J. Warren Holshouser, MD, FACC
Director, Cardiac Electrophysiology
Atrial fibrillation (AF) is the most common heart rhythm disorder in the adult cardiology population. The number of patients with AF is expected to double from 2010 to 2050, translating into a tremendous challenge for our healthcare system and for our patients. Strategies to manage this ever-increasing population will be important for every practice and hospital system and is a priority for Sanger Heart & Vascular Institute and Carolinas HealthCare System. Whether we treat patients with ablation, new rhythm- or rate-control medications, anticoagulation or novel device therapies, AF promises to keep the medical community busy in the 21st century.
The cornerstone of AF care focuses on the management of stroke risk and the treatment of disabling symptoms. Historically, patients deemed at high risk for stroke have used vitamin-K antagonists such as warfarin to produce a 70 percent reduction in overall stroke risk. Risk factors for nonvalvular AF include Congestive heart failure, Hypertension, Age over 75, Diabetes, and Stroke (CHADS2 risk score).
The last quarter of 2010 saw the introduction of the first new oral anticoagulant for stroke prevention in AF in nearly half a century. With a second agent introduced in 2011, the options for anticoagulation in nonvalvular AF are burgeoning. Tailoring these options to our patients remains a challenge given the absence of an objective way to quantify the countering bleeding risk.
Treating a patient's disabling symptoms remains the most gratifying component to AF care. Consistent with the AFFIRM trial, using a rate-control or a rhythm-control strategy must be tailored to the individual, factoring in his or her underlying symptoms and clinical circumstances.
Pulmonary vein (PV) isolation map
New Model of AF Care
Carolinas HealthCare System and Sanger have developed a center to manage patients who suffer from AF. Sanger's Atrial Fibrillation Center will offer state-of-the-art techniques and therapies. Our team of experts, including clinical cardiac electrophysiologists, cardiothoracic surgeons, a cardiac anesthesiologist and coagulation specialists, will manage patient care, focusing on the entire spectrum of AF, from initial evaluation with first-line therapies to more complex procedures, such as catheter-based or surgical ablation. Our goal is to provide comprehensive AF care that's personalized to the needs of our patients.
CABANA Enrollment Center
Left atrial appendage occlusion device
Treatment of atrial fibrillation (AF) has focused on a tailored approach, including medical therapy or catheter ablation in symptomatic but drug-resistant patients. Sanger Heart & Vascular Institute is one of six southeastern enrollment centers for the NIH-sponsored CABANA trial, which compares medical therapy with ablation for AF with a primary endpoint of mortality.
New anticoagulant agents have been shown to be noninferior or even superior to warfarin for stroke prevention. There has also been a consistent signal for less intracranial bleeding—perhaps the most dreaded complication of oral anticoagulation. The newer agents have fewer drug and food interactions and don't require routine monitoring. Concerns over reversibility and cost remain.
Device therapy for stroke prevention using left atrial appendage (LAA) occlusion is also under investigation at Sanger. We're actively involved in the PREVAIL trial, comparing treatment with a LAA occlusion device to oral anticoagulation with warfarin to prevent strokes in patients with AF. Patients taking newer anticoagulation agents aren't candidates for this trial. Ideal patients are those using warfarin for AF.
As the incidence of AF increases, Sanger stands poised to continue its tradition of high-quality care. Collaboration between our partners and referring physicians remains the cornerstone of success in bringing new advances to patients.
Contact our Clinical Research Department at 704-355-4794 if you have a patient who may be a candidate for one of these clinical trials.