The complexity of atrial fibrillation

Atrial fibrillation (AF), once thought of as a disease with a simple diagnosis, is emerging as a disease of great complexity and one needing a great deal of clinical judgment to manage effectively.

Positioning the disease as the “tip of the iceberg,” Valentin Fuster, MD, Director, Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY spoke on the need to understand the causative “roots” of AF in order to manage it properly in a presentation he delivered at the ACC meeting entitled “Atrial Fibrillation – Clinical Challenges 2015, Quality of Life & Preventing Stroke.”

“Atrial fibrillation is the end result of many things that we still have to learn,” Fuster said. He indicated that there are now at least 7 to 10 etiologies known to cause AF, among these are causes that are modifiable such as obesity, hypertension, and alcohol use. These etiologies when present, he said, can be managed even before treating AF.

A critical issue that is becoming worrisome is the increasingly number of people with AF experiencing micro strokes in the brain that may affect their cognitive function.  “When we talk about stroke in people with AF, this is the tip of another ice berg,” he noted, “because there are minor clots going on that can affect the microvasculature of the brain and cognitive function.”

Another issue contributing to the complexity of AF, he said, is intensive management of AF.  “It is important to recognize that  symptoms attributed to AF, such as fatigue and shortness of breath, may involve other conditions as well so that the symptoms may not go away after ablation”, he noted. For example, automatic nervous system dysfunction, which is very common in people, is associated with all sorts of symptoms, one of which may be AF. In these patients, ablation for AF will not rid the patient of their symptoms.

“Whenever we send patients to ablation because they have symptoms,” Fuster said, “we should always tell them that we are not entirely sure the symptoms will completely go away.”

Throughout his talk, Fuster emphasized that AF tests clinical judgment. He judges fellows in training by how good they are in assessing and managing AF. This highlights the complexity of the disease, and how much clinical judgment is needed to understand and manage it.