Atrial Fibrillation

1
Atrial Fibrillation The Tip of the Iceberg

• Marc Cohen, MD
• Professor of Medicine
• Mt. Sinai School of Medicine
• New York, NY

2
AF Prevalence Is Predicted to Increase at Least
2.5-fold by 2050 in the US
7
6
5
4
Adults With AF (millions)
3
2
1
0
1990
1995
2000
2005
2010
2015
2020
2025
2030
2035
2040
2045
2050

• Upper and lower curves represent the upper and
  lower scenarios based on sensitivity analyses.

Go AS, et al. JAMA. 200128523702375.
3
Impact of Atrial Fibrillation Over Time

• Contractile remodeling
• Reduced atrial contractility
• Sets the stage for thrombus formation
• May lead to atrial dilation further altering
  electrophysiologic properties
• Occurs rapidly

• Electrical remodeling
• Shortening of atrial refractory periods
• Occurs rapidly (within several days) and
  contributes to the increased stability of AF

Shortened refractory period

• Structural remodeling
• Histologic changes
• Left atrium and left atrial appendage enlargement
• Decrease in cardiac output
• Occurs after a period of weeks to months

-80 mV
1. Van Gelder IC, et al. Europace.
20068943-949.2. Veenhuyzen GD, et al. Can Med
Assoc J. 2004171755-760.
4
Atrial Remodeling and Persistent AF

• AF induces electrophysiologic changes that
  promote more prolonged AF (experimental study in
  animals).1
• These changes cause and result from electrical,
  contractile, and structural atrial remodeling,
  and occur within days.2

SR Sinus rhythm1. Wijffels MCEF, et al.
Circulation. 1995921954-1968.2. Schotten U, et
al. Circulation. 20031071433-1439.
5
Independent Risk Factors for AF
Framingham
Odds ratio
Men (n 2090)
Women (n 2641)
Heart failure
2-year pooled logistic regression
Benjamin EJ, et al. JAMA. 1994271840-844.
6
AF Adversely Affects QoL
AF
Post MI
120
Controls


100

92
88

80
85
81
78
SF-36 Score
76
71
70
68
68
60
59
54
40
20
0
General Health
Physical Function
Social Function
Mental Health
Lower scores poorer QoL
P lt .05 AF vs controls
Dorian P, et al. J Am Coll Cardiol.
2000361303-1309.
7
Hospitalizations Represent a Major Driver in Cost
of AF Patients (EU)

• 70 of the cost of AF management is driven by
  inpatient care and interventional procedures

EuroHeart Survey (20042005)
Work loss
Consultations
Inpatient care
Interventions
Drugs
Diagnostics
Ringborg A, et al. Europace. 200810403-411.
8
AF Worsens the Prognosisof Patients With
Comorbidities
AF is associated with larger MI's AF is
associated with a longer duration of hypertension
1. Adapted from Wachtell K, et al. J Am Coll
Cardiol. 200545712-719.2. Adapted from Wang
TJ, et al. Circulation. 20031072920-2925.3.
Adapted from Pizzetti F, et al. Heart.
200186527-532.
9
AF Increases the Risk for Stroke in All Age
Groups1
Framingham
5
4.5
4.0
4
3.3
2.6
3
Relative Risk for Stroke
2
1
0
50-59
60-69
70-79
80-89
Age (years)
P lt .001 vs non-AF patients
Wolf PA, et al. Stroke. 199122983-988.
10
Ischemic Stroke Associated With AFIs Typically
More Severe Than Stroke due to Other Etiologies
50
41.2
40
30
Bedridden Patients
23.7
20
P lt .0005
10
0
Without AF
With AF
Odds ratio for bedridden state following stroke
due to AF was 2.23 (95 CI, 1.87-2.59 P lt .0005)
Dulli DA, et al. Neuroepidemiology.
200322118-123.
11
AF Approximately Doubles the Risk for Mortality
in Younger and Older Patients
Age 7594 years
Age 5574 years
Benjamin EJ, et al. Circulation. 199898946-952.
12
AF Epidemiology and Impact

• Widely prevalent and increasing
• A progressive disease, with treatments gradually
  becoming less effective
• Can adversely affect quality of life
• Has a significant socio-economic impact
• Increases the risk for cardiovascular morbidity
  and mortality