MANAGEMENT OF ATRIAL FIBRILLATION - A BRIEF REVIEW

Atrial fibrillation has been receiving much medical press lately. In the middle of the last decade, it was because of the advent of radio frequency ablation, as a treatment for A.F. ( atrial fibrillation for short ). Towards the end of the last decade, it was because of a new group of anti-coagulants to replace warfarin. It has become important enough for us to have a whole symposium on it, at our coming weekend seminar in Cardiology, to update the GPs.
Atrial Fibrillation ( A.F.), is an atrial arrhythmia characterised by an irregularly, irregular pulse. It is more common in the elderly, and although it can compromise the cardiovascular system, and trigger heart failure, its most common complication is strokes and TIAs ( transient ischemic attack ) cause by clots from the left atrial appendage, migrating to the brain.
The good old treatment strategy is to control the AF rate ( rate control so that the heart does not race too fast ), and to anti-coagulate with warfarin ( rat poison ), to prevent strokes, and TIAs. I like this strategy as it is cheap and effective, although I run the risk of bleeding with warfarin. But this simple, cheap strategy does reduce the rate of stroke to 1-2%, compared to 5% in non-warfarinised AF.
Of course there was always the wish that all patients with atrial fibrillation, be return to good old sinus rhythm. Sometimes, in patients with recent onset AF, this can be achieved with electric ( DC ) cardioversion. I usually try this once in all AFs. Sometimes, sinus rhythm can be restored with drugs. Recently, a new drug, Multag has been tried and seem better than the older drugs like cordarone, beta blockers, quinidine, etc..
This blog is partly due to an article published in the January 2011 issue of the Journal of the American College of Cardiology. The study comes from Bordeaux. Besides good red wine, Bordeaux is also the city in France that pioneered radio frequency ablation of the left atrium to treat atrial fibrillation, converting them from AF to sinus rhythm. When this group first published their work, many were hoping that this new method of radiofrequency ablation would be a cure for AF. Alas, this is not to be. Dr Rukshen Weerosooriya and Dr Michel Haissuguerra, both pioneers in this technique, reported their 5 year followup of 100 patients with the use of this technique. They reported that after 5 years, only 29% remained in sinus rhythm. There was an almost 8.9% recurrence annually following the ablation. So many of them need a repeat ablation ( almost like angioplasty ) after a year. So we now know that radiofrequency ablation, is a treatment and not a cure. Just like angioplasty. This findings is even more important because the technique was done by the pioneers ( real experts ), and also the case selection were of a younger, lower risk population. Should this technique be more widely used by all and sundry ( when it is open for all who are trained ), the numbers can only get worse. That is the real AF world.
Besides Multag ( dronedarone - SanofiA ) which is a new anti-arrhythmic agent, there are also new anti-coagulants for reducing strokes in AF, like the "gartans ", example Dabigatran, and the " xabans" example apixaban, and many more xabans in the pipeline. These new agents are good. It does reduce the risk of strokes ( data from the early trials ), the risk of bleeding and so the need for close monitoring with PT-INR. However, they are expensive, at RM 10 a tab, compared to Warfarin at a few cents a tablet. I told the manufacturer that so far, all my AF patients have decline a change to dabigatran.
There is no doubt, as always, that healthcare is getting better. We live longer and better, but at what cost? Can the country afford it? That is another issue.