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Program in Cardiac Arrhythmias: Atrial Fibrillation

What is atrial fibrillation?

Atrial fibrillation is the most common heart rhythm disorder. It is a chaotic activation of the top chambers of the heart, typically at rates of 400-500 beats/min (much faster than the normal rates of 50-80 beats/min), that interferes with the heart’s normal pacemaker function.

How many people have atrial fibrillation?
 
Atrial fibrillation affects over 2.2 million people in the U.S.; some estimates project that it will affect 12 million people in the U.S. by 2050. Atrial fibrillation increases the risk for heart failure, stroke, and death. Of the estimated 600,000 ischemic strokes that occur yearly in the US, 15-20% are thought to be secondary to atrial fibrillation.
 
What are the current treatments?
           
There are many different treatment approaches to atrial fibrillation, which include medications or interventional procedures to restore normal rhythm, as well as blood thinners to prevent stroke, one of the most devastating complications of atrial fibrillation. Which treatments are optimal for individual patients is currently unknown.
 
What are the current challenges in treating atrial fibrillation?
 
Many of our treatments are either not very effective or have significant side effects, toxicities, or other risks. Moreover, it is not known which treatment will be effective for an individual patient, requiring a trial-and-error approach in the selection of treatments. One example of this challenge is in the use of blood thinners for patients with atrial fibrillation. While these agents are very effective at reducing the risk of stroke, they come at the price of a significant yearly risk of major bleeding, including hemorrhagic stroke. Currently, we treat many more patients with these blood thinners than actually need them, thereby exposing them unnecessarily to the bleeding risks. Yet, there is no better way to pick patients for treatment than the current approach.
 
How is the Center for Cardiovascular Innovation addressing this problem?
 
Dr. Jeffrey Goldberger, a specialist in heart rhythm disorders and an established researcher in this area, has assembled a multidisciplinary team to foster new ideas and new collaborations to address these many problems related to this public health issue. Specialists in arrhythmias, clinical research, basic science, imaging, engineering, and epidemiology are developing new approaches that will leverage existing technologies and new paradigms that can change the face of therapy for atrial fibrillation. The figure below shows a novel MRI technique that is being developed by Dr. Goldberger and colleagues from the Departments of Cardiology and Radiology to identify areas of low blood flow in the atrium during atrial fibrillation that are responsible for the development of blood clots that can lead to strokes.
 
 

Selected Bibliography

  1. Ehlert F, Goldberger J, Rosenthal J, Kadish A: Relation between QT and RR intervals during exercise testing in atrial fibrillation. Am J Cardiol 70:332-338, 1992.
  2. Schilling R, Kadish A, Peters N, Goldberger J, Davies DW: Endocardial mapping of atrial fibrillation to the human right atrium using a non-contact catheter. Eur Heart J 21:550-564, 2000.
  3. Horvath G, Goldberger JJ, Kadish AH: Simultaneous occurrence of atrial fibrillation and atrial flutter. J Cardiovasc Electrophysiol 11(8):849-858, 2000.
  4. Schilling RJ, Peters NS, Goldberger J, Kadish AH, Davies DW: Characterization of the anatomy and conduction velocities of the human right atrial flutter circuit determined by noncontact mapping. J Am Coll Cardiol 38:385-393, 2001.
  5. Larsen J, McPherson D, Kadish A, Goldberger J: Course of intraatrial thrombi resolution using transesophageal echocardiography. Echocardiography 20:121-128, 2003.
  6. Passman RS, Kadish AH, Dibs SR, Engelstein ED, Goldberger JJ: Radiofrequency ablation of atrial flutter: A randomized controlled trial of two anatomic approaches. Pacing Clin Electrophysiol 27:83-88, 2004.
  7. Passman RS, Weinberg KM, Freher M, Denes P, Schaechter A, Goldberger JJ, Kadish AH: Accuracy of mode switch algorithms for detection of atrial tachyarrhythmias. J Cardiovasc Electrophysiol 15(7):773-777, 2004.
  8. Ng J, Kadish AH, Goldberger JJ: Effect of electrogram characteristics on the relationship of dominant frequency to atrial activation rate in atrial fibrillation. Heart Rhythm 3(11):1295-1305, 2006.
  9. Arora R, Ng J, Ulphani J, Mylonas I, Subacius H, Shade G, Gordon D, Morris A, He X, Lu Y, Belin R, Goldberger JJ, Kadish AH: Unique autonomic profile of the pulmonary veins and posterior left atrium. J Am Coll Cardiol 49(12):1340-1348, 2007.
  10. Weinberg KM, Denes P, Kadish AH, Goldberger JJ: Criteria for the electrocardiographic diagnosis of atrial flutter improve diagnostic accuracy. Am J Med 120:814-8, 2007.
  11. Ng J, Kadish AH, Goldberger JJ: Technical considerations for dominant frequency analysis. J Cardiovasc Electrophysiol 18:757-64, 2007.
  12. Ulphani JS, Ng J, Aggarwal R, Cain JH, Gordon D, Yang E, Morris AR, Arora R, Goldberger JJ, Kadish AH: Frequency gradients during two different forms of fibrillation in the canine atria. Heart Rhythm 4:1315-1323, 2007.
  13. Ulphani JS, Arora R, Cain JH, Villuendas R, Shen S, Gordon D, Inderyas F, Harvey LA, Morris A, Goldberger JJ, Kadish AH: The ligament of Marshall as a parasympathetic conduit. Am J Physiol 293(3):H1629-1635, 2007.
  14. Ng J, Goldberger JJ: Understanding and interpreting dominant frequency analysis of AF electrograms. J Cardiovasc Electrophysiol 18:680-685, 2007.
  15. Arora R, Ulphani JS, Villuendas R, Ng J, Harvey LA, Thordson S, Inderyas F, Lu Y, Gordon D, Denes P, Greene R, Crawford S, Decker RS, Morris A, Goldberger JJ, Kadish AH: Neural substrate for atrial fibrillation: implications for targeted parasympathetic blockade in the posterior left atrium. Am J Physiol 294:134-144, 2008.
  16. Weinberg KM, Denes P, Kadish AH, Goldberger JJ: Development and validation of diagnostic criteria for atrial flutter on the surface electrocardiogram. Ann Noninvasive Electrocardiol 13(2):145-154, 2008.
  17. Dibs SR, Ng J, Arora R, Passman RS, Kadish AH, Goldberger JJ: Spatiotemporal characterization of atrial activation in persistent human atrial fibrillation: multisite electrogram analysis and surface electrocardiographic correlations--a pilot study. Heart Rhythm 5(5):686-693, 2008.
  18. Aistrup GL, Villuendas R, Ng J, Gilchrist A, Lynch TW, Gordon D, Cokic I, Mottl S, Zhou R, Dean DA, Wasserstrom JA, Goldberger JJ, Kadish AH, Arora R: Targeted G-protein inhibition as a novel approach to decrease vagal atrial fibrillation by selective parasympathetic attenuation. Cardiovasc Res 83:481-492, 2009.
  19. McCarthy PM, Kruse J, Shalli S, Ilkhanoff L, Goldberger JJ, Kadish AH, Arora R, Lee R: Where does atrial fibrillation surgery fail? Implications for increasing effectiveness of ablation. J Thorac Cardiovasc Surg 139(4):860-867, 2010.
  20. Berry JD, Prineas RJ, van Horn L, Passman R, Larson J, Goldberger J, Snetselaar L, Tinker L, Liu K, Lloyd-Jones DM: Dietary fish intake and incident atrial fibrillation (from the Women's Health Initiative). Am J Cardiol 105(6):844-848, 2010.
  21. Ng J, Borodyanskiy AI, Chang ET, Villuendas R, Dibs S, Kadish AH, Goldberger JJ. Measuring the complexity of atrial fibrillation electrograms. J Cardiovasc Electrophysiol 21(6):649-655, 2010.
  22. Schwartz GG, Chaitman B, Goldberger JJ, Messig M: Effect of high-dose atorvastatin on risk of atrial fibrillation in patients with prior stroke or transient ischemic attack: An analysis of the Stroke Prevention by Aggressive Reduction in Cholesterol Levels (SPARCL) trial. Am Heart J 161:993-999, 2011.
  23. Ng J, Villuendas R, Cokic I, Schliamser JE, Gordon D, Koduri H, Benefield B, Simon J, Murthy SNP, Lomasney JW, Wasserstrom JA, Goldberger JJ, Aistrup GL, Arora R: Autonomic remodeling in the left atrium and pulmonary veins in heart failure – creation of a dynamic substrate for atrial fibrillation. Circulation Arrhythmia and Electrophysiology 4(3):388-396, 2011.

 

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