Atrial fibrillation in China

• DOI: 10.3760/cma.j.issn.0366-6999.20131078
• Publication Date: 2024-01-16T17:55:53Z
• Authors: Kai XU; Xu LIU
• Keywords: China; Atrial Fibrillation; Catheter Ablation; Humans

Atrial fibrillation (AF) is one of the most great challenges cardiology in twenty-first century. The prevalence AF increases with age, ranging from 1% youth to approximately 10% among those over age 80 years.1 Three million people United States are affected by AF, and number estimated increase 5.6 2050 owing both aging population alarming rise individuals risk factors for AF.1 Similar trends also found China.2 intense independent factor stroke heart failure, 20% strokes related while nearly 30% failures induced AF. enlargement, remodeling, fibrosis keys initiation perpetuation Therapy directed at symptom control via rate or rhythm control, as well prevention thromboembolic events. In recent years, multiple alternatives, including pharmacological non-pharmacological, have emerged possible therapies AF.3 EPIDEMIOLOGY OF IN CHINA common arrhythmia encountered clinical practice. Medical social problems caused been drawing increasing attention. According a population-based study conducted cluster sampling, 29 079 participants forming 14 cohorts 13 provinces across China, where was billion,4 age-standardized China (≥30 years old) 0.65%, increased age. Men showed higher than women (0.91% (age-standardized, 0.66%) vs. 0.65% (0.63%), P=0.013). Another overall cohort 1.4% men 0.7% women.5 Incidence rates were 1.68 per 1000 person-years 0.76 women. retrospective investigation hospitalized patients AF,6 percentage hospital admissions gradually compared total cardiovascular admission during three an average 7.9%. MECHANISMS mechanisms underlying maintenance not clearly understood. occurs result multitude pathophysiological changes that take place within atrium. It has recently demonstrated paroxysmal initiated focal triggers localized usually more pulmonary veins (PVs).7 Initiation rapid activity only structurally normal hearts but process reinitiation persistent after electrical cardioversion, presence absence associated structural disease. However, prevailing theory multiple, random wavelets activation coexist create chaotic cardiac rhythm. Both experimental human mapping studies generally characterized excitation propagate around atrial myocardium. Perpetuation facilitated existence development abnormal tissue substrate capable maintaining arrhythmia, meandering can be accommodated determining stability AF.8 Meanwhile, artificial leads marked shortening effective refractory period, reversion its physiological adaptation, rate, inducibility AF.9 Chinese researchers made progress basic research. CTGF upregulated TGF-β1/Smad pathway myocardium patients. Furthermore, may play important role remodeling fibrosis.10 Ang II/AT1R/ signaling serves key mechanism AF.11 Our AngII/TGF-β1/TRAF6 participated remodeling.12 genetic partly because largest world. Chen et al13 gene mutation linked family's hereditary form 2003. This first report identify specific KCNQ1 (KvLQT1) on chromosome 11p15.5 reduction action potential duration period myocytes, which likely maintains episode. Subsequently, other mutations familial lone located KCNE2 R27C, KCNJ2 V93I, KCNE3 R53H, SCN4B, PITX2c, NKX2.5, GATA5, GATA6 identified researchers.14-18 CLASSIFICATIONS Various classification systems proposed When patient had two episodes, considered recurrent. If terminates spontaneously, recurrent designated paroxysmal; when sustained beyond seven days, persistent. Termination therapy direct-current cardioversion does change designation. First-detected either category includes cases long-standing (eg. greater year), leading permanent failed attempted.19 CATHETER ABLATION Catheter ablation increasingly shown method achieve carefully selected populations updated 2012 HRS/EHRA/ECAS guidelines ablation,20 catheter class I indication recommended symptomatic intolerant least III antiarrhythmic medication. ESC guideline management,21 who recurrences drug prefer further therapy, performed electrophysiologist received appropriate training performing procedure center (class indication). line guidelines, Society Pacing Electrophysiology (CSPE) reasonable first-line drug-refractory patients.22 Circumferential vein isolation (CPVI) guided 3D (CARTO EnSite) currently major type China. Additionally, modification (CFAE linear ablation) chronic dramatically since case 1998.23 A registration study24 2000, there 10 811 procedures arrhythmias 136 hospitals about 20 000 2006.25 up 2005 included 3196 40 hospitals, 2193 males 1003 females.26 mean 54.77 (5.98) old. proportions paroxysmal, 85.67%, 11.51%, 2.82%, respectively. Ablation central triggering foci PVs accepted, therefore, PVI base concepts. CPVI widespread technique ablation. description this published “inventor”, Carlo Pappone Milan (San Raffaele University Hospital).27 With approach, wide encircling lesions placed outside ostia ipsilateral PV (0.5-1.0 cm away ostium) aim modify delay LA-PV conduction. local bipolar electrogram amplitude ≥80% ≤0.1 mV conduction endpoint technique.27,28 addition lesions, connecting inferioposterior part left circle posterolateral mitral annulus should deployed (the so-called isthmus line). non-paroxysmal still cornerstone nonparoxysmal it enough. Because properties poorer type, additional required PVs. Linear roof lines commonly modification. requires (12±6) minutes radiofrequency delivery (7±2) fluoroscopy achieved 96% patients.29 Generally immediate abolition electrograms along continuous between previously isolated right superior bidirectional block technically difficult, tamponade30 coronary sinus two-thirds completion. CFAE CFAEs defined very short cycle length (<120 ms) averaged s recording period.31 Nademanee al31 reported areas represent electrophysiologic ideal sites eliminate maintain relatively consistent exhibit spatial temporal Non-PV ectopies same location CFAEs, targeting effectively meta-analysis investigators adjuvant standard PVAI long-term single without drugs provide benefit patients.32 combined safe efficacious treatment valvular diseases.33 another supplemented defragmentation seem improve success efficacy might diluted their proarrhythmic effects.34 So larger, randomized controlled trials needed confirm FIRM CONFIRM (Conventional Fibrillation Without Focal Impulse Rotor Modulation) trial,35 rotors impulses detected 98 101 (97%) each exhibiting 2.1±1.0 sources. acute (AF termination slowing) 86% FIRM-guided versus FIRM-blinded (P <0.001). alone primary source terminated median 2.5 minutes. They impulse sources prevalent sustaining patient-specific acutely slowed improved outcome. Long-term outcome following Several outcomes quite variable results initial experience pioneering centers types substrate) certain proportion recurrence, especially procedural will markedly repeated procedures. Studies 5 follow-up data 80%-90% repeat procedures.36-38 (2-5 years) 57% 63% AF.39,40 Effects significantly better SURGICAL FOR attempts cure surgical treatments started 1990s. One video-assisted minimally invasive effective, optimistic our comparative study. Freedom obtained 59.0% 74.7% group respectively (P=0.047).41 previous concomitant Cox Maze using Saline-Irrigated Cooled-tip Radiofrequency system subsequent treating long-lasting rheumatic disease.42 ANTICOAGULATION 17.5%.6 nonvalvular patients, advanced history hypertension, disease Sixty-four point five percent these antithrombotic dominated use antiplatelet agents. anticoagulants accounted 6.6%. case-control 18 January 2000 April 2002,43 4511 adult diagnosed having There 1086 3425 Among 273 (26.88%) strokes, non-valvular 827 (24.15%) strokes. multivariate analysis 75, diabetes, high systolic blood pressure thrombi independently epidemiological survey44 ischaemic frequent observed cases, (12.1% 2.1%, P <0.01). Anticoagulants used widely UPSTREAM THERAPY Preventing could suppress progression substrate. Some available like statins, omega-3 fatty acids, renin-angiotensin-aldosterone inhibitors prevent models prognosis alleviate new onset clinic.45 PPAR-gamma agonist pioglitazone preservation reduced reablation 2 diabetes mellitus ablation.46 CONCLUSIONS While practice, many researchs proceeded all Treatments rapidly evolving, promising future decrease cost experienced hospitals. Nevertheless, poor anticoagulant therapy. Much efforts doctors