Ali Alsayegh, MD, FRCPC,FACC
Consultant Cardiologist, Consultant Cardiac
Electrophysiologist
One
AF is relatively common and
Challenging
Prevalence of Atrial Fibrillation
Go AS, Hylek EM, Phillips KA, et al. Prevalence of diagnosed atrial fibrillation in adults. JAMA. 2001; 285:23702375
Clinical Events (outcomes) affected by AF
Two
Types of AF
Clinical Types
Pathophysiological Types
 AF cause by trigger with normal left atrium
(substrate). Possible cure
 AF without trigger but abnormal substrate.
Progressive
Three
Patient profile very well
Common coexistent conditions
European Heart Journal. ESC Guidelines
EHRA score of AF-related
symptoms
AF = atrial fibrillation; EHRA = European Heart Rhythm Association
CHADS2 score and stroke rate
Risk factor-based point-based
scoring
system - CHA2DS2-VASc
The HAS-BLED bleeding risk score
Four
Treatment Options
Rate and rhythm control of AF. Mortality outcome
The Atrial Fibrillation Follow-up Investigation of Rhythm Management
(AFFIRM) Investigators
Predictor of Mortality In AFFIRM
Aliot E , and Ruskin J N Eur Heart J Suppl 2008;10:H32-H54
Five
Prevent Stroke Before It Happens
Highly preventable (65% RRR)
Six
Novel New Anticoagulants
Approved agents for the prevention of stroke in
patients with AF
Antiplatelet agents used for stroke prophylaxis
in patients with AF
Seven
Rate Control is not Bad in Many
Patients
Optimal level of heart rate control
Rate control of atrial fibrillation
AV node ablation in AF patients
aClass
of recommendation. bLevel of evidence.
AF = atrial fibrillation; AV = atrioventricular; CRT = cardiac resynchronization therapy; LV = left ventricular;
LVEF = left ventricular ejection fraction; NYHA = New York Heart Association.
Quality of life and symptoms after
AV junctional ablation and pacing
Wood M et al. Circulation 2000;101:1138-1144
Choice of pacemakers after
AV node ablation
Eight
Rhythm control: Drug
Principles of antiarrhythmic drug
therapy to maintain sinus rhythm
1. Treatment is motivated by attempts to reduce AF-related
symptoms.
2. Efficacy of antiarrhythmic drugs to maintain sinus rhythm is modest.
3. Clinically successful antiarrhythmic drug therapy may reduce rather
than eliminate recurrence of AF.
4. If one antiarrhythmic drug ‘fails’ a clinically acceptable response
may be achieved with another agent.
5. Drug-induced proarrhythmia or extra-cardiac side-effects are
frequent.
6. Safety rather than efficacy considerations should primarily guide
the choice of antiarrhythmic agent.
Chance of Staying in Sinus Rhythm
Choice of antiarrhythmic drug
according to underlying pathology
Nine
Rhythm control: Left Atial Ablation
Current approaches to catheter ablation
 Catheter ablation is currently based on four main
strategies:
 Isolation of the triggers and perpetuating re-entrant
circuits located in the pulmonary veins;
 Disruption of the substrate for perpetuating rotors in
the antra of the pulmonary veins;
 Disruption of putative dominant rotors in the left and
right atria, recognized by high-frequency complex
fractionated electrograms during mapping of AF.
 Targeted ablation of ganglionated autonomic plexi in
the epicardial fat pads.
Pulmonary veins isolation
Success Rate of AF Ablation
Rhythm control more likely to
succeed
 Recent Onset AF
 No structural heart disease
 Small LA
 Younger Age
 Reversed precipitating factor
Ten
Newer Therapeutic options
Blood thinner alternative: Left Atrial
Occlusion Device
Investigational Antiarrhythmic
Agents
Summary for AF Management from ESC
Guidelines
Thank You