First comes diagnosis then comes treatment: an underappreciated paradigm in atrial fibrillation managementThe opinions expressed in this article are not necessarily those of the Editors of the European Heart Journal or of the European Society of Cardiology.

Abstract

This editorial refers to ‘Left atrial volume predicts cardiovascular events in patients originally diagnosed with lone atrial fibrillation: three-decade follow-up’† by M. Osranek et al., on page 2556 Atrial fibrillation (AF), the most common arrhythmia encountered in clinical practice, has a very complex, incompletely understood pathophysiology with various triggers and substrates interacting in multiple ways. All, genetic pre-disposition, structural changes and fibrosis, progression of heart disease, inflammation, autonomic dysfunction coupled with electrophysiological abnormalities of the atria, and pulmonary vein sleeves, may act, to various degrees, as contributors to initiation and maintenance of the fibrillatory process. Clinically, the atrial remodelling process is accompanied by progression from paroxysmal to persistent AF, failure to restore and maintain sinus rhythm, and also increased risk of thrombogenesis and embolism.1 If one takes a closer look at current ACC/AHA/ESC AF management guidelines,1 one must realize, however, that the focus of clinical evaluation includes characterizing the pattern of the arrhythmia as paroxysmal or persistent, determining its cause, and defining associated cardiac and extracardiac factors. Except for left atrial (LA) dimension, AF pattern, and duration, there is no other atrial-specific variable recommended, which takes, at least partially, into account one or more of the aforementioned contributors. Risk stratification of ischaemic stroke is based on age, the presence of heart disease, hypertension, and diabetes mellitus, as well as left ventricular function, not considering individual coagulation properties or structure and function of the LA appendage, as the most common site for thrombus formation. In other words, characterization of the atrial disease process is largely neglected or at best attempted by clinical variables on which therapeutic guidance is based on. Results of various therapeutic … *Corresponding author. Tel: +49 391 67 13203; fax: +49 391 67 13202. E-mail address : andreas.bollmann{at}medizin.uni-magdeburg.de