CARDIOVASCULAR JOURNAL OF AFRICA • Vol 23, No 7, August 2012
AFRICA
415
increased oxygen demand for some 20
minutes before eventuating in the briefer
experience of angina’, Dr Dalby said.
The safety of combining ivabradine
with beta-blockade has been demonstrat-
ed. The combination has been shown
to increase exercise time on the tread-
mill.
6
Importantly, a sub-study of the
BEAUTI
f
UL trial
7
suggested that ivabra-
dine was safe and effective in angina
patients with left ventricular dysfunction,
Dr Dalby added.
‘I am not proposing that ivabradine
should replace
β
-blockade in angina but
that it be employed as a useful alternative
therapy when the patient is intolerant of
beta-blockade, or as an add-on to standard
anti-anginal therapies when the symptoms
cannot be controlled adequately.’ Dr
Dalby concluded with a personal proposal
to include ivabradine in a South African
guideline, based upon similar proposals
from the European Society (Fig. 1).
J Aalbers
1.
Bethan JF, Weekes AJ, Morgan C, Tavella R,
Spertus JA. The prevalence of weekly angina
among patients with chronic stable angina in
primary care practices (CADENCE) study.
Arch Intern Med
2009;
169
(16): 1491–1499.
2.
Gehi AK, Ali S, Na B, Schiller NB,
et al
.
Inducible ischemia and the risk of recurrent
cardiovascular events in outpatients with
stable CAD – the heart and soul study.
Arch
Intern Med
2008;
168
(13): 1423–1428.
3.
Maron DJ, Boden WE, O’Rourke RA,
et al
, COURAGE Trial Research Group.
Intensive multi-factorial intervention for
stable CAD: optimal medical therapy in the
COURAGE (Clinical Outcomes Utilizing
Revascularization and Aggressive Drug
Evaluation) trial.
J Am Coll Cardiol
2010;
55
(13): 1348–1358.
4.
Ruzyllo W, Tendera M, Ford I, Fox KM.
Antianginal efficiacy and safety of ivabra-
dine compared with amlodipine in patients
with stable effort angina: a 3-month rand-
omized, double blind, multicentre, non-infe-
riority trial.
Drugs
2007;
67
: 393.
5.
Koster R, Kaehler J, Meinertz T; Reduction
study group. Treatment of stable angina
pectoris by ivabradine in everyday practice:
the REDUCTION study.
Am Heart J
2009;
158
(4): e51–e57.
6.
Amasova E, Andrejev E, Zaderey I,
et
al.
Efficacy of ivabradine in combination
with beta-blocker versus uptitration of
beta-blocker in patients with stable angi-
na.
Cardiovasc Drugs Ther
2011;
25
(6):
531–537.
7.
Tendera M, Talajic M, Robertson M, Tardif
JC,
et al.
Safely of ivabradine in patients
with CAD and LV systolic dysfunction
(from the BEAUTI
f
UL Holter substudy).
Am J Cardiol
2011;
107
(6): 805–811.
Catheter ablation of atrial fibrillation: evidence shows significant benefit and reduced
progression of disease
Catheter ablation for patients with
paroxysmal atrial fibrillation (PAF) and
long-standing atrial fibrillation (LS-AF)
delays progression of the disease, with
improved results if patients are treated
early and aggressively. Presenting the
evidence for this approach, Dr R Tilz,
representing Prof K Kuck of St Georg
Hospital, Hamburg, Germany, noted that
clinicians should consider AF ablation
earlier and not wait too long.
‘We should aim to intervene with
ablation after the first recurrence of AF
after anti-arrhythmic therapy. Multiple
cardioversions are also no longer the norm
in Germany, as education of physicians
and referring cardiologists has led to
acceptance of the approach that catheter
ablation should not be the last option, it
should be an early option’, Dr Tilz noted.
Technological advances have also
supported the use of ablation with new
rotor-guided cryo-ablation and force-
sensing catheters, combined with three-
dimensional visualisation, allowing
individual laboratories to achieve
consistent and reproducible results. ‘There
are several revolutionary technologies
that are en route and the cutting edge of
anti-arrhythmic intervention is very fast
paced’, Dr Tilz said.
The natural progression of AF
from paroxysmal AF to persistent and
permanent AF is well documented
and annual progression is 10–15% per
year, with 77% of patients developing
permanent AF within 14 years without
catheter ablation (Fig. 1).
‘Atrial fibrillation is a very complex
disease and there are many contribu-
tors to its initiation and maintenance.
While age and genetic predisposition are
not treatable, factors such as atrial and
pulmonary vein stretch due to hyperten-
sion and obesity, and endocrine factors
such as diabetes and hyperthyroidism are
treatable and can help to reduce AF preva-
lence.’ AF is relatively rare in the under
50-year-old, with a prevalence of one in 1
000 women and double that among men.
The prevalence rises to about 10% in over
85-year-olds.
The benefit of catheter ablation at
the onset of PAF, thereby preventing
1st diagnosed
paroxysmal
persistent
Time
permanent
Fig. 1. Natural time course of atrial fibrillation. Amended from Kirchhof P,
et
al
.
Europace
2009; 11: 860–885.
TABLE 1. INDEPENDENT PREDICTORS
OFAF PROGRESSION
OR SCORE
History of heart failure
2.22
2
Hypertension
1.52
1
Chronic obstructive lung
disease
1.51
1
History of stroke/TIA 2.02
2
Age
>
75 years
1.52
1
Amended from reference 2.
