Personalized management of atrial fibrillation is on its way, a new, more individualized approach to diagnosing and treating atrial fibrillation that will vary from patient to patient depending on the pathophysiology, clinical risk, and predisposition of each patient.
But while the trajectory toward personalization seems clear based on recent advances in understanding the many patient factors that produce variations in AF presentation and treatment response, the time for fully personalized management is not yet here, concluded a panel of experts who recently gathered to discuss the issue.
"Emerging markers may allow a more personalized management" in terms of selecting optimal strategies for anticoagulation or rhythm control in different patients based on factors including atrial morphology and damage, brain imaging, genetic predispositions, inflammatory state, and markers of coronary strain. But "each of these promising avenues requires validation in the context of existing risk factors in patients," wrote the 72-member task force in their consensus statement published online Aug. 27 (Europace 2013 [doi: 10.1093/europace/eut232]).
In short, a rough outline of the parameters that will be the basis for personalized assessment and management of patients with AF now exists, but specifics on which factors are proven useful and how to integrate this information into improved patient care remain to be determined from results of ongoing studies, concluded the panel, which represented the Fourth Atrial Fibrillation Competence Network/European Heart Rhythm Association (AFNET/EHRA) consensus conference.
"The hope is that within the next few years, we will be able to propose personalized management of AF and thereby reduce the excess mortality associated with the disease."
"The care of each patient with AF will depend upon how the patient presents, the medical history and treatment, and the presence or absence of an identifiable precipitant. Further refinements of the management plan will be based on ECG, cardiac and brain imaging, and laboratory findings," the panel wrote.
"The hope is that within the next few years, we will be able to propose personalized management of AF and thereby reduce the excess mortality associated with the disease," said Dr. Paulus Kirchhof, lead author of the consensus task force, in a statement. Personalized AF management "is the most promising way to further improve morbidity and mortality in AF patients," said Dr. Kirchhof, professor and chair of cardiovascular medicine at the University of Birmingham (England).
The panel noted that AF assessment and management already involve some degree of personalization, including assessing each patient’s presentation and need for restoration of sinus rhythm, the need for anticoagulant treatment and the type of treatment, choice of a rate-control agent, and the need for rhythm control by drug treatment or catheter ablation. Further refinement could come from applying other assessment tools. An ECG can help identify concurrent heart disease, silent AF, and the best candidates for catheter ablation. Long-term rhythm monitoring by ECG has the potential to better guide the type of antiarrhythmic therapy each patient receives.
The role of brain imaging by MRI remains poorly defined right now. Brain MRI scans hold promise to "help tailor individual treatment decisions on anticoagulation," but for now the evidence is inadequate. "Large prospective studies using serial MRI measurements in AF patients are needed to support" a role for this approach. "Present knowledge does not support the unselected or serial use of MRI to guide stroke prevention in AF patients," the task force said.
Heart imaging can provide information on valvular disease, left ventricular hypertrophy and dysfunction, and left atrial size and function, factors that can affect stroke risk and rhythm control. Biomarkers in a patient’s blood or urine, together with genetic markers, provide important information on bleeding and thrombosis risks as well as kidney function. Other important blood-based biomarkers relevant to assessing AF risk include natriuretic peptides, inflammatory markers, and unsaturated fatty acids. Genetic markers for familial AF may also provide potentially important risk information.
The task force also called for a new taxonomy for AF based on pathophysiology. The current system for classifying AF is "imperfect because there are overlaps between categories, and the majority of AF patients fall into the ‘unclassified AF’ group," Dr. Kirchhof said. "We need a better understanding of why AF develops in an individual patient before we can classify them based on biomarkers, imaging, or ECG, in addition to clinical parameters, and develop better therapies."
The consensus statement laid out a preliminary classification framework that drew distinctions among different types of AF etiologies that "could provide a step toward a taxonomy." The panel divided AF patients into seven types: monogenic for patients with an inherited cardiomyopathy, focally induced for patients with frequent paroxysmal episodes, postoperative, valvular, elderly for patients who first develop AF at age 80 years or older, polygenic for patients with genetic variants linked to early-onset AF, and unclassified.