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Therapy focus - Atrial Fibrillation

Looking at the challenges, goals and developments for the pharma industry within specific disease and therapy areas

Atrial FibrilationAtrial fibrillation (AF) is the most common heart rhythm condition, affecting about 1 per cent of the population, rising to 10 per cent in people above the age of 80. A total of 6.3 million people in the US, Japan, Germany, Italy, France, the UK and Spain were living with the condition in 2007. This is expected to increase to 7.5 million by 2017, primarily owing to the ageing population. One in four people aged 40 years or older will develop AF during their lifetime. The condition can be hereditary, with recent studies revealing that up to 30 per cent of people with AF may have a family history of the condition.

There are three types of AF:
Paroxysmal: episodes that come and go without treatment within seven days
Persistent: an episode that lasts longer than seven days and is unlikely to revert back to normal without cardioversion treatment
Permanent: is present long-term and the heartbeat has not reverted to a normal rhythm.

The condition is associated with several serious consequences including heart failure, blot clots, dyspnoea, fatigue and chest pain. However, the leading complication is stroke, therefore antithrombotic therapy is recommended for all patients.

AF is currently an area of intensive research because it is so common, causes so much disease and is such a huge burden on healthcare systems. In Europe, treating AF costs €6.2bn per year, while hospital admissions from the condition have increased by 60 per cent in the past 20 years.

Condition management
AF was not truly described until 1874 when Edmé Vulpian, a French physician and neurologist, observed the irregular atrial electrical behaviour in dog hearts. He was the first to use the term fibrillation, while German pharmaceutical chemist Carl Wilhelm Hermann Nothnagel recorded the irregular pulse associated with AF in 1876.

Present day management of AF has two broad objectives: to eliminate the cause and to suppress and control symptoms. The goals of therapy are individual to each patient. Studies have demonstrated that rate-control has similar efficacy to rhythm-control, however, rate-control is generally better tolerated. Consequently, it is recommended as the first-line strategy for many patients.

There are several drugs that are used to slow the heart rate down, such as beta blockers, diltiazem, verapamil and digoxin. These drugs work by interfering with the electrical impulses of the heart.

Commonly prescribed medications used to maintain a normal heart rhythm include: Rythmol (propafenone), Tambocor (flecainide), Betapace (sotalol), Tikosyn (dofetilide), Multaq (dronedarone) and Cordarone (amiodarone).

However, the strategy of trying to restore and maintain a normal rhythm can be problematic. For this reason, added to the fact that clinical trials have shown no overall benefit for this treatment strategy, in many patients it is better to select a rate-control strategy.

The toxicity of antiarrhythmic drugs falls into two categories: the standard side-effects seen with many drugs, such as allergies, insomnia, gastrointestinal disturbances, plus proarrhythmia where, rather than eliminating arrhythmias, the drugs actually cause them.

Anticoagulation therapy is also used to reduce the threat of strokes by interfering with chemicals in the blood to prevent clots forming so easily. Anticoagulants, like warfarin, have the side effects of bleeding problems and can also interact with many other medications. As a result, some patients may be treated with asprin. It is not as effective as warfarin, but it is less likely to cause problems. Patients taking warfarin need regular blood tests to check how quickly their blood clots.

Another method of treating AF is through electrical cardioversion. However, risks include skin burns, fluid in the lungs, heart attack, stroke and even death. A newer technique to restore the heartbeat is catheter ablation, where a catheter is passed in to the heart's chambers and is used to destroy sections of the tissue that may be the source of the abnormal electrical impulses. Catheter ablation is being used increasingly because it does not require any major surgery, meaning that patients recover quickly after the procedure. Surgical ablation can also be a very effective method for treatment. However, it can be more disruptive to the patient as it requires an incision be made in the chest to access the heart and the use of high-frequency energies to destroy heart tissue.

There is little evidence that compares the different modes of cardioversion, according to the UK's National Institute for Health and Clinical Excellence (NICE), particularly in terms of cost-effectiveness, despite being a core treatment for many patients with AF.

Future developments
At present, long-term management strategies for AF are far from ideal and there are unmet needs in treating the condition. Currently, 60 per cent of patients on antiarrhythmic drugs are still in AF and unmet needs in the management of patients with the condition will place greater emphasis on preventive measures, including risk factor management and education, in addition to early diagnostic strategies.

Also, because of the limitations of current anticoagulants, there is a need for an effective, safe and convenient oral anticoagulant with a predictable effect, no drug-food interactions and no requirement for routine coagulation monitoring. As things stand, about half of AF patients do not receive anticoagulation due to the contraindications and limitations associated with available drugs.

The Author
Liz Wells
is deputy editor of PME


Atrial fibrillation - an increasing problem

US is highlighted on a globe

Europe is highlighted on a globe

All countries highlighted on a globe

Patients with AF in the US in 2010

Patients with AF in Europe in 2010

The number of people with AF is expected to more than double by 2050

Source: Boehringer Ingelheim


Atrial fibrillation - cost burden and need for treatment

US is highlighted on a globe

Europe is highlighted on a globe

All countries highlighted on a globe

Euros per year costs of treating AF


Euros per year costs of treating AF

Three million people worldwide have an AF-related stroke every year

Source: Boehringer Ingelheim

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23rd May 2011


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