Almost everyone has seen the ads for the new anticoagulants at this point. However, many Americans still remain in the dark regarding what atrial fibrillation (Afib) is and it’s potentially devastating consequences. Despite increasing efforts to improve the awareness for atrial fibrillation, many still do not know it’s signs and symptoms or that it is a progressive disease. Afib is the most common arrhythmia in the world affecting 3-6 million Americans with projections of up to 16 million by the year 2050. Yet, far too many Americans are walking around with undiagnosed and therefore untreated Afib which is progressing every day they remain out of normal sinus rhythm, unaware of the warning signs. They lack awareness that their palpitations, sob, fatigue, swelling, and dizziness are caused by this progressive disease that carries a 500 percent increased risk of stroke and increased risk for congestive heart failure, dementia and early death. Many who have delayed diagnosis initially say they had no symptoms but in retrospect say they knew they did not feel themselves but were unable to exactly pinpoint and failed to investigate further. They are often diagnosed many months or years later after the disease has progressed to a persistent or permanent stage at which point the left atrium is significantly enlarged and damaged. A person’s stroke risk increases even further in these later stages of Afib.
A remaining issue needing clarification is addressing the erroneous conclusions made in the AFFIRM trial. This flawed trial concluded that there was no survival benefit in maintaining normal sinus rhythm in someone with Afib. There were many issues with this poorly constructed trial including excessive crossover between control and treatment groups. To this point, over a third of the rate control group was in normal sinus rhythm at the end of this trial so they had yet to progress to the more harmful stages of Afib. Thus, a central problem was that patients were not followed long enough to elucidate the very harmful effects of long standing Afib. Furthermore, nearly half of patients originally enrolled had to be excluded as their Afib was too symptomatic to be considered for the rate control arm of the trial. More recently, follow up studies have proven the benefits of early Afib treatment aimed toward maintaining normal sinus rhythm offering many advantages including improving quality of life, as well as reduction in rates of dementia, heart failure, stroke and mortality. Regardless, the AFFIRM trial led to the conclusion and general sentiment that Afib only required treatment with anticoagulation and that aggressive attempts to keep patients in normal sinus rhythm offered little to no benefit, survival or otherwise. Thus, we are still living the aftermath of the AFFIRM trial as it has deflated the importance and impeded efforts to improve awareness and early treatment of Afib. What makes this so unfortunate is that Afib is relatively easy to treat in the early stages if diagnosis and treatment occur early during the paroxysmal or intermittent stage. As AFib progresses to the persistent stages, the left atrium suffers substantial damage. At this point, medication and ablation are much less successful. Yet, in the current environment where early recognition, diagnosis and treatment of Afib are not high priorities, many are developing Afib and progressing beyond the easily treatable stage before they are ever diagnosed. Therefore, patients are missing a huge opportunity to receive successful treatment during the most treatable stage of Afib.
The explosion of technology in the field of Cardiac Electrophysiology has led to high-fidelity, integrative mapping and ablation systems. High-density mapping catheters can now better define left atrial anatomy and create sophisticated electrical activation maps which facilitate identification of ablation targets. Merging electroanatomic data from mapping catheters with interactive, intracardiac ultrasound catheter data now can create a refined, precise electroanatomic cardiac map giving very detailed electrical and anatomic data for the arrhythmia being studied during a procedure. Combining all of this technology with contact force sensing ablation catheters has made ablation safer, more precise and more effective. This innovative technology can now merge all relevant modalities into one platform allowing performance of ablation in a zero fluoroscopic environment. Success rates for ablation of paroxysmal Afib were 88 percent in a recent study when advanced technology was used with proper contact ablation force in experienced hands. With all of these technological advances and better knowledge of the damaging effects of progressive Afib, the time is prime to increase community focus on Afib awareness and early diagnosis so that patients can receive these advanced therapies earlier in the progression of Afib so they may have the best chance of successful therapy. We will ensure earlier treatment and better outcomes of this rapidly growing problem if we as a medical community become dedicated to doing a better job in both screening and educating at risk segments of our population such as those with hypertension, diabetes, heart disease, obesity, thyroid disease and obstructive sleep apnea.
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