Atrial Fibrillation

• Issues in Management of AF

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

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• 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

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

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• Cardioversion
• Role of Transoesophageal Echo in Cardioversion

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

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• Non-Pharmacological Therapy
• Options

Anticoagulation is superior to the combination of Aspirin and Clopidogrel

The ACTIVE-W trial (Lancet 2006; 367: 1903–12) compared standard anticoagulation with the combination of aspirin and clopidogrel. The participants had an average age of 70 years and an average CHADS2 score of about 2.

The trial was stopped early because of superiority of anticoagulation over the combination of aspirin and clopidogrel.

The primary event rate was 5.6% per year in the aspirin and clopidogrel group. The rate was about 1% less in the anticoagulation group.

The difference between the two groups was not as large as in older studies that compared warfarin and aspirin.

Whether addition of clopidogrel to aspirin does confer benefits to patients with chronic atrial fibrillation will be addressed in another limb of this study, the ACTIVE-A study. ACTIVE-A is comparing aspirin vs aspirin plus clopidogrel in paricipants not eligible for anticoagulant therapy.

Of note is that the most of the difference between the two limbs of this study were accounted by less serious events, such as non-disabling stroke.

Rates of serious bleeding was the same in the two groups at about 2.2-2.4% per year.

As always caution is required when viewing subgroup analysis, however, of interest is the observation that myocardial infarction rates were also lower in the anticoagulant group compared with the aspirin and clopidogrel group.

Hitesh Patel, Cardiologist
6th August, 2006