Division of Cardiovascular Diseases Strategic Plan

Goals in Cardiovascular Clinical Problems or Disease States

2.3b. Halt the epidemic of atrial fibrillation and its associated morbidity

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Atrial Fibrillation (AF) is a major public health burden with a lifetime risk of 1 in 4 for its development (1 in 6, even if no heart failure or MI is present) and costs of $6.4 billion per year. The prevalence of AF in the U.S is 2.2 million and will double by 2020. AF prevalence increases with age, and AF doubles the risk for death and accounts for 15-20 percent of all strokes. True prevalence is unknown, but is likely higher. Although often associated with hypertension and structural heart disease, AF is also triggered by acute illness and by surgery. Among individuals aged 65 years or older, AF prevalence increased from 3.2 percent in 1992 to 6.0 percent in 2002, with higher prevalence in older subsets of the study population. Progression from paroxysmal AF to persistent permanent AF appears inevitable in many patients. Despite knowing the mechanisms of electrical and structural derangements, the transition to permanent AF is incompletely understood. Similarly genetic predisposition to AF has been identified but the implications of that knowledge are not fully realized. Current therapeutic strategies include rate control, rhythm control, antithrombotic treatment and ablation.

Strategies to Accomplish this Goal May Entail:

Basic Research:

  • Investigate the principles underlying electrical and structural remodeling that facilitate and perpetuate AF and how these may be influenced by age and possible sex differences.
  • Use a systems biology approach to aid in understanding AF initiation and persistence.
  • Develop new imaging modalities to better characterize conduction abnormalities in three dimensions by simultaneously mapping electrical activity upon atrial anatomic features in the sub-millimeter range.
  • Investigate the nature of chamber-specific channels as potential targets for AF therapies.
  • Encourage the development of new thrombin inhibitors and other potent but safe anticoagulants.
  • Elucidate the role of atrial endothelium in thrombogenesis.
  • Explore interventions to minimize pacemaker cell death and develop cell-based therapeutic strategies to restore pacemaker activity and abnormal conduction pathways.

Translational Research:

  • Investigate genetic factors that drive susceptibility to AF in various disease states and “lone” AF, including epigenetic or environmental factors occurring with aging.
  • Apply novel genetic strategies (such as using genome-wide association techniques and candidate gene mapping) to identify gene variants in patients at increased risk for AF and predict their response to therapy.
  • Investigate promising pharmacologic or other interventions designed to reduce the incidence of AF in animal models with spontaneously occurring AF.
  • Develop minimally invasive image-guided ablation interventions.

Clinical Research:

  • Capture AF occurrence in large phenotyped cohorts and clinical trials.
  • Evaluate interventions that may delay or prevent first development and recurrence of AF.
  • Evaluate the safety and efficacy of ablation procedures relative to appropriate pharmacologic therapies.
  • Identify and improve control of specific AF risk factors.
  • Investigate the use of new anticoagulant and antiplatelet agents for stroke prevention in AF.

Contributing Sources:

September 2008

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