In Reply

Letters to the Editor Medical, Interventional, and Surgical Treatment Strategies for Atrial Fibrillation by Prof. Dr. med. Stephan Willems, Dr. med. Melanie A. Gunawardene, Dr. med. Christian Eickholt, Dr. med. Jens Hartmann, Prof. Dr. med. Michael Schmoeckel, and Dr. med. Benjamin Schäffer in issue 1–2/2022

We thank your correspondent for his interest in our article and his personal assessment of the ESC guidelines. We now wish to comment on the three issues raised:

• Devices and wearables have mostly not been systematically evaluated—in contrast to established diagnostic procedures. Registered recordings can be a blessing or a curse. On the one hand, recording sporadic cardiac arrythmias in symptomatic patients may be successful and treatment can be initiated to improve the prognosis. On the other hand, it is not known if treating brief asymptomatic episodes is beneficial. Potential risks and benefits and the importance of interpretation are explained in the section entitled “Basic principles, diagnosis, and clinical findings” and in the Box. General screening for atrial fibrillation is currently not recommended. The STROKESTOP trial has, however, recently shown a potential benefit of broad-ranging screening in older patients (1).
• To consider the duration of atrial fibrillation as a factor for the risk of embolic complications seems obvious and is supported by the ASSERT Study, among others. Differentiating the duration of episodes is clinically difficult as asymptomatic episodes are common. Furthermore, the prothrombotic milieu in the left atrium is subject to multiple influences. Applying a validated score (for example, CHA2DS2-VASc-Score) should be preferred until meaningful studies become available. Among others, the ATRESiA (2) and NOAH-AFNET-6 (3) studies will be able to yield valuable information in the future4.
• The EAST-AFNRT-4 study is explicitly not an “ablation study” and should not be interpreted as such. The study randomized patients with atrial fibrillation and additional cardiovascular risk factors: early rhythm control (mostly using antiarrhythmic drugs) versus usual care (rate control). The study is not generalizable to “general” atrial fibrillation. Atrial fibrillation ablation has a prognostic benefit in certain patient groups (for example, those with heart failure). For a more general patient population, this approach provides improved rhythm stability, less progression in atrial fibrillation, and fewer symptoms for the patients.

DOI: 10.3238/arztebl.m2022.0215

On behalf of the authors
Prof. Dr. med. Stephan Willems
Klinik für Kardiologie und Internistische Intensivmedizin
ASKLEPIOS Klinik St. Georg, Hamburg

Conflict of interest statement
The authors of both contributions declare that no conflict of interests exists.

References

1. Svennberg E, Friberg L, Frykman V, Al-Khalili F, Engdahl J, Rosenqvist M. Clinical outcomes in systematic screening for atrial fibrillation (STROKESTOP): a multicentre, parallel group, unmasked, randomised controlled trial. Lancet. 2021; 398: 1498–1506

2. Lopes RD, Alings M, Connolly SJ, et al. Rationale and design of the Apixaban for the reduction of thrombo-embolism in patients with device-detected sub-clinical atrial fibrillation (ARTESiA) trial. Am Heart J 2017; 189: 137–45

3. Kirchhof P, Blank BF, Calvert M, et al.: Probing oral anticoagulation in patients with atrial high rate episodes: Rationale and design of the Non-vitamin K antagonist oral anticoagulants in patients with atrial high rate episodes (NOAH-AFNET 6) trial. Am Heart J 2017; 190:12–18

4. Willems S, Gunawardene MA, Eickholt C, Hartmann J, Schmoeckel M, Schäffer B: Medical, interventional, and surgical treatment strategies for atrial fibrillation. Dtsch Arztebl Int 2022; 119: 11–22