SA JOURNAL OF DIABETES & VASCULAR DISEASE
EDITORIAL
VOLUME 7 NUMBER 2 • JUNE 2010
55
This is therefore a logical target for intervention in order to protect a
patient from thrombo-embolic events. The auricle may be removed
surgically or may be occluded by means of a percutaneous approach.
Last year it was reported by the investigators of the PROTECT-AF
study that the efficacy of left atrial appendage closure by means
of the Watchman device was not inferior to the use of warfarin.
16
There were, however, more adverse events in the group treated
with the occlusion device. As the risk of serious haemorrhage is a
reality for any patient treated with anticoagulation, this may be an
alternative option.
In this edition of the
South African Journal of Diabetes &
Vascular Disease
, David Jones and colleagues review in depth the
management strategies for atrial fibrillation. This review focuses on
how this condition is managed in a first-world setting. The question
is: How can this be applied to Africa?
Some of the challenges facing doctors in South Africa include:
the unavailability of tertiary resources; the geographic challenges,
making it difficult to follow up on patients regularly; inconsistent
medical supplies; and the poor level of education and lack of
insight into their condition of many of our patients. There is also
the duality with the private sector, where most of the first-world
treatments are available.
The reality is that in South Africa, most patients with atrial
fibrillation will be managed with a rate-control strategy. This is
not an inferior method of management and can be done by most
primary physicians. The fact that it has been proven in the RACE-II
trial that lower target heart rates are as effective as the previous
goals set by the 2006 ACC/AHA/ESC guidelines makes this form of
therapy even more attractive.
Anticoagulation is a major problem in the South African
context. The inability of patients to attend INR clinics regularly due
to problems with transport and immobility makes therapy with
warfarin a difficult option. Aspirin or the combination of aspirin
and clopidogrel, which does not need regular monitoring, is an
attractive option. Unfortunately we know that the efficacy of either
of these regimes is much less compared to warfarin.
17,18
Dabigatran will be launched in South Africa this year. This drug
may be the answer to some of these problems. The results of the
ROCKET-AF study are still pending. Rivaroxaban, which is already
available in South Africa, might be another alternative to warfarin.
When these drugs will be available in the state sector is currently a
matter of uncertainty.
Catheter ablation therapy is not generally available in South
Africa. Some centres do offer it, but this therapy will be available to
only a few selected patients. The procedure is not risk free and only
experienced centres should offer it.
Whether all patients should be referred to secondary or tertiary
care is another difficult question. The ACC/AHA/ESC guidelines
recommend that every patient diagnosed with atrial fibrillation
should be evaluated with echocardiography.
4
As rheumatic heart
disease is still a major problem in South Africa, all patients should
have an echocardiogram to exclude valvular pathology. Assessment
of heart structure and function also helps in choosing an adequate
management strategy. Due to limited resources, patients might
have to wait to be evaluated in secondary care. The primary-care
physician should therefore already start embolic risk-stratification
and anticoagulation therapy.
Patients who are still symptomatic despite a rate-control
strategy, or with lone atrial fibrillation or structural heart disease
should be referred to a cardiologist for further evaluation and
management. Cardiologists will be the predominant physicians
opting for a rhythm-control strategy in selected patients. The
resources needed for this management strategy, such as trans-
oesophageal echocardiography and knowledge of the use of anti-
arrhythmic drugs are in their domain of practice and freely available
to cardiologists in a tertiary-care setting.
The article by David Jones and colleagues provides a good
background and guidelines on how to manage a patient with atrial
fibrillation, and these principles should be applied to patients in
South Africa as extensively as possible.
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