Atrial Fibrillation

• Issues in Management of AF

---

• Should We Maintain Sinus Rhythm?
• The AFFIRM trial
• The SAFE-T trial- amiodarone vs sotalol vs placebo

---

• Anticoagulation in AF
  • Risk of Thromboembolism-CHADS2
  • "Moderate Risk" Patients
  • "High-Risk" Patients
  • Secondary Prevention
  • Target INR level for AF patients
  • Maintain INR in theurapeutic range

---

• Clopidogrel
  • Anticoagulation slightly better than Clopidogrel with Aspirin
  • Clopidogrel with Asprin better than Aspirin alone for those not eligible for anticoagulation

  ---

• Cardioversion
• Role of Transoesophageal Echo in Cardioversion

---

• Use of ACE-inhibitors or ARBs
• ACE-inhibitors may reduce the risk of recurrent PAF in those with lone PAF

---

• Non-Pharmacological Therapy
• Options

ACE-Inhibitors or Angiotensin Receptor Blockers may reduce risk of recurrent AF in some groups

Trials have assessed the potential for these agents to reduce the risk of recurrent AF. The renin-angiotensin-aldosterone system has been implicated in the genesis of atrial fibrillation, and blockade of the system prevents electrical and structural remodelling of the atrium.

One recent trial (J Am Coll Cardiol 2009;53:24–9) found that the use of Ramipril reduced the risk of recurrent PAF in those with lone atrial fibrillation. There will be debate on the mechanism of the benefit- whether this benefit was the result of lowering of blood pressure or on other effects of ACE-inhibitor therapy.

In an adhoc analysis of a heart failure trial, there was evidence for reduction of incidence of AF in those treated with the ARB Valsartan in addition to ACE-inhibitor therapy. Over a two year period thirty nine patients needed to be treated with Valsartan to prevent one patient developing atrial fibrillation.

A subsequent randomised trial- GISSI-AF (N Engl J Med 2009;360:1606-17), however, did not find the use of Valsartan reduced the risk of recurrent AF in those with PAF. The trial had enrolled a broad group of patients and not just those with lone AF or AF with congestive heart failure. These findings may not apply to those with just lone atrial fibrillation.

Comments
• Consider the use of ACE-inhibitors or ARB in those with Lone AF.
• ACE-inhibitors or ARBs are part of established therapy for those with congestive heart failure and may reduce the risk of development of AF in these patients.

Hitesh Patel
July, 2009