Natriuretic peptides in atrial fibrillation: evidence is here, but are we ready to go one step beyond?

When making a diagnosis of atrial fibrillation (AF), we are all of a sudden flagging our patient with an increased risk of stroke, heart failure and death. Then, we aim at preventing these complications and improving the quality of life of our patient, but our chances of success will largely depend on the availability of safe and effective treatments and on our ability to accurately identify those patients at the highest risk. Anticoagulants have been used for more than six decades, and heparins and vitamin K antagonists were early found to prevent thromboembolic events. In the absence of other therapeutic options, the prognostic evaluation of patients with AF has been largely, almost exclusively, limited to the thromboembolic risk assessment. However, even after proper anticoagulation, patients with AF remain at a high risk of death and hospitalisation.1 Early epidemiological studies had already demonstrated that AF independently associates with increased mortality, but such poor prognosis could not be blunted through reducing AF burden with antiarrhythmic drugs. In keeping with these results, pursuing sinus rhythm maintenance was reserved for symptomatic patients. Fortunately, recent large trials have challenged this paradigm. Integrated care management may reduce mortality in patients with AF. Importantly, the recently published Early Treatment of Atrial Fibrillation for Stroke Prevention Trial (EAST) trial demonstrated that an early rhythm control approach incorporating an up-to-date therapeutic armamentarium reduces cardiovascular death and heart failure hospitalisation in high-risk patients.2 With novel tools to reduce mortality and heart failure available, identifying those patients at the highest risk should become a cornerstone of AF management.1 Assessment of left atrial structure and function with either echocardiography or magnetic resonance predicts stroke, AF incidence and recurrence, but their limited availability or accuracy narrows their use to specific settings. Certain …