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Atriumfibrilleren – in welke richting beweegt het onderzoek zich ?
Isabelle C Van Gelder
University Medical Center Groningen
The Netherlands
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AF – future research
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Classification of AF
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Clinical events affected by atrial fibrillation
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Associated diseases
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Systolic blood pressure and new AF
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Rhythm control
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Amiodarone the best: SAFE-T
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Prediction of successful rhythm control
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PA-tdi
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New onset AF associated with severity of structural remodeling
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Diagnostics to evaluate atrial substrate for AF
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AFFIRM and RACE
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Atrial remodeling starts far before first AF
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ACE-I and ARBs for prevention of AF
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Primary prevention in hypertensives and LVH
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Primary prevention in hypertensives and LVH
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Primary prevention with ACE-I early after AMI with LV-dysfunction
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Future goal: primary prevention in patients at risk
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Future goal: upstream therapy for secondary prevention
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GISSI AF: secondary prevention in AF and risk factors with valsartan
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Time to first recurrence of AF
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GISSI AF: secondary prevention with valsartan
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ACE-I/ ARB + amiodarone is superior
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RACE 3 Routine versus aggressive upstream rhythm control for prevention of early atrial fibrillation in heart failure
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Hypothesis RACE 3
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Endpoints
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Inclusion criteria
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Inclusion criteria
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Definitions
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Inclusion
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Reduction of CV morbidity and mortality
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Cardiovascular events in AF patients (RACE)
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MACCE and hospitalization in 5333 AF patients Euro Heart AF Survey
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Do not shoot the messenger AF
Get the message that AF represents vascular disease
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Prevention CV morbidity and mortality
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New treatment goals in AF and unmet need
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New treatment goals in AF and unmet need
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Eurides, Adonis: Dronedarone for rhythm control
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Dionysos: Dronedarone vs Amiodarone
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Erato: Dronedarone for rate control
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ATHENA – endpoints
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ATHENA: Dronedarone for prevention CV morbidity and mortality
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ATHENA – primary endpoint
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ATHENA – death from cardiovascular cause – 29%
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ATHENA – 1st hospitalization due to CV events – 26%
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Dronedarone reduces CV hospitalizations: – 26%
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ATHENA - risk of stroke – 34%
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Dronedarone – safety: adverse events
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Potential ways in which dronedarone could influence morbidity and mortality
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Upstream therapy for prevention CV morbidity and mortality
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Conclusions
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Thank you for your attention
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Conclusions dronedarone
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Dronedarone – multiple benefits
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Upstream therapy – applying drugs that ameliorate the substrate of AF
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Why upstream therapy ?
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AF – natural time course
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Endpoints/ outcome parameters in AF trials
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Prevalence of atrial fibrillation
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Primary prevention of AF
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Identify patients at risk for AF
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Identify patients at risk for AF
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Diastolic heart failure and risk on AF
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Identify patients at risk for AF
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Non ion channel AADs may inhibit pathways that promote atrial remodeling
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Vraag 2
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Secondary prevention with ACE-I/ARB and amiodarone
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GISSI AF: secondary prevention in AF and risk factors with valsartan
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Time to first recurrence of AF
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GISSI AF: secondary prevention with valsartan
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Vraag 3
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Statins for the prevention of AF
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Statins and AF: a meta-analysis
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GISSI HF: primary prevention in HF patients with rosuvastatin 10 mg
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GISSI HF
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GISSI HF
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GISSI HF: role of statins
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GISSI HF: role of statins
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Upstream therapy: future
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RACE 3 Routine versus aggressive upstream rhythm control for prevention of early atrial fibrillation in heart failure
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Conclusions
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Conclusions
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Interdependence of AF mechanisms
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HATCH score to predict AF progression
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AF is a progressive disease
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‘My take home message’
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MACCE and hospitalization in 5333 AF patients Euro Heart AF Survey
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Indication for LA Catheter Ablation
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Ablation when structural heart disease is present
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Modulating factors for AF
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Risk of AF in 10 years
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HATCH score and AF progression 1 Year AF progression in 1219 paroxysmal AF patients, EuroHeartSurvey on AF
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Primary prevention of AF
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Diagnostics to evaluate atrial substrate for AF
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Primary prevention of AF
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Identify patients at risk for AF
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Identify patients at risk for AF
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Possible new risk factors
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Nieuwlaat R et al, Eur Heart J 2008
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Efficacy of Amiodarone and Dronedarone in preventing recurrence of AF
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AF – the epidemic
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Rhythm control
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Was Antiarrhythmic Effect Important? Permanent AF Patients
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Cardiovascular events in permanent AF (RACEII)
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Rhythm control
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Prediction of successful AF ablation
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Prediction of successful AF ablation
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