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type=\u0022text\/css\u0022 rel=\u0022stylesheet\u0022 href=\u0022\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/cdn\/css\/http\/css_Xg7z6oCTVgud_Q0huYz9x9iiD5H_2YPSJ5z2ZViSWdY.css\u0022 media=\u0022all\u0022 \/\u003E\n\u003Clink rel=\u0027stylesheet\u0027 type=\u0027text\/css\u0027 href=\u0027\/sites\/all\/modules\/contrib\/panels\/plugins\/layouts\/onecol\/onecol.css\u0027 \/\u003E\u003C\/head\u003E\u003Cbody\u003E\u003Cdiv class=\u0022panels-ajax-tab-panel panels-ajax-tab-panel-sageoa-tab-art\u0022\u003E\u003Cdiv class=\u0022panel-display panel-1col clearfix\u0022 \u003E\n  \u003Cdiv class=\u0022panel-panel panel-col\u0022\u003E\n    \u003Cdiv\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-markup\u0022 \u003E\n  \n      \n  \n  \u003Cdiv class=\u0022pane-content\u0022\u003E\n    \u003Cdiv class=\u0022highwire-markup\u0022\u003E\u003Cdiv xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block-markup\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv class=\u0022article fulltext-view \u0022\u003E\u003Cspan class=\u0022highwire-journal-article-marker-start\u0022\u003E\u003C\/span\u003E\u003Cdiv class=\u0022section abstract\u0022 id=\u0022abstract-1\u0022\u003E\u003Ch2\u003ESummary\u003C\/h2\u003E\n            \u003Cp id=\u0022p-1\u0022\u003EThis article discusses methods to control and reduce the level of mortality in patients with atrial fibrillation (AF). Dedicated clinics with nurse-led programs addressing of nonstroke-related mortality, ablation, and rate and rhythm control are potential strategies to explore to reduce AF-related cardiovascular outcomes.\u003C\/p\u003E\n         \u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003ECerebrovascular Disease\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EHeart Failure\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EArrhythmias\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003ECardiology\u003C\/li\u003E\u003C\/ul\u003E\u003Cul class=\u0022kwd-group clinical-trial\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003ECerebrovascular Disease\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EHeart Failure\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EArrhythmias\u003C\/li\u003E\u003C\/ul\u003E\u003Cp id=\u0022p-2\u0022\u003EA panel of experts discussed possible methods to control and reduce the level of mortality in patients with atrial fibrillation (AF). Dedicated clinics with nurse-led programs addressing of nonstroke-related mortality, ablation, and rate and rhythm control are potential strategies to explore to reduce AF-related cardiovascular (CV) outcomes.\u003C\/p\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-1\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003ETHE ROLE OF DEDICATED AF CLINICS TO REDUCE STROKE AND MORTALITY IN AF PATIENTS\u003C\/h2\u003E\n         \u003Cp id=\u0022p-3\u0022\u003EJohn Camm, MD, St George\u0027s University of London, London, United Kingdom, addressed the role of specialist AF clinics in reducing stroke and mortality in patients with AF. These clinics may improve adherence to AF treatment guidelines [Gorin L et al. \u003Cem\u003EChest.\u003C\/em\u003E 2011; Nieuwlaat R et al. \u003Cem\u003EAm Heart J.\u003C\/em\u003E 2007]. Suboptimal control of anticoagulant therapy is associated with increased stroke or systemic embolism, major bleeding episodes, and death [Kakkar AK et al. AHA. 2012].\u003C\/p\u003E\n         \u003Cp id=\u0022p-4\u0022\u003EMinimizing undertreatment of AF has been successful via guideline-based care delivered in a nurse-centered interdisciplinary fashion [Berti D et al. \u003Cem\u003EEur Heart J.\u003C\/em\u003E 2013]. Cardioversion of persistent AF performed by trained nurses yields high rates of patient satisfaction and success at discharge and reduces waiting times for elective procedures [Gillis AM et al. \u003Cem\u003ECan J Cardiol.\u003C\/em\u003E 2008; Boodhoo L et al. \u003Cem\u003EHeart.\u003C\/em\u003E 2004]. The only randomized comparison of usual care versus nurse-coordinated care documented significantly fewer deaths and hospitalizations due to CV causes [Hendriks JM et al. \u003Cem\u003EEur Heart J.\u003C\/em\u003E 2012]. The advantages as compared with usual care include lower costs and improved survival and quality of life [Hendricks J et al. \u003Cem\u003EEuropace.\u003C\/em\u003E 2013].\u003C\/p\u003E\n         \u003Cp id=\u0022p-5\u0022\u003EThe design of nurse-centered care is debatable [Berti D et al. \u003Cem\u003EEur Heart J.\u003C\/em\u003E 2013]. A system where nurses are the main patient-physician conduit (ie, nurse coordinated; \u003Ca id=\u0022xref-fig-1-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F1\u0022\u003EFigure 1A\u003C\/a\u003E) is more popular. Alternatively, nurses can play a central role while being jointly managed by clinicians and clinical nurse specialists (ie, nurse assisted; \u003Ca id=\u0022xref-fig-1-2\u0022 class=\u0022xref-fig\u0022 href=\u0022#F1\u0022\u003EFigure 1B\u003C\/a\u003E).\u003C\/p\u003E\n         \u003Cdiv id=\u0022F1\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/27\/35\/F1.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022Interdisciplinary AF Expert Programs\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-1344729765\u0022 data-figure-caption=\u0022Interdisciplinary AF Expert Programs\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 1.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/27\/35\/F1.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/27\/35\/F1.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 1.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/27\/35\/F1.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/14994\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption attrib\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 1.\u003C\/span\u003E \n               \u003Cp id=\u0022p-6\u0022 class=\u0022first-child\u0022\u003EInterdisciplinary AF Expert Programs\u003C\/p\u003E\n            \u003Cq class=\u0022attrib\u0022 id=\u0022attrib-1\u0022\u003EAF, atrial fibrillation.\u003C\/q\u003E\u003Cq class=\u0022attrib\u0022 id=\u0022attrib-2\u0022\u003EReproduced from Berti D et al. A proposal for interdisciplinary, nurse-coordinated atrial fibrillation expert programmes as a way to structure daily practice. \u003Cem\u003EEur Heart J\u003C\/em\u003E. 2013;34:2725\u201330. With permission from Oxford University Press.\u003C\/q\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n         \u003Cp id=\u0022p-7\u0022\u003EThe National Institute for Health and Care Excellence\u0027s 2014 guidelines on AF recommended, with some caveats, personalized patient care and information for AF patients [National Clinical Guideline Centre. \u003Cem\u003EAtrial Fibrillation: The Management of Atrial Fibrillation.\u003C\/em\u003E 2014]. This approach will be assessed in the upcoming RACE 4 study [\u003Ca class=\u0022external-ref external-ref-type-clintrialgov\u0022 href=\u0022\/lookup\/external-ref?link_type=CLINTRIALGOV\u0026amp;access_num=NCT01740037\u0026amp;atom=%2Fspmdc%2F14%2F27%2F35.atom\u0022\u003ENCT01740037\u003C\/a\u003E] of \u0026gt; 1700 patients with newly diagnosed AF. The primary end point will be a composite of unplanned hospitalization for any CV cause and CV death.\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-2\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003ECV MORBIDITY AND MORTALITY IN AF PATIENTS BEYOND STROKE PREVENTION\u003C\/h2\u003E\n         \u003Cp id=\u0022p-8\u0022\u003EEloi Marijon, MD, PhD, Paris Descartes University, Paris, France, addressed the association between AF and nonstroke CV outcomes. AF affects an estimated 35 million people globally, with an incidence of 5 million new cases annually [Chugh SS et al. \u003Cem\u003ECirculation.\u003C\/em\u003E 2013]. The Framingham Heart Study revealed that men with AF are twice as likely to die as men without AF, while women with AF are 3 times as likely as those without AF (\u003Ca id=\u0022xref-fig-2-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F2\u0022\u003EFigure 2\u003C\/a\u003E). The authors found that although approximately one-half of the increased risk was due to comorbid CV conditions, AF still independently predicted all-cause mortality after control for confounders and predictors.\u003C\/p\u003E\n         \u003Cdiv id=\u0022F2\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/27\/35\/F2.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022Higher Mortality With Atrial Fibrillation: Framingham Study Data\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-1344729765\u0022 data-figure-caption=\u0022Higher Mortality With Atrial Fibrillation: Framingham Study Data\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 2.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/27\/35\/F2.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/27\/35\/F2.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 2.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/27\/35\/F2.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/14995\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption attrib\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 2.\u003C\/span\u003E \n               \u003Cp id=\u0022p-9\u0022 class=\u0022first-child\u0022\u003EHigher Mortality With Atrial Fibrillation: Framingham Study Data\u003C\/p\u003E\n            \u003Cq class=\u0022attrib\u0022 id=\u0022attrib-3\u0022\u003EAF, atrial fibrillation.\u003C\/q\u003E\u003Cq class=\u0022attrib\u0022 id=\u0022attrib-4\u0022\u003EReproduced from Benjamin EJ et al. Impact of Atrial Fibrillation on the Risk of Death: The Framingham Heart Study. \u003Cem\u003ECirculation\u003C\/em\u003E. 1998;98:946\u201352. With permission from Lippincott Williams \u0026amp; Wilkins.\u003C\/q\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n         \u003Cp id=\u0022p-10\u0022\u003EThe causal relationship between AF and stroke has led to the development and expanded use of new oral anticoagulants and left atrial appendage occlusion. While reduction in stroke risk continues to be a pressing problem, identification and better understanding of whether there are causal relationships between AF and nonstroke causes of mortality have been explored in large randomized controlled trial populations [Marijon E et al. \u003Cem\u003ECirculation.\u003C\/em\u003E 2013; Roy D et al. \u003Cem\u003EN Engl J Med.\u003C\/em\u003E 2008; Steinberg JS et al. \u003Cem\u003ECirculation.\u003C\/em\u003E 2004]. These studies have demonstrated that in patients receiving anticoagulation treatment, CV mortality still remains the leading cause of death, often due to congestive heart failure (CHF), myocardial infarction (MI), and sudden cardiac death (SCD), not stroke. In one study, stroke constituted only about one-quarter of CV mortality up to 5 years after a first AF event [Piccini JP et al. \u003Cem\u003EEur Heart J.\u003C\/em\u003E 2014].\u003C\/p\u003E\n         \u003Cp id=\u0022p-11\u0022\u003EThe relationship between AF and MI, SCD, and CHF is more complex than it is with stroke. The nearly 2-fold increased risk of MI in patients with AF [Soliman EZ et al. \u003Cem\u003EJAMA Intern Med.\u003C\/em\u003E 2014] is reduced with anticoagulation, suggesting that at least for some patients, coronary embolism may be the cause [Dukes JW et al. \u003Cem\u003EJAMA Intern Med.\u003C\/em\u003E 2014]. Other hypotheses include AF-induced inflammation leading to plaque rupture or simply no causal relationship (ie, only presence of concomitant MI-related risk factors). Whether AF leads to SCD is not definitively known, but studies suggest not [Chen LY et al. \u003Cem\u003EJAMA Intern Med.\u003C\/em\u003E 2013]. CHF is one of the strongest predictors of SCD, and when adjusted for, there appears to be no remaining association between AF and SCD [Marijon E et al. \u003Cem\u003ECirculation.\u003C\/em\u003E 2013; Reinier K et al. \u003Cem\u003EJACC Heart Fail.\u003C\/em\u003E 2014]. AF can be a direct cause of CHF (eg, tachycardia-induced cardiomyopathy). Whether there are other unknown mechanisms by which AF causes CHF is likely but poorly defined.\u003C\/p\u003E\n         \u003Cp id=\u0022p-12\u0022\u003EDr Marijon concluded by stressing that since AF is directly associated with nonstroke causes of mortality, practitioners should consider estimating the risk of adverse CV outcomes beyond stroke; for example, the CHADS\u003Csub\u003E2\u003C\/sub\u003E score has just been reported to predict broader CV outcomes [Ruwald AC et al. \u003Cem\u003EInt J Cardiol.\u003C\/em\u003E 2014].\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-3\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003EAF AND HEART FAILURE: A QUESTION OF MANAGEMENT?\u003C\/h2\u003E\n         \u003Cp id=\u0022p-13\u0022\u003EIsabelle Van Gelder, MD, PhD, University Medical Center, Groningen, Netherlands, discussed the management of AF in the setting of concomitant heart failure (HF).\u003C\/p\u003E\n         \u003Cp id=\u0022p-14\u0022\u003EAF may be caused by a primary electrical anomaly that, especially in younger patients, responds well to ablation treatment. Much more common, AF results from long-term atrial remodeling, including enlargement and fibrosis, due to conditions such as hypertension, HF, aging, and diabetes [Wyse DG et al. \u003Cem\u003EJ Am Coll Cardiol.\u003C\/em\u003E 2014].\u003C\/p\u003E\n         \u003Cp id=\u0022p-15\u0022\u003EThe discovery of an increasing number of risk factors suggests that true \u201clone\u201d AF is probably extremely rare. Almost all patients presenting with AF have at least one of the reported risk factors for AF (eg, subclinical diastolic HF) [Wyse DG et al. \u003Cem\u003EJ Am Coll Cardiol.\u003C\/em\u003E 2014]. These risk factors should be sought and aggressively treated during follow-up. One particular risk factor, HF, has been found to be much more prevalent in AF than previously recognized [Maisel WH, Stevenson LW. \u003Cem\u003EAm J Cardiol.\u003C\/em\u003E 2003]. As demonstrated in the CHARM study, AF carries a much worsened prognosis for HF patients, regardless of whether ejection fraction (EF) is preserved or reduced [Olsson LG et al. \u003Cem\u003EJ Am Coll Cardiol.\u003C\/em\u003E 2006].\u003C\/p\u003E\n         \u003Cp id=\u0022p-16\u0022\u003EAF therapy seeks to prevent and reduce symptomatic burden and associated clinical outcomes. Therapy for self-terminating AF is symptom driven and seeks to prevent recurrent episodes. In these patients, catheter ablation is significantly more effective than use of antiarrhythmic medication (log-rank \u003Cem\u003EP\u003C\/em\u003E \u0026lt; .001) [Wilber DJ et al. \u003Cem\u003EJAMA\u003C\/em\u003E. 2010]. Catheter ablation, with repeated procedures as needed for persistent AF, can produce long-lasting protection (\u2264 8 years), but it still does not provide a cure [Sorgente A et al. \u003Cem\u003EAm J Cardiol.\u003C\/em\u003E 2012]. In the past, trials have demonstrated that rhythm versus rate control did not affect clinical outcomes. Importantly, rhythm control in these trials did not include catheter ablation; thus, it is unclear whether more effective, modern rhythm control strategies might demonstrate a benefit with maintenance of sinus rhythm.\u003C\/p\u003E\n         \u003Cp id=\u0022p-17\u0022\u003EHeart rate control is important when symptoms are present. The choice of medication is lifestyle dependent (\u003Ca id=\u0022xref-fig-3-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F3\u0022\u003EFigure 3\u003C\/a\u003E) [Camm AJ et al. \u003Cem\u003EEur Heart J.\u003C\/em\u003E 2010].\u003C\/p\u003E\n         \u003Cdiv id=\u0022F3\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/27\/35\/F3.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022Choice of Heart Rate Control Medication\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-1344729765\u0022 data-figure-caption=\u0022Choice of Heart Rate Control Medication\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 3.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/27\/35\/F3.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/27\/35\/F3.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 3.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/27\/35\/F3.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/14996\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption attrib\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 3.\u003C\/span\u003E \n               \u003Cp id=\u0022p-18\u0022 class=\u0022first-child\u0022\u003EChoice of Heart Rate Control Medication\u003C\/p\u003E\n            \u003Cq class=\u0022attrib\u0022 id=\u0022attrib-5\u0022\u003ECOPD, chronic obstructive pulmonary disease.\u003C\/q\u003E\u003Cq class=\u0022attrib\u0022 id=\u0022attrib-6\u0022\u003EReproduced from Camm AJ et al. Guidelines for the management of atrial fibrillation. The Task Force for the Management of Atrial Fibrillation of the European Society of Cardiology (ESC). \u003Cem\u003EEur Heart J\u003C\/em\u003E. 2010;31:2369\u2013429. With permission from Oxford University Press.\u003C\/q\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n         \u003Cp id=\u0022p-19\u0022\u003ENote that the benefits of \u03b2-blockers in HF were studied in patients in sinus rhythm, not AF. Reductions in CV outcomes have been reported for bisoprolol and nebivolol in those with sinus rhythm, with no difference found in those with AF [Mulder BA et al. \u003Cem\u003EEur J Heart Fail.\u003C\/em\u003E 2012; Lechat P. \u003Cem\u003ECirculation.\u003C\/em\u003E 2001]. The European Society of Cardiology 2012 guidelines\u2014which recommended the use of both \u03b2-blockers and angiotensin-converting enzyme inhibitors for patients with EF \u2264 40% [McMurray JJV et al. \u003Cem\u003EEur Heart J.\u003C\/em\u003E 2012]\u2014were based on these studies enrolling patients in sinus rhythm.\u003C\/p\u003E\n         \u003Cp id=\u0022p-20\u0022\u003EDigoxin has been associated with increased AF-related mortality [Corley SD et al. \u003Cem\u003ECirculation.\u003C\/em\u003E 2004], CV mortality, and all-cause mortality [Turakhia MP et al. \u003Cem\u003EJ Am Coll Cardiol.\u003C\/em\u003E 2014; Whitbeck MG et al. \u003Cem\u003EEur Heart J.\u003C\/em\u003E 2013]. Reexamination of this association has yielded conflicting results. Until this hypothesis can be properly tested, these observational data should not discourage use of digoxin in all AF patients. Digoxin remains useful in the treatment of conditions like AF, with low blood pressure, difficult rate control, and frequent HF hospitalizations.\u003C\/p\u003E\n         \u003Cp id=\u0022p-21\u0022\u003ERecent trials of lifestyle management among obese subjects with AF have demonstrated not only reduced weight circumference and body mass index but also decreased scores of symptom burden and severity [Abed HS et al. \u003Cem\u003EJAMA.\u003C\/em\u003E 2013]. This reinforces the view that early and comprehensive lifestyle interventions are needed to reduce the prevalence of AF.\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-4\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003EIMPROVING OUTCOMES THROUGH EARLY RHYTHM CONTROL THERAPY\u003C\/h2\u003E\n         \u003Cp id=\u0022p-22\u0022\u003EThe importance of early intervention with modern therapies was expanded on by Paulus Kirchhof, MD, University of Birmingham, Birmingham, United Kingdom. Dr Kirchhof highlighted that the increased risk of AF-related death is especially evident early following the first episode of AF, even when patients receive optimal anticoagulation and heart rate control therapy.\u003C\/p\u003E\n         \u003Cp id=\u0022p-23\u0022\u003EWhat makes this period so dangerous is not known. AF is a complex phenomenon that influences the cardiac calcium load, which affects the structural and hemodynamic loops. These effects can exacerbate AF, which can lead to chronic atrial dilation. The interplay between AF and atrial dilation can produce recurrent A F. Chronic dilation can induce fibrosis, which also exacerbates AF. Most important, these long-standing alterations can occur within weeks, if not hours. This raises the hypothesis whether early rhythm control might reduce AF-related complications. As mentioned, while prior studies have not supported a benefit of rhythm control compared to rate control, Dr Kirchhof highlighted that subjects enrolled in many of these studies probably had longer-standing AF and that rhythm control during the period of these trials was less effective [Hohnloser SH et al. \u003Cem\u003EN Engl J Med.\u003C\/em\u003E 2009; Roy D et al. \u003Cem\u003EN Engl J Med.\u003C\/em\u003E 2008; AFFIRM Investigators. \u003Cem\u003EJ Am Coll Cardiol.\u003C\/em\u003E 2003; Carlsson J et al. \u003Cem\u003EJ Am Coll Cardiol.\u003C\/em\u003E 2003; AFFIRM Investigators. \u003Cem\u003EN Engl J Med.\u003C\/em\u003E 2002; Van Gelder IC et al. \u003Cem\u003EN Engl J Med.\u003C\/em\u003E 2002; Hohnloser SH et al. \u003Cem\u003ELancet.\u003C\/em\u003E 2000], but none of them was targeted at the early disease stages. This may have been one of the reasons why the outcome of the prior trials was neutral.\u003C\/p\u003E\n         \u003Cp id=\u0022p-24\u0022\u003EIn support of these data, the prospective, randomized, open, blinded outcome EAST trial [Kirchhof P et al. \u003Cem\u003EAm Heart J.\u003C\/em\u003E 2013] is being conducted by Prof Kirchhof and colleagues to test the hypothesis that a safely delivered, more effective antiarrhythmic regimen (including catheter ablation and antiarrhythmics) can prevent major complications of death, stroke, and HF as compared with usual care. More than 50% of the required patients have been enrolled (\u003Ca href=\u0022http:\/\/www.easttrial.org\u0022\u003Ewww.easttrial.org\u003C\/a\u003E).\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cul class=\u0022copyright-statement\u0022\u003E\u003Cli class=\u0022fn\u0022 id=\u0022copyright-statement-1\u0022\u003E\u00a9 2014 MD Conference Express\u00ae\u003C\/li\u003E\u003C\/ul\u003E\u003Cspan class=\u0022highwire-journal-article-marker-end\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Cspan id=\u0022related-urls\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Ca href=\u0022http:\/\/mdc.sagepub.com\/content\/14\/27\/35.abstract\u0022 class=\u0022hw-link hw-link-article-abstract\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView Summary\u003C\/a\u003E\u003C\/div\u003E  \u003C\/div\u003E\n\n  \n  \u003C\/div\u003E\n\u003C\/div\u003E\n  \u003C\/div\u003E\n\u003C\/div\u003E\n\u003C\/div\u003E\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_figures.js?nzoule\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_openurl.js?nzoule\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}