Case studies with the experts

BOSTON, MASSACHUSETTS. A special satellite symposium was held during the 2007 Heart Rhythm Society meeting. During the symposium 5 experts (Eric Prystowsky MD, Pierre Jais MD, Peter Kowey MD, Stanley Nattel MD, and Jeremy Ruskin MD) discussed various aspects of atrial fibrillation (NOTE: Their comments are not specifically aimed at lone AF). Following are some highlights from the discussion.

  • Re: Aspirin vs. warfarin for stroke prevention
    Comment: “Of course, you have the discussion with the patients and the patients do generally make the right decision, but I think there is a tendency among many physicians to be somewhat aggressive in many cases and decide to prescribe warfarin just to be on the safe side. That’s not fair either.

  • Re: Damage to atrium due to long-term AF
    Summary: The atrial rate is increased about 10-fold in persistent afib. This causes a calcium overload which the body compensates for by inactivating calcium channels. This results in a shortening of the refractory period (AERP) making it more likely that afib will persist. Animal experiments have also shown that persistent/permanent afib increases fibrosis and collagen expression in the heart.

  • Re: Choice of antiarrhythmic drugs
    Comments: “In people with minimal or no structural heart disease, drugs with minimal organ toxicity are preferred, such as flecainide, propafenone, and sotalol; amiodarone and dofetilide are second-line choices.”

    “We talked about cardiac risks, but we can’t forget extracardiac risks, and beta blockers, propafenone, sotalol, and dofetilide are all pretty much equivalent and fairly low. Amiodarone is by far the worst. So in the AF management guidelines, there’s a pretty simple general rule. The rule is that amiodarone is kept in reserve because of its significant risk of extracardiac toxicity, particularly with longer term therapy, so it’s not a first-line drug unless the risks of the alternatives are too high.

Prystowsky, EN, et al. Case studies with the experts: Management decisions in atrial fibrillation. Journal of Cardiovascular Electrophysiology, Vol. 19, Suppl. 1, 2008, pp. S1-S12