A colloquio con John Camm, Cardiac and Vascular Sciences, St. George’s University of London, UK, e Paulus Kirchhof, Centre for Cardiovascular Sciences, University of Birmingham, UK
What are the long-term outcomes of patients with newly diagnosed atrial fibrillation?
Atrial fibrillation is a significant development medically, because it indicates that the patient has a risk of stroke, a risk of developing or worsening heart failure, a risk of dying sooner than patients who do not have atrial fibrillation. We do know ways of managing atrial fibrillation, so we can prevent this, but, unfortunately, many patients with atrial fibrillation are not referred to specialists and are not managed correctly, even in simple terms like for example the provision of an appropriate anticoagulant.
What is the impact of ethnicity and gender on stroke outcomes?
We do know that in Asia, for example, ischemic stroke is more common than in Europe and occurs in younger age. We also know that with anticoagulation we can really reduce the likelihood of ischemic stroke but the likelihood of some degree of hemorrhage is more common in the Asian subgroup than it is in the Western subgroup. So, there is certainly an Asian influence with regard to the prognosis of this disease and how to manage it.
Are current risk scores enough to assess the risk of stroke and hemorrhage in complex patients such as elderly hypertensive patients?
We would like a perfect score, but we do not have it. We do have several scoring schemes in Europe presently using the CHADS class scheme, and that tools serve here and the United States but there are proposed developments on over about that using biomarkers for example or using more graduated scoring systems which may be more difficult to apply but might be much more accurate. There is a lot of work going in to find a really good stratification scheme, so we can use that to identify those patients who will really benefit from particular treatments.
What are the key points for the early detection of AF?
First of all, we have got much better in providing anticoagulation treatment to patients with AF who are at risk for a stroke. Secondly, we still have a lot of missed opportunities because many patients who develop a stroke because of AF are not diagnosed before the first stroke and screening for undiagnosed AF is probably one of the big avenues in the future to improve stroke prevention in AF and to improve the survival and social function and happiness of AF patients and their families.
When strict guidelines application should be stopped and a case by case evaluation should be started?
Guidelines are guidelines, they provide the boundaries of what we usually do and there have always been a small number of patients that need different treatments that cannot be covered, and these decisions cannot be made based on evidence generated in controlled trials. This is the art of medicine, guidelines are the foundation of that art, without that foundation the art is worthless but on that foundation this art will help a few patients who need special treatment.