A presentation on atrial fibrillation : Old wine in Old bottle
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Good news: Nothing much has changed since 2008
- Recognizing the clinical importance of AF and the need to rule out a systemic cause is the key, Further, a genuine bedside debate about the pros and cons of simple vs aggressive treatment discussion is welcome.
- The nomenclature issue of valvular vs non-valvular has finally seemed to have settled. The latter is banished for good reason. (Funny to note Aortic valve was considered as not a valve for so long !)
- The rate vs rhythm control debate still favors the former. (AFFIRM/RACE)
- Stroke prevention is the concern & anticoagulation is the mainstay. OAC/DAPT /triple therapy has evolved a little more in the last decade. Though stoke is a major concern, we rarely see neurologists & cardiologists debate closely on risk profiling issues of such patients. (at least in this part of the world.)
- Whether we have conquered AF or not we have become experts in creating an unlimited number of bleeding risk scores. Understanding and applying them at the bedside need special memory and expertise.
- On the combative front, ablation strategies, however, advanced they look, are vested with the risk of injuring the surrounding structures. My biased opinion is that the risks are prohibitive except in very refractory and troublesome AFs. (with all these 4D, contact, cryo, etc) Recall the CABANA study. We are beginning to understand, the true embryological face of pulmonary veins insertion points is so variable, and residual sleeves are very rampant that will sustain the AF even after an apparently successful ablation.
- LAA appendage closure studies again don’t look rosy as the device itself is prone to thrombus at least in the early periprocedural period. (Watchman requires more security and protection than the Inmates !)
AF is a simple arrhythmia in 9/10 patients. Please, let us not complicate it. We must ensure, systemic and non-permanent forms of AF should not drain our cardiac resources. We shall follow basic principles of managing a cardiac arrhythmia that will suffice in the majority. An occasional patient needs to be referred to an EP specialist.