Atrial fibrillation: still an issue.

Atrial fibrillation is undoubtedly a clinically important condition. While is it steadily increasing in prevalence and incidence in ageing Western societies, management has become more effective and complex, involving drugs and interventions (figure 1 from Haegeli and Calkins). In this issue, important novel evidence is provided to our readers. The first paper by Michael Ezekowitz from the Sidney Kimell Medical College, Broomall, PA, USA entitled ‘Rivaroxaban vs. vitamin K antagonists for cardioversion in atrial fibrillation’ is an ESC FAST TRACK paper presented at the Hotline Session in Barcelona at the ESC’s Annual Congress 2014. The X-VeRT trial randomly compared rivaroxaban (20 or 15 mg/day with renal failure) or dose-adjusted vitamin K antagonists (VKAs) in 1504 patients with atrial fibrillation (AF) undergoing elective cardioversion. The primary efficacyoutcome was stroke, transient ischaemic attack, peripheral embolism, myocardial infarction, and cardiovascular death, while the safety outcome was major bleeding. The authors found that oral rivaroxaban was as effective and safe as VKAs. This is a clinically important finding, which will affect daily practice of many cardiologists. The second paper by Stine Darkner et al. from the Copenhagen University Hospital ‘Recurrence of arrhythmia following short-term oral AMIOdarone after CATheter ablation for atrial fibrillation: a double-blind, randomized, placebocontrolled study (AMIO-CAT trial)’ is another ESC FAST TRACK paper from Barcelona accompanied by a thought-provoking Editorial by Karl-Heinz Kuck, current president of the ESC Heart Rhythm Association. The clinical background of this study is that patients undergoing catheter ablation for AF often experience recurrent arrhythmias afterwards. The authors investigated whether or not short-termuseof amiodaronepreventsearlyarrhythmias following radiofrequency ablation. Contrary to the expectations of many, they found that short-term amiodarone treatment following ablation for AF did not reduce the recurrence of atrial tachyarrhythmias at 6 months. However, it more than halved atrial arrhythmia-related hospitalization and cardioversion rates during that period. Thus, the use of amiodarone may still have some clinical value. In a third paper, Gregory Y.H. Lip from the University of Birmingham, UK reports on the ‘Prognosis and treatment of atrial fibrillation patients by European cardiologists: 1-year follow-up of the EURObservational Research ProgrammeAtrial Fibrillation General Registry Pilot Phase (EORP-AF Pilot registry)’, another ESC FASTTRACK manuscript fromBarcelona, accompanied by an Editorial by Jayasree Pillarisetti. The ESC EURObservational Research Programme (EORP), currently led by Roberto Ferrari, is an important initiative of the ESC. In this case, the EORP focused on the management of AF in 3119 patients from nine member countries. In the current 1-year follow-up, the authors provide data obtained since the publication of the new ESC Guidelines on AF. Overall oral anticoagulant (OAC) use remains high, although persistence with therapy appears to be a problem. Nonetheless, continued OAC use was more common than in previous reports. Despite the high prescription of OAC, 1-year mortality and morbidity remained high in AF, particularly from heart failure and hospitalizations. This report thus suggests that ESC Guidelines, in this case on AF, do impact on clinical practice, although improvements in guideline implementation remain an issue. In a last paper, Günter Breithardt et al. from the University of Münster analysed a subgroup of the Rocket-AF trial in their study on the ‘Clinical characteristics and outcomes with rivaroxaban vs. warfarin in patients with non-valvular atrial fibrillation but underlying native mitral and aortic valve disease participating in the ROCKET AF trial’. This manuscript is accompanied by an Editorial by Stefan Hohnloser from the Wolfgang-Goethe-University of Frankfurt. The authors investigated clinical characteristics and outcomes of patients with valvular disease in the ROCKET AF trial. The results suggest that many patients classified as having ‘non-valvular AF’ have significant valvular