Review articles in Deutsches Ärzteblatt are published in as comprehensive a format as possible, but at the same time they are compressed. For this reason, not all aspects of a given topic can be included.
Atrial fibrillation is the subject of extensive discussion in the current guidelines (60 pages), especially questions surrounding anticoagulation (1). The ESC recommendations are based on large data sets from the BAFTA and ACTIVE-W studies, as well as a Japanese study. All studies showed that oral anticoagulation is superior to platelet inhibition, including dual platelet inhibition, but that on the other hand, acetylsalicylic acid is no better than placebo in terms of the prognosis. It goes without saying that the risk of hemorrhage increases the more aggressive the anticoagulation measures (2).
Obstructive sleep apnea has a raised prevalence in patients with atrial fibrillation (3). Bitter and colleagues showed in 150 patients with atrial fibrillation that 74% had obstructive sleep apnea. The influence of obstructive sleep apnea on the recurrence of atrial fibrillation was also documented after cardioversion: 82% of patients with atrial fibrillation and untreated obstructive sleep apnea had recurrences of atrial fibrillation, compared with 42% who received treatment with CPAP devices. In patients with atrial fibrillation, sleep screening (if required, with treatment) is indicated.
The high expectations for new drug treatments have not been met. Vernakalant is not only very expensive but has conversion rates of only 50%, which limits its use compared with electric cardioversion. The initial euphoria associated with dronedarone has also turned into disappointment, especially after the results of the PALLAS study, which showed increased rates of death, stroke, and heart failure in patients with permanent atrial fibrillation receiving dronedarone, and which therefore had to be stopped. Pulmonary vein isolation is an established intervention with success rates of 70% and is an option for patients with symptomatic atrial fibrillation.
Prof. Dr. med. Hans-Joachim Trappe
Medizinische Klinik II (Schwerpunkte Kardiologie und Angiologie)
Conflict of interest statement
Professor Trappe has received travel and hotel expenses from St Jude Medical, Boston Scientific for ASC and DKG Mannheim. He has also received honoraria for continuing medical educational events from St Jude Medical and Boston Scientific.
|1.||The Task Force for the Management of Atrial Fibrillation of the European Society of Cardiology (ESC): Guidelines for the management of atrial fibrillation. Eur Heart J 2010; 31: 2369–429. CrossRef MEDLINE|
|2.||Kirchhof P, Goette A, Gulba D, Hindricks G, Hohnloser SH: Kommentar zu den Leitlinien der ESC zum Vorhofflimmern. Kardiologe 2012; 6: 12–27. CrossRef|
|3.||Bitter T, Langer C, Vogt J, Lange M, Horstkotte D, Oldenburg O: Sleep disordered breathing in patients with atrial fibrillation and normal systolic left ventricular function. Dtsch Arztebl Int 2009; 106(10): 164–70.VOLLTEXT|
|4.||Trappe HJ: Atrial fibrillation: established and innovative methods of evaluation and treatment. Dtsch Artzebl Int 2012; 109(1–2): 1–7.VOLLTEXT|