The National Heart, Lung, and Blood Institute (NHLBI) convened a Workshop of researchers with expertise in the basic science, epidemiology, and clinical aspects of atrial fibrillation (AF) on April 28-29, 2008 in Bethesda, Maryland, to advise the Institute on new research directions needed to prevent AF. Participants were asked to review evidence associated with the initial development of AF and its progression to a persistent state. Specifically, they were asked to identify opportunities for possible prevention strategies from existing large clinical studies, as well as to make recommendations for future basic science and clinical studies and analyses on the prevention of AF. The Workshop furthers the goals of the NHLBI Strategic Plan, particularly Goal 2: to improve understanding of the clinical mechanisms of disease and thereby enable better prevention, diagnosis, and treatment.
AF is the most common arrhythmia in the United States, and is associated with significant morbidity, particularly stroke, and mortality. The increasing size of the affected population as well as growing recognition of the associated morbidity, mortality and spiraling costs have spurred increased interest in the development of more effective treatments for AF. However, prevention of AF has received relatively little attention.
The workshop participants reviewed evidence from large observational cohort studies, basic science findings most relevant to etiology and prevention, and clinical trials that included AF outcomes. Following deliberation, a consensus was reached identifying knowledge gaps and research needs.
- Enhance data collection on the natural history of AF.
- Systematically and longitudinally ascertain both symptomatic and asymptomatic AF in NIH-sponsored and other appropriately designed cohort studies.
- Define AF etiologic subtypes in the community.
- Leverage existing data sets and cohorts.
- Examine existing and future clinical trial data to systematically include AF as an outcome.
- Systematically ascertain both symptomatic and asymptomatic AF in NIH and other appropriately designed clinical trials not specifically focused on AF, including diagnostic codes and hospital and outpatient surveillance EKGs.
- Improve detection.
- Examine the feasibility, cost and utility of existing and emerging methods and technology to detect asymptomatic, unrecognized, symptomatic paroxysmal and persistent AF.
- Conduct more intensive monitoring for AF in subsets of patients.
- Improve subclinical characterization.
- Develop and improve noninvasive methods (e.g., biomarkers, - genomic, metabolomic and proteomic markers, molecular imaging, MRI, echocardiography, signal-averaged electrocardiography) to detect the processes occurring at the atrial tissue and electrical remodeling levels, such as fibrosis, inflammation, thrombogenesis, and autonomic innervation.
- Advance mechanistic insights.
- Develop better animal models to inform translational science.
- Determine the mechanisms of human AF phenotypes (e.g., AF with aging, hypertension, ischemia, left atrial enlargement/dysfunction and diastolic dysfunction, and autonomic dysfunction).
- Conduct studies of prevention of AF recurrence (secondary prevention).
- Conduct secondary intervention studies in patients with presumed early AF (e.g. initial onset) to prevent recurrent AF. Such studies should include morbidity and mortality endpoints.
- Use results of secondary prevention studies to inform any future primary AF prevention studies.
Report is planned for publication in a peer-reviewed journal.
Diane Bild, MD, MPH
Division of Prevention and Population Sciences
Alice M. Mascette, MD
Division of Cardiovascular Diseases
Working Group Members:
- Emelia J. Benjamin, MD, Boston University
- Peng-Sheng Chen, MD, Indiana University
- Christine M. Albert, MD, Brigham and Women’s Hospital
- Alvaro Alonso, MD, PhD, University of Minnesota
- Hugh G. Calkins, MD, Johns Hopkins Hospital
- Stuart J. Connolly, MD, McMaster University
- Anne B. Curtis, MD, University of South Florida Heart Health
- Dawood Darbar, MD, Vanderbilt University School of Medicine
- Patrick T. Ellinor, MD, PhD, Massachusetts General Hospital
- Alan S. Go, Kaiser Permanente, Oakland, CA
- Nora Goldshlager, MD, San Francisco General Hospital
- Susan R. Heckbert, MD, PhD, University of Washington
- José S. Jalife, MD, University of Michigan
- Charles Kerr, MD, St. Paul’s Hospital, Vancouver
- Daniel Levy, Framingham Heart Study, NHLBI
- Donald M. Lloyd-Jones, MD, Northwestern University
- Barry M. Massie, MD, VA Medical Center, San Francisco
- Stanley Nattel, Montreal Heart Institute
- Jeffrey E. Olgin, MD, University of California San Francisco
- Douglas L. Packer, MD, Mayo Clinic, Rochester
- Sunny Po, MD, PhD, Oklahoma University Health Science Center
- Teresa S. M. Tsang, MD, Mayo Clinic Rochester
- David Van Wagoner, PhD, Case Western Reserve University
- Albert L. Waldo, MD, Case Western Reserve University
- D. George Wyse, MD, PhD, The University of Calgary
Last updated: July 14, 2008