, medications for anticoagulation (warfarin, dabigatran, rivaroxaban, apixaban) are used to lower the risk of stroke. Recent adavances in electrophysiology, however, have opened up an entirely new paradigm in treating this disease. Nonpharmacological therapies have rapidly developed and allow physicians to offer patients percutaneous interventions that may obviate the need for antiarrhythmic drugs or anticoagulation.

Any Atrial Arrhythmia

1.00

0.80

0.60

Each Individual Requires an Individualized Approach

Catheter ablation Antiarrhythmic drug therapy

0.40

0.20 HR, 0.29; 95% CI, 0.18-0.45; log-rank P,.001 0.00 0 1 2 3 4 5 6 7 8 9

Follow-up, mo
106 61 84 33 78 22 72 17 70 13 70 11 69 10 68 9 65 6 52 4
Figure 1

The appropriate treatment strategy for patients with AF varies from patient to patient and depends on the presence or absence of symptoms and the risk of thromboembolism. For those whose quality of life is signicantly impacted by atrial brillation, options exist to best suit the wants and needs of each patient. Most importantly, a satisfactory decision can be made only when a thorough discussion of every reasonable treatment modality has been discussed. Ultimately, it is the patient who will decide how to proceed with the understanding of the risks and benets of each pathway available.

(a)

(b)

Contemporary Treatment Options for Symptomatic Patients

For patients with symptomatic AF who feel better in sinus rhythm, radiofrequency ablation offers an opportunity for cure. While success rates are highest in patients with paroxysmal atrial brillation, many centers, including The Al-Sabah Arrhythmia Institute, have physicians with excellent cure rates even in patients with long-standing persistent atrial brillation. At our institution, more than half of all patients referred have persistent AF. Despite the upfront risk of complications with interventional therapy, the longterm proarrhythmic effects, (including that of life threatening ventricular tachyarrhythmias) of antiarrhythmic drug therapy are well known.1 Thus, while antiarrhythmic drug therapy simply decreases

the burden of AF, ablation offers a real opportunity for cure; randomized clinical trials support this nding2 and explain how ablation has become an important option for the symptomatic patient (gure 1). In addition, studies have shown that patients3,4 treated with catheter ablation for AF have fewer hospitalizations as compared to those randomized to drug therapy, thus improving quality of life and decreasing outpatient as well as inpatient visits.5 It is critical to note that ablation is indicated only in patients with symptomatic atrial brillation6 given the current data and recommendations from the Heart Rhythm Society. While patients at relatively low risk for thromboembolism (CHADS 2 score of 1) can be considered for cessation of anticoagulation after a successful ablation for AF, the guidelines do not recommend discontinuation of anticoagulation for those at high risk for stroke. Other non-pharmacological therapies offer alternative options to lifelong anticoagulation.

References:
1

Corley SD, Epstein AE, DiMarco JP, et al. Relationships between sinus rhythm, treatment, and survival in the Atrial Fibrillation Fol- low-Up Investigation of Rhythm Management (AFFIRM) Study. Circulation. Mar 30 2004;109(12):1509 1513. Jais P, Cauchemez B, Macle L, et al. Catheter ablation versus antiarrhythmic drugs for atrial brillation: the A4 study. Circulation. Dec 9 2008;118(24):2498 2505.

Wilber DJ, Pappone C, Neuzil P, et al. Comparison of antiarrhyth- mic drug therapy and radiofrequency catheter ablation in patients with paroxysmal atrial brillation: a randomized controlled trial. JAMA. Jan 27 2010;303(4):333340.

(c)
Figure 1: Freedom from any atrial arrhythmia in patients who have undergone catheter ablation is signicantly reduced as compared to those randomized to anti-arrhythmic drug (AAD) therapy. From: Comparison of antiarrhythmic drug therapy and radio frequency catheter ablation in patients with paroxysmalatrial brillation: a randomized controlled trial. Wilber DJ, Pappone C, Neuzil P, De Paola A, Marchlinski F, Natale A, Macle L, Daoud EG, Calkins H, Hall B, Reddy V, Augello G, Reynolds MR, Vinekar C, Liu CY, Berry SM, Berry DA; ThermoCool AF Trial Investigators. JAMA. 2010 Jan 27;303(4):333-40. Figure 2: (a) and (b) Intracardiac echo (ICE) images of catheters placed in the left atrium and pulmonary veins. ICE utilization has added signicantly to the safety and outcomes with ablations. (c) Illustration showing the position of catheters as demonstrated in (a) and (b) above

Wazni OM, Marrouche NF, Martin DO, et al. Radiofrequency ablation vs antiarrhythmic drugs as rst-line treatment of symptom- atic atrial brillation: a randomized trial. JAMA. Jun 1 2005; 293(21):2634 2640. Piccini JP, Lopes RD, Kong MH, Hasselblad V, Jackson K, and AlKhatib SM. Pulmonary Vein Isolation for the Maintenance of Sinus Rhythm in Patients With Atrial Fibrillationf: A Meta-Analysis of Randomized, Controlled Trials. Circ Arrhythm Electrophysiol. 2009 Dec;2(6):626-33.
6 5

Save the the Date Save Date

CME: Update on August 20, 2013 Atrial Fibrillation October 17, 2013, 5:30 pm Lincoln Center

Calkins H, Kuck KH, Cappato R, Brugada J, Camm J, et al. 2012 HRS/EHRA/ECAS Expert Consensus Statement on Catheter and Surgical Ablation of Atrial Fibrillation: Recommendations for Patient Selection, Procedural Techniques, Patient Management and Follow-up, Denitions, Endpoints, and Research Trial Design. Heart Rhythm, 2012.

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St. Lukes Hospital 1111 Amsterdam Avenue New York, NY 10025

NONPROFIT ORGANIZATION U.S. POSTAGE PAID PERMIT NO. 8048 NEW YORK, NY

The Al-Sabah Arrhythmia Institute Andrea Natale, MD Executive Director Conor D. Barrett, MD Director Stephan B. Danik, MD Director, Electrophysiology Lab Robert K. Altman, MD Francesco Santoni, MD Emad Aziz, DO Walter Pierce, MD Erdal Gursoy, MD Sam Hanon, MD Patrick W. Lam, MD Pretty Chawla, MD St. Luke's Hospital 1111 Amsterdam Avenue 5 Babcock New York, NY 10025 Roosevelt Hospital Brodsky Building 425 West 59th Street, Suite 9C New York, NY 10019 Phone: 212.523.2400

VOL.1, ISSUE 1 SEPTEMBER 2013

Atrial Fibrillation: Does Your Patient Have to Live with It?

Does the increasing burden of atrial brillation (AF) mean those affected will need to take more medications and adjust their lifestyles accordingly? Not necessarily. A diagnosis of AF even 10 years ago would have condemned one to a whole cocktail of medications for treatment. For many patients, the addition of three to four more pills per day can mean the tipping point when it becomes difcult to remember to take the right dose at the right time. In addition, does the fear of an episode in symptomatic patients with paroxysmal atrial brillation require that patients curtail their activities or avoid travelling and stay close to home? Such was the case that atrial brillation was a disease that, once diagnosed, would usually mean lifelong medications to help manage the debilitating symptoms and the risk of stroke. Unfortunately, there was no cure, and while anticoagulation was extremely effective at reducing the risk of stroke, antiarrhythmic drug therapy could at best decrease the burden of the disease in those with severe symptoms who would eventually have to learn to live with it.

This Issue: Atrial Fibrillation: Does Your Patient Have to Live with It?

The Continuum Cardiovascular Centers of New York is pleased to announce the appointments of: Andrea Natale, MD Executive Director of the Al-Sabah Arrhythmia Institute Conor Barrett, MD Director of the Al-Sabah Arrhythmia Institute Stephan Danik, MD Director, Electrophysiology Lab The Al-Sabah Arrhythmia Institute is a state-ofthe-art facility that offers the most advanced and sophisticated arrhythmia care. Funded by His Highness Sheikh Sabah Al-Ahmad Al-Jaber Al-Sabah, the Amir of Kuwait, the Institute has the capacity to serve more than 3,000 patients annually and is one of the only facilities focused specically on arrhythmia treatments in the New York City metro area.

L to R: Stephan Danik, MD; Andrea Natale, MD and Conor Barrett, MD

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