The evolving landscape of atrial fibrillation: diagnosis and therapy

Atrial fibrillation (AF) is one of the most common arrhythmias in patients with cardiovascular diseases, and its management has undergone significant evolution over the years.¹ The present issue provides new insights into the diagnosis and management of the condition, with a focus on complex patient populations. These data offer valuable perspectives for the future, highlighting existing knowledge gaps and the need for further studies to optimize clinical management of AF.

Technological advancements have improved both diagnoses, through the increasing use of continuous monitoring devices for symptomatic and asymptomatic patients, and treatment, with advanced rhythm control strategies. However, systematic screening for AF in asymptomatic individuals remains a controversial topic within the scientific community. A meta-analysis² conducted on a large cohort of 74 145 asymptomatic patients found out that the AF screening reduced the incidence of thromboembolic events with subsequent increase of anticoagulant therapy prescription. Even though a benefit in terms of reduced ischaemic events was observed, no impact on overall mortality or risk of haemorrhagic stroke was recorded. While these findings support the potential benefit of screening even in asymptomatic patients, concerns are raised about its economic sustainability and large-scale applicability. In this context, home self-monitoring devices and artificial intelligence-based systems could represent innovative solutions to make screening more efficient and accessible. Further studies will be necessary to validate such approaches.

The improvement in AF management in recent years has been confirmed by a study conducted by Noubiap et al.,³ which reported a significant reduction in ischaemic strokes, intracranial haemorrhages, and mortality, particularly among high-risk patients such as the elderly. Although this study is observational and does not allow for a definitive determination of the causes of this prognostic improvement, several factors may have contributed: the increasing use of direct oral anticoagulants over vitamin K antagonists, the greater utilization of catheter ablation for rhythm control, the widespread adoption of devices for subclinical AF monitoring (pacemakers, defibrillators, and loop recorders), and a heightened focus on cardiovascular risk factors. Another study conducted by Liao et al.⁴ highlighted a progressive increase in the prescription of novel oral anticoagulants over the years, resulting in a significant reduction in ischaemic events and a positive impact on overall mortality.

European guidelines recommend a comprehensive AF management approach using the ABC (Atrial fibrillation Better Care) pathway. However, Krittayaphong et al.⁵ demonstrated that initial adherence to this approach is not sufficient; continuous monitoring of its application over time is crucial, as poor adherence during follow-up is associated with worse prognosis. Therefore, periodic clinical reassessment is essential to ensure optimal patient management.

The complexity of AF management is further heightened in specific patient subgroups, such as the elderly, those with concomitant myocardial infarction, perioperative patients, and individuals with tricuspid valve disease. In elderly patients, the incidence of AF increases with age, making therapeutic management more challenging due to the greater frailty of this population. A study by Inoue et al.⁶ analysed the risks associated with catheter ablation in elderly patients, showing that advanced age is an independent risk factor for peri-procedural complications such as cardiac tamponade, sinus node dysfunction, and ischaemic cerebral events. However, post-treatment recurrence rates do not appear to be influenced by age, suggesting that with careful candidate selection, catheter ablation may be effective even in older patients.

In the perioperative setting, Tas et al.⁷ observed that patients undergoing abdominal surgery who develop post-operative atrial fibrillation (POAF) have a stroke risk comparable to that of patients with chronic AF 1 year after surgery, highlighting the importance of looking for this arrythmias in the perioperative time even for non-cardiac surgery. Additionally, in patients with obstructive hypertrophic cardiomyopathy, the risk of developing POAF is particularly high. Nie et al.⁸ demonstrated that the presence of more than 200 supraventricular extrasystoles or episodes of supraventricular tachycardia in a 24-h Holter ECG significantly increases the risk of POAF, suggesting to better evaluate those patients as they are at higher risk.

In patients with AF and myocardial infarction, therapeutic management requires careful risk–benefit assessment, balancing thrombotic and haemorrhagic risks. Deakin et al.⁹ conducted an observational study on an Australian cohort of patients with myocardial infarction and AF, revealing that one-quarter of patients did not receive anticoagulant therapy, while another quarter were treated with both anticoagulant and antiplatelet therapy using ticagrelor or prasugrel, thereby increasing haemorrhagic risk. These findings indicate a discrepancy between guidelines and clinical practice, emphasizing the importance of specialized follow-up to ensure appropriate therapeutic management.

Finally, there is a bidirectional relationship between tricuspid regurgitation (TR) and AF: the last induces atrial remodelling, leading to tricuspid annular dilatation and TR, while the first results in progressive right atrial dilation, increasing the risk of AF. Loutati et al.¹⁰ demonstrated that patients with permanent AF have an increased risk of TR progression, which impacts overall mortality. Moreover, TR progression is particularly evident in patients with normal pulmonary artery systolic pressure.

Conflict of interest

none declared.

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