While significant progress has been made in addressing atrial fibrillation (AFib), a better understanding may be needed on substrate progression, evolution of nonpulmonary vein triggers and a comprehensive approach to multisystem risk factor modification, according to a perspective from ACC's Electrophysiology Council published April 6 in the Journal of the American College of Cardiology.

Mina K. Chung, MD, FACC, et al., review the current knowledge on the prevalence, pathophysiology, risk prediction, prophylaxis and treatment options, as well as new insights for optimizing treatment outcomes and emerging concepts of AFib. They note that AFib is a cardiovascular pandemic with a complex pathophysiology and contributes to significant patient morbidity and mortality.

In reviewing strategies for primary and secondary prevention of AFib, they explain that primary prevention has focused mostly on reversing the modifiable risk factors and secondary prevention has focused on reducing the burden of AFib and preventing its progression to more persistent forms. They discuss the potential of upstream targets and agents, and using genetics to target AFib therapy.

Following the initial assessment of patients with AFib, the authors state treatment strategies need to be developed with two major goals: 1) preventing thromboembolism, and 2) symptom control with either a rhythm control or rate control strategy. Along with a review of oral anticoagulation therapy and management of bleeding, they look at the use of left atrial appendage closure as well as rate and rhythm control strategies, including ablation.

While a "unifying hypothesis" that explains all causes of AFib has not emerged, the authors state AFib appears to be a "final common pathway" resulting from the influence of varied genetic, environmental, cellular stress and lifestyle factors.

"Difficulties in predicting the consequences of AFib and its therapies and the limitations of current therapies make it imperative to study and improve preventive and therapeutic strategies," the authors conclude. "A hope is that basic and translational research will lead to more effective and safe therapeutic options, including pharmacological and nonpharmacological ablative approaches."

Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Cardiovascular Care Team, Prevention, Anticoagulation Management and Atrial Fibrillation, Atrial Fibrillation/Supraventricular Arrhythmias

Keywords: Atrial Fibrillation, Risk Factors, Secondary Prevention, Prevalence, Translational Medical Research, Pandemics, Atrial Appendage, Thromboembolism, Treatment Outcome, Morbidity, Hemorrhage, Primary Prevention, Anticoagulants

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