Atrial Fibrillation Prevention

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1 Atrial Fibrillation Prevention Thierry C. Gillebert, MD, PhD, FESC Ghent University, Belgium ESC Global Scientific Activities SHA, Riyadh, Feb. 14, 2015

2 Mechanisms of AF Sinusal rhythm

3 Mechanisms of AF Atrial fibrillation

4 Mechanisms of AF TRIGGER Focal activity of pulmonary vein cells Triggered activity and re-entry This leads to extrasystoles and runs of extrasystoles SUBSTRATE Any kind of structural heart disease may trigger a slow but progressive process of structural remodeling in both the ventricles and the atria WAVELETS The impulse no longer progresses as a wavefront but as multiple small wavelets (> 350 pm) with micro-re-entry European Heart Journal (2010) 31,

5 AF and outcome 20% of stroke = VKF European Heart Journal (2010) 31,

6 Incidence of AF Framingham (38 years follow up) men women Benjamin JAMA. 1994;271:

7 Epidemiology of AF Framingham The odds ratio (OR) of atrial fibrillation are: (full multivariable model) Advancing age: OR 2.1 for men and 2.2 for women Diabetes: OR 1.4 for men and 1.6 for women Hypertension: OR 1.5 for men and 1.4 for women Congestive heart failure: OR 4.5 for men and 5.9 for women Valve disease: OR 1.8 for men and 3.4 for women Myocardial infarction: OR 1.4 BMI, alcohol use, smoking: not significantly related Risk factors for cardiovascular disease also predispose to atrial fibrillation Benjamin JAMA. 1994;271:

8 Population-attributable risk Population-attributable risk incorporates both the odds ratio of the risk factor and the risk factor's prevalence in the study population. It reflects the percentage of atrial fibrillation cases that potentially would be reduced if a causal risk factor could be eliminated from the population. Cigarette smoking, diabetes mellitus, hypertension, and prevalent CHD combined explained 44% of the burden in men and 58% in women Benjamin JAMA. 1994;271:

9 The Atherosclerosis Risk in Communities (ARIC) Study Investigators computed the population-attributable fraction (PAF) of AF resulting from having a non-optimal risk profile Previously established AF risk factors were categorized into optimal, borderline, and elevated levels. AF risk factors were: high blood pressure elevated body mass index diabetes mellitus cigarette smoking prior cardiac disease ARIC, Circulation 2011;123:

10 The Atherosclerosis Risk in Communities (ARIC) Study ARIC, Circulation 2011;123:

11 The Atherosclerosis Risk in Communities (ARIC) Study ARIC, Circulation 2011;123:

12 Resistant hypertension PV ablation ± renal artery denervation Pokushalov, J Am Coll Cardiol 2012;60:

13 RF for AF in Patients With Normal Versus Dilated Left Atrium Substudy of the ARIC study In normal-sized left atria, risk factors are Age > 75 Heart failure In enlarged left atria, risk factors are: Female gender Weight Alcohol use Qureshi Am J Cardiol 2014;114:

14 Global Burden of Atrial Fibrillation Medical insurance database involving > 10 million individuals for the years 2001 to 2012 in the SW of China A total of 471,446 individuals were studied 921 patients with incident AF (62% male; mean age 62) CHA 2 DS 2 -VASc was tested in predicting the occurrence of incident AF Guo... Lip Chest 2015;147:

15 Global Burden of Atrial Fibrillation (e.g. SW China) Prevalence of AF classified by age and sex. The prevalence of AF increased with age and became marked in elderly people. Guo... Lip Chest 2015;147:

16 Global Burden of AF over the years in China Guo... Lip Chest 2015;147:

17 Risk factors for AF CHA 2 DS 2 -VASc score reasonably predicts AF C-statistic = 0.72 Guo... Lip Chest 2015;147:

18 Rubber duck tells

19 What to do? 1. Early detection of AF 2. Primary prevention at the population level Reduction of risk factors 3. Careful follow up and prescription of anticoagulants according to the prevailing ESC guidelines

20 AF screening by all physicians European Heart Journal (2010) 31,

21 What should we all do? Get regular physical activity Eat a heart-healthy diet Manage high blood pressure Avoid excessive amounts of alcohol and caffeine Don t smoke Control cholesterol Maintain a healthy weight Be aware of your familial history

22 AF due to long-term exercise Follow-up at older age of long-term endurance crosscountry skiers in Norway A high prevalence (12.8%) of AF was found Predictors: Long PQ time Sinus bradycardia LA volume Grimsmo Eur J Cardiovasc Prev Rehabil 2010;17:

23 Appropriate treatment of: Hypertension Sleep apnea Thyroid disease Diabetes Chronic lung disease (COPD, emphysema) Other heart conditions

24 The incidence of AF is markedly rising worldwide Risk factors for atherosclerosis and for AF are similar Most important for AF: hypertension and obesity 50% of the AF s can be prevented by lifestyle measures and by treatment of co-morbidities (cardiac, non-cardiac) Early detection of AF should become a medical priority Be aware of still poorly defined familial and genetic predisposition to AF

25 Opportunities for AF prevention NHLBI Workshop Circulation. 2009;119:

26 Recommendations for AF prevention 1. enhance understanding of the epidemiology of AF in the population 2. improve detection of AF 3. improve noninvasive modalities for identifying key components of cardiovascular remodeling that promote AF (genetic, fibrotic, structural, autonomic, electrical) 4. develop additional animal models 5. conduct secondary analyses of already-completed clinical trials & include AF as an outcome in ongoing and future studies 6. conduct clinical studies focused on secondary prevention of AF recurrence NHLBI Workshop Circulation. 2009;119:

27 Mechanisms of AF European Heart Journal (2010) 31,

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