- Email: [email protected]
Atrial Fibrillation: State of the Art in 2017 – Shifting Paradigms in Pathogenesis, Diagnosis, Treatment and Prevention
EDITORIAL
Heart, Lung and Circulation (2017) 26, 867–869 1443-9506/04/$36.00 http://dx.doi.org/10.1016/S1443-9506(17)31276-3
Atrial Fibrillation: State of the Art in 2017 – Shifting Paradigms in Pathogenesis, Diagnosis, Treatment and Prevention Haris M. Haqqani, MBBS, PhD a,b*, Kim H. Chan, MBBS, PhD a,c, Ann T. Gregory, MBBS, Grad Dip Pop Health d, A. Robert Denniss, MD, FRACP e,f,g a
Heart Rhythm Section Editor, Heart Lung and Circulation; Special Issue Co-editor, Atrial Fibrillation: State of the Art in 2017 Cardiology, The Prince Charles Hospital, Brisbane, Qld, Australia Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia d Commissioning Editor, Heart Lung and Circulation e Editor in Chief, Heart Lung and Circulation f Department of Cardiology, Westmead Hospital, University of Sydney, Sydney, NSW, Australia g Department of Cardiology, Blacktown Hospital, Western Sydney University, Sydney, NSW, Australia b c
The regular readership of Heart Lung and Circulation includes cardiovascular clinicians, cardiac geneticists, basic and translational cardiovascular scientists, neurologists, thoracic physicians, haematologists, sports physicians, clinical trialists and cardiothoracic surgeons. It is hard to imagine a disease process which spans the expertise and interests of these various craft groups in the same way that atrial fibrillation (AF) does. The commonest sustained disorder of cardiac rhythm, AF is responsible for a growing pandemic of cardiovascular morbidity and mortality with its attendant health economic implications. Given these facts, as well as the rapidly changing AF research and practice landscape, we felt compelled to commission a Special Issue of Heart Lung and Circulation dedicated to this important condition. As readers will observe, we have been fortunate to have gathered contributions from the most recognised Australasian thought leaders in AF and their international collaborators. Their reviews cover the current state of the field, with a particular focus on areas of relevance to the treating clinician. At the outset, Wong et al. clearly define the scope of the problem in their comprehensive review of the regional epidemiology of AF in Australia and the Asia-Pacific region, including in Indigenous people [1]. While the Global Burden of Disease study estimated that the worldwide, age-adjusted prevalence of AF in 2010 was about 0.5% or 33.5 million individuals [2], Wong et al. report an estimated projection,
in Asia alone, of 49 million men and 23 million women with AF by the year 2050, about 12-fold higher than equivalent predictions for American men and women. Neubeck et al. closely analyse the evidence supporting population screening for AF, systematically countering arguments against screening [3]. For example, they posit that inadequate treatment for people for AF is not an argument against screening but rather an argument in favour of improving treatment. Lau et al. and Fatkin et al. concisely review the present understanding of AF pathophysiology and genetics, respectively [4,5]. Lau et al. report that atrial fibrosis has been identified as the key structural change in different substrates responsible for the perpetuation in AF, and that novel imaging modalities can assist in identifying and quantifying atrial fibrosis [4]. Further, in patients undergoing catheter ablation, increased atrial fibrosis has been shown to be linked with higher AF recurrence [6]. They discuss two major arrhythmic mechanisms in AF, rotational activations (‘‘rotors’’) and ectopic focal activations (‘‘foci). Fatkin et al. report paradigm-shifting discoveries which suggest that abnormalities of atrial specification arising during cardiac development may provide a template for AF in later, adult life [5]. The intricate relationship between AF and sleep disordered breathing is then explored by Al-Falahi et al., who identify intertwined pathophysiological pathways down to the neurohumoral and cellular levels [7]. They state that not only does untreated obstructive sleep apnoea provide the substrates and triggers for AF but also that obstructive sleep
*Corresponding author at: Assoc. Prof. of Medicine, The University of Queensland etc., The University of Queensland, Senior Cardiologist and Electrophysiologist, The Prince Charles Hospital, 627 Rode Road, Chermside, Brisbane, QLD 4032 Australia, Email: [email protected] © 2017 Published by Elsevier B.V. on behalf of Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ).
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apnoea may be a therapeutic target, itself, in the management of AF. The extremely important issues of pharmacological and device-based stroke prevention are examined in detail by Amerena and Ridley, and by Phillips and Paul, respectively [8,9]. Amerena and Ridley say that the availability of novel, direct acting oral anticoagulants and the results of seminal trials have triggered a paradigm shift in anticoagulation treatment philosophy [10–12]. Whereas, in the past, physicians needed to decide in which patients they should use anticoagulation, today, Amerena and Ridley say physicians need to, instead, consider in which patients they should not use anticoagulation. Phillips and Paul conclude that left atrial appendage device occlusion represents a major evolution in stroke prevention in AF, with multiple lines of evidence supporting the left atrial appendage as being the predominant source of thrombi leading to thromboembolism in AF in patients with non-rheumatic aetiologies. Given that several of these devices have been commercially available in Australia since 2009, they provide useful decision-making considerations for referring doctors. Kanagaratnam et al. discuss rhythm and rate control strategies in AF management, and summarise the pharmacology and practical use of antiarrhythmic medications in patients with AF [13]. Many factors influence whether the treatment strategy in AF should be to aim for rhythm control or for rate control; however, any strategy can change with changing clinical circumstances. Lau et al. concentrate on the use of pacing, resynchronisation and AV node ablation for patients with drug-refractory rate control problems [14]. They discuss the evolving concept that biventricular pacing may be preferable in patients requiring AV node ablation for AF, particularly if there is a degree of left ventricular impairment, as supported by the left ventricular-based cardiac stimulation post AV nodal ablation evaluation (PAVE) study [15]. The indications for and complications of non-pharmacological approaches to AF rhythm control are then examined in turn for radiofrequency catheter ablation (Kalla et al.)[16], catheter cryoablation (Shakkottai et al.) [17], and surgical ablation (Davies et al.) [18]. The place of each of these approaches to catheter ablation in clinical practice has been the subject of international practice guidelines or consensus statements [19–21]; generally speaking, however, catheter ablation is now at the forefront of the management of atrial fibrillation which remains symptomatic despite optimal pharmacological therapy. Three important contexts — with specific management considerations — in which AF is seen are expertly reviewed: heart failure (Prabhu et al.), which shares pathophysiological mechanisms with AF, and therefore frequently co-exists [22]); hypertrophic cardiomyopathy (Vaidya et al.), for which there is a growing body of evidence that early, aggressive rhythm control may lead to better outcomes [23]; and, elite endurance athletics (Flannery et al.), in which lifetime hours of participation appear to increase the risk of developing AF in men [24]. Finally, and perhaps most importantly, recent paradigmchanging evidence for risk factor modification is reviewed in
H.M. Haqqani et al.
detail by Mahajan et al., with practical recommendations regarding disease-focussed clinics [25]. Among other factors, weight loss in obesity is identified as a cornerstone of risk factor management. Clearly, new biological insights, improved detection, novel therapies, better evidence translation and increased multidisciplinary collaboration are all going to be needed if serious inroads into global AF-related morbidity and mortality are to be made. We welcome these invited experts’ contributions in this Special Issue as providing insightful reviews of the current state of play and shifting paradigms in AF pathogenesis, diagnosis and management. We are pleased to commend it to our readership.
References [1] Wong CX, Brown A, Tse H-F, Albert CM, Kalman JM, Marwick TH, et al. Epidemiology of Atrial Fibrillation: The Australian and Asia-Pacific Perspective. Heart Lung Circ 2017;26(9):870–9. [2] Chugh SS, Havmoeller R, Narayanan K, Singh D, Rienstra M, Benjamin EJ, et al. Worldwide epidemiology of atrial fibrillation: a global burden of disease 2010 study. Circulation 2014;129:837–47. [3] Neubeck L, Orchard J, Lowres N, Freedman SB. To Screen or Not to Screen? Examining the Arguments Against Screening for Atrial Fibrillation. Heart Lung Circ 2017;26(9):880–6. [4] Lau DH, Linz D, Schotten U, Mahajan R, Sanders P, Kalman J. Pathophysiology of Paroxysmal and Persistent Atrial Fibrillation: Rotors, Foci and Fibrosis. Heart Lung Circ 2017;26(9):887–92. [5] Fatkin D, Santiago CF, Huttner IG, Lubitz S, Ellinor PT. Genetics of Atrial Fibrillation: State of the Art in 2017. Heart Lung Circ 2017;26(9):894–901. [6] Marrouche NF, Wilder D, Hindricks G, Jais P, Akoum N, Marchlinski F, et al. Association of atrial tissue fibrosis identified by delayed enhancement MRI and atrial fibrillation catheter ablation: the DECAAF study. JAMA 2014;311:498–506. [7] Al-Falahi Z, Williamson J, Dimitri H. Atrial Fibrillation and Sleep Apnoea: Guilt by Association? Heart Lung Circ 2017;26(9):902–10. [8] Amerena J, Ridley D. An Update on Anticoagulation in Atrial Fibrillation. Heart Lung Circ 2017;26(9):911–7. [9] Phillips KP, Paul V. Dealing with the Left Atrial Appendage for Stroke Prevention: Devices and Decision-Making. Heart Lung Circ 2017;26 (9):918–25. [10] Connolly SJ, Ezekowitz MD, Yusuf S, Eikelboom J, Oldgren J, Parekh A, et al., RE-LY Steering Committee and Investigators. Dabigatran versus warfarin in patients with atrial fibrillation. N Engl J Med 2009;361 (12):1139–51. [11] D. Patel MR, Mahaffey KW, Garg J, Pan G, Singer DE, Hacke W, et al. ROCKET AF Investigators Rivaroxaban versus warfarin in nonvalvular atrial fibrillation. N Engl J Med 2011;365(10):883–91. [12] Granger CB, Alexander KH, McMurray JJ, Lopes RD, Hylek EM, Hanna M, et al. ARISTOTLE Committees and Investigators Apixaban versus warfarin in patients with atrial fibrillation. N Engl J Med 2011;365(11):981–92. [13] Kanagaratnam L, Kower P, Whalley D. Pharmacological therapy for rate and rhythm control in 2017. Heart Lung Circ 2017;26(9):926–32. [14] Lau DH, Thiyagarajah A, Willems S, Rostock T, Linz D, Stiles M, et al. Device Therapy for Rate Control: Pacing, Resynchronisation and AV Node Ablation. Heart Lung Circ 2017;26(9):934–40. [15] Doshi RN, Daoud EG, Fellows C, Turk K, Duran A, Hamdan MH, et al., PAVE Study Group. Left ventricular-based cardiac stimulation post AV nodal ablation evaluation (the PAVE study). J Cardiovasc Electrophysiol 2005;16(11):1160–5. [16] Kalla M, Sanders P, Kalman JM, Lee G. Radiofrequency catheter ablation for atrial fibrillation: approaches and outcomes. Heart Lung Circ 2017;26 (9):941–9. [17] Shakkottai P, Sy RW, McGuire MA. Cryoablation for Atrial Fibrillation in 2017: what have we learned? Heart Lung Circ 2017;26(9):950–9. [18] Davies RA, Kumar S, Chard RB, Thomas SP. Surgical and Hybrid Ablation of Atrial Fibrillation. Heart Lung Circ 2017;26(9):960–6. [19] Calkins H, Kuck KH, Cappato R, Brugada J, Camm AJ, Chen SA, et al. 2012 HRS/EHRA/ECAS Expert Consensus Statement on Catheter and Surgical Ablation of Atrial Fibrillation: recommendations for patient selection,
Editorial
procedural techniques, patient management and follow-up, definitions, endpoints, and research trial design. Europace 2012;14(4):528–606. [20] January CT, Wann LS, Alpert JS, Calkins H, Cigarroa JE, Cleveland Jr JC, et al., ACC/AHA Task Force Members. 2014 AHA/ACC/HRS guidelines for the management of patients with atrial fibrillation: executive summary: a report from the American College of Cardiology/American Heart Association Task Force on practice guidelines and the Heart Rhythm Society. Circulation 2014;130(23):2071–104. [21] Kirschhof P, Benussi S, Kotecha D, Ahlsson A, Atar D, Casadei B, et al. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J 2016;37(38):2893–962.
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[22] Prabhu S, Voskoboinik A, Kaye DM, Kistler PM. Atrial Fibrillation and Heart Failure — cause or effect? Heart Lung Circ 2017;26 (9):967–74. [23] Vaidya K, Semsarian C, Chan KH. Atrial Fibrillation in Hypertrophic Cardiomyopathy. Heart Lung Circ 2017;26(9):975–82. [24] Flannery MD, Kalman JM, Sanders P, La Gerche A. State of the Art Review: Atrial Fibrillation in Athletes. Heart Lung Circ 2017;26 (9):983–9. [25] Mahajan R, Pathak R, Thiyagarajah A, Lau D, Marchlinski F, Dixit S, et al. Risk Factor Management and Atrial Fibrillations Clinics: Saving the Best for Last? Heart Lung Circ 2017;26(9):990–7.
Heart, Lung and Circulation (2017) 26, 867–869 1443-9506/04/$36.00 http://dx.doi.org/10.1016/S1443-9506(17)31276-3
Atrial Fibrillation: State of the Art in 2017 – Shifting Paradigms in Pathogenesis, Diagnosis, Treatment and Prevention Haris M. Haqqani, MBBS, PhD a,b*, Kim H. Chan, MBBS, PhD a,c, Ann T. Gregory, MBBS, Grad Dip Pop Health d, A. Robert Denniss, MD, FRACP e,f,g a
Heart Rhythm Section Editor, Heart Lung and Circulation; Special Issue Co-editor, Atrial Fibrillation: State of the Art in 2017 Cardiology, The Prince Charles Hospital, Brisbane, Qld, Australia Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia d Commissioning Editor, Heart Lung and Circulation e Editor in Chief, Heart Lung and Circulation f Department of Cardiology, Westmead Hospital, University of Sydney, Sydney, NSW, Australia g Department of Cardiology, Blacktown Hospital, Western Sydney University, Sydney, NSW, Australia b c
The regular readership of Heart Lung and Circulation includes cardiovascular clinicians, cardiac geneticists, basic and translational cardiovascular scientists, neurologists, thoracic physicians, haematologists, sports physicians, clinical trialists and cardiothoracic surgeons. It is hard to imagine a disease process which spans the expertise and interests of these various craft groups in the same way that atrial fibrillation (AF) does. The commonest sustained disorder of cardiac rhythm, AF is responsible for a growing pandemic of cardiovascular morbidity and mortality with its attendant health economic implications. Given these facts, as well as the rapidly changing AF research and practice landscape, we felt compelled to commission a Special Issue of Heart Lung and Circulation dedicated to this important condition. As readers will observe, we have been fortunate to have gathered contributions from the most recognised Australasian thought leaders in AF and their international collaborators. Their reviews cover the current state of the field, with a particular focus on areas of relevance to the treating clinician. At the outset, Wong et al. clearly define the scope of the problem in their comprehensive review of the regional epidemiology of AF in Australia and the Asia-Pacific region, including in Indigenous people [1]. While the Global Burden of Disease study estimated that the worldwide, age-adjusted prevalence of AF in 2010 was about 0.5% or 33.5 million individuals [2], Wong et al. report an estimated projection,
in Asia alone, of 49 million men and 23 million women with AF by the year 2050, about 12-fold higher than equivalent predictions for American men and women. Neubeck et al. closely analyse the evidence supporting population screening for AF, systematically countering arguments against screening [3]. For example, they posit that inadequate treatment for people for AF is not an argument against screening but rather an argument in favour of improving treatment. Lau et al. and Fatkin et al. concisely review the present understanding of AF pathophysiology and genetics, respectively [4,5]. Lau et al. report that atrial fibrosis has been identified as the key structural change in different substrates responsible for the perpetuation in AF, and that novel imaging modalities can assist in identifying and quantifying atrial fibrosis [4]. Further, in patients undergoing catheter ablation, increased atrial fibrosis has been shown to be linked with higher AF recurrence [6]. They discuss two major arrhythmic mechanisms in AF, rotational activations (‘‘rotors’’) and ectopic focal activations (‘‘foci). Fatkin et al. report paradigm-shifting discoveries which suggest that abnormalities of atrial specification arising during cardiac development may provide a template for AF in later, adult life [5]. The intricate relationship between AF and sleep disordered breathing is then explored by Al-Falahi et al., who identify intertwined pathophysiological pathways down to the neurohumoral and cellular levels [7]. They state that not only does untreated obstructive sleep apnoea provide the substrates and triggers for AF but also that obstructive sleep
*Corresponding author at: Assoc. Prof. of Medicine, The University of Queensland etc., The University of Queensland, Senior Cardiologist and Electrophysiologist, The Prince Charles Hospital, 627 Rode Road, Chermside, Brisbane, QLD 4032 Australia, Email: [email protected] © 2017 Published by Elsevier B.V. on behalf of Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ).
868
apnoea may be a therapeutic target, itself, in the management of AF. The extremely important issues of pharmacological and device-based stroke prevention are examined in detail by Amerena and Ridley, and by Phillips and Paul, respectively [8,9]. Amerena and Ridley say that the availability of novel, direct acting oral anticoagulants and the results of seminal trials have triggered a paradigm shift in anticoagulation treatment philosophy [10–12]. Whereas, in the past, physicians needed to decide in which patients they should use anticoagulation, today, Amerena and Ridley say physicians need to, instead, consider in which patients they should not use anticoagulation. Phillips and Paul conclude that left atrial appendage device occlusion represents a major evolution in stroke prevention in AF, with multiple lines of evidence supporting the left atrial appendage as being the predominant source of thrombi leading to thromboembolism in AF in patients with non-rheumatic aetiologies. Given that several of these devices have been commercially available in Australia since 2009, they provide useful decision-making considerations for referring doctors. Kanagaratnam et al. discuss rhythm and rate control strategies in AF management, and summarise the pharmacology and practical use of antiarrhythmic medications in patients with AF [13]. Many factors influence whether the treatment strategy in AF should be to aim for rhythm control or for rate control; however, any strategy can change with changing clinical circumstances. Lau et al. concentrate on the use of pacing, resynchronisation and AV node ablation for patients with drug-refractory rate control problems [14]. They discuss the evolving concept that biventricular pacing may be preferable in patients requiring AV node ablation for AF, particularly if there is a degree of left ventricular impairment, as supported by the left ventricular-based cardiac stimulation post AV nodal ablation evaluation (PAVE) study [15]. The indications for and complications of non-pharmacological approaches to AF rhythm control are then examined in turn for radiofrequency catheter ablation (Kalla et al.)[16], catheter cryoablation (Shakkottai et al.) [17], and surgical ablation (Davies et al.) [18]. The place of each of these approaches to catheter ablation in clinical practice has been the subject of international practice guidelines or consensus statements [19–21]; generally speaking, however, catheter ablation is now at the forefront of the management of atrial fibrillation which remains symptomatic despite optimal pharmacological therapy. Three important contexts — with specific management considerations — in which AF is seen are expertly reviewed: heart failure (Prabhu et al.), which shares pathophysiological mechanisms with AF, and therefore frequently co-exists [22]); hypertrophic cardiomyopathy (Vaidya et al.), for which there is a growing body of evidence that early, aggressive rhythm control may lead to better outcomes [23]; and, elite endurance athletics (Flannery et al.), in which lifetime hours of participation appear to increase the risk of developing AF in men [24]. Finally, and perhaps most importantly, recent paradigmchanging evidence for risk factor modification is reviewed in
H.M. Haqqani et al.
detail by Mahajan et al., with practical recommendations regarding disease-focussed clinics [25]. Among other factors, weight loss in obesity is identified as a cornerstone of risk factor management. Clearly, new biological insights, improved detection, novel therapies, better evidence translation and increased multidisciplinary collaboration are all going to be needed if serious inroads into global AF-related morbidity and mortality are to be made. We welcome these invited experts’ contributions in this Special Issue as providing insightful reviews of the current state of play and shifting paradigms in AF pathogenesis, diagnosis and management. We are pleased to commend it to our readership.
References [1] Wong CX, Brown A, Tse H-F, Albert CM, Kalman JM, Marwick TH, et al. Epidemiology of Atrial Fibrillation: The Australian and Asia-Pacific Perspective. Heart Lung Circ 2017;26(9):870–9. [2] Chugh SS, Havmoeller R, Narayanan K, Singh D, Rienstra M, Benjamin EJ, et al. Worldwide epidemiology of atrial fibrillation: a global burden of disease 2010 study. Circulation 2014;129:837–47. [3] Neubeck L, Orchard J, Lowres N, Freedman SB. To Screen or Not to Screen? Examining the Arguments Against Screening for Atrial Fibrillation. Heart Lung Circ 2017;26(9):880–6. [4] Lau DH, Linz D, Schotten U, Mahajan R, Sanders P, Kalman J. Pathophysiology of Paroxysmal and Persistent Atrial Fibrillation: Rotors, Foci and Fibrosis. Heart Lung Circ 2017;26(9):887–92. [5] Fatkin D, Santiago CF, Huttner IG, Lubitz S, Ellinor PT. Genetics of Atrial Fibrillation: State of the Art in 2017. Heart Lung Circ 2017;26(9):894–901. [6] Marrouche NF, Wilder D, Hindricks G, Jais P, Akoum N, Marchlinski F, et al. Association of atrial tissue fibrosis identified by delayed enhancement MRI and atrial fibrillation catheter ablation: the DECAAF study. JAMA 2014;311:498–506. [7] Al-Falahi Z, Williamson J, Dimitri H. Atrial Fibrillation and Sleep Apnoea: Guilt by Association? Heart Lung Circ 2017;26(9):902–10. [8] Amerena J, Ridley D. An Update on Anticoagulation in Atrial Fibrillation. Heart Lung Circ 2017;26(9):911–7. [9] Phillips KP, Paul V. Dealing with the Left Atrial Appendage for Stroke Prevention: Devices and Decision-Making. Heart Lung Circ 2017;26 (9):918–25. [10] Connolly SJ, Ezekowitz MD, Yusuf S, Eikelboom J, Oldgren J, Parekh A, et al., RE-LY Steering Committee and Investigators. Dabigatran versus warfarin in patients with atrial fibrillation. N Engl J Med 2009;361 (12):1139–51. [11] D. Patel MR, Mahaffey KW, Garg J, Pan G, Singer DE, Hacke W, et al. ROCKET AF Investigators Rivaroxaban versus warfarin in nonvalvular atrial fibrillation. N Engl J Med 2011;365(10):883–91. [12] Granger CB, Alexander KH, McMurray JJ, Lopes RD, Hylek EM, Hanna M, et al. ARISTOTLE Committees and Investigators Apixaban versus warfarin in patients with atrial fibrillation. N Engl J Med 2011;365(11):981–92. [13] Kanagaratnam L, Kower P, Whalley D. Pharmacological therapy for rate and rhythm control in 2017. Heart Lung Circ 2017;26(9):926–32. [14] Lau DH, Thiyagarajah A, Willems S, Rostock T, Linz D, Stiles M, et al. Device Therapy for Rate Control: Pacing, Resynchronisation and AV Node Ablation. Heart Lung Circ 2017;26(9):934–40. [15] Doshi RN, Daoud EG, Fellows C, Turk K, Duran A, Hamdan MH, et al., PAVE Study Group. Left ventricular-based cardiac stimulation post AV nodal ablation evaluation (the PAVE study). J Cardiovasc Electrophysiol 2005;16(11):1160–5. [16] Kalla M, Sanders P, Kalman JM, Lee G. Radiofrequency catheter ablation for atrial fibrillation: approaches and outcomes. Heart Lung Circ 2017;26 (9):941–9. [17] Shakkottai P, Sy RW, McGuire MA. Cryoablation for Atrial Fibrillation in 2017: what have we learned? Heart Lung Circ 2017;26(9):950–9. [18] Davies RA, Kumar S, Chard RB, Thomas SP. Surgical and Hybrid Ablation of Atrial Fibrillation. Heart Lung Circ 2017;26(9):960–6. [19] Calkins H, Kuck KH, Cappato R, Brugada J, Camm AJ, Chen SA, et al. 2012 HRS/EHRA/ECAS Expert Consensus Statement on Catheter and Surgical Ablation of Atrial Fibrillation: recommendations for patient selection,
Editorial
procedural techniques, patient management and follow-up, definitions, endpoints, and research trial design. Europace 2012;14(4):528–606. [20] January CT, Wann LS, Alpert JS, Calkins H, Cigarroa JE, Cleveland Jr JC, et al., ACC/AHA Task Force Members. 2014 AHA/ACC/HRS guidelines for the management of patients with atrial fibrillation: executive summary: a report from the American College of Cardiology/American Heart Association Task Force on practice guidelines and the Heart Rhythm Society. Circulation 2014;130(23):2071–104. [21] Kirschhof P, Benussi S, Kotecha D, Ahlsson A, Atar D, Casadei B, et al. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J 2016;37(38):2893–962.
869
[22] Prabhu S, Voskoboinik A, Kaye DM, Kistler PM. Atrial Fibrillation and Heart Failure — cause or effect? Heart Lung Circ 2017;26 (9):967–74. [23] Vaidya K, Semsarian C, Chan KH. Atrial Fibrillation in Hypertrophic Cardiomyopathy. Heart Lung Circ 2017;26(9):975–82. [24] Flannery MD, Kalman JM, Sanders P, La Gerche A. State of the Art Review: Atrial Fibrillation in Athletes. Heart Lung Circ 2017;26 (9):983–9. [25] Mahajan R, Pathak R, Thiyagarajah A, Lau D, Marchlinski F, Dixit S, et al. Risk Factor Management and Atrial Fibrillations Clinics: Saving the Best for Last? Heart Lung Circ 2017;26(9):990–7.