“Upstream Therapy” Concept: Alternative Therapies for A-Fib? 2014 Boston AF Symposium

Boston AF Symposium 2014

Dr Eric Prystowsky

Dr Eric Prystowsky

“Upstream Therapy” Concept: Alternative Therapies for A-Fib?

Report by Steve S. Ryan, PhD

Dr. Eric Prystowsky of The Care Group in Indianapolis, IN introduced the thought-provoking concept of “Upstream Therapy” in his presentation Alternative Therapies for Atrial Fibrillation.

Up to now, most A-Fib research has been focused on meds or devices to stop or control A-Fib. But can we find ways to stop A-Fib from developing in the first place? Dr. Eric Prystowsky lectured on the concept of “Upstream Therapies”

Dr. Eric Prystowsky Slide 1

Dr. Eric Prystowsky Slide 1: Concept of “upstream” therapies.

What is Upstream Therapy?

An example of an Upstream Therapy is the Galectin-3 inhibitor which prevents fibrosis from developing in the heart thereby also preventing A-Fib from developing or progressing. (See Dr. Jalife’s 2014 presentation: The Holy Grail: Preventing A-Fib by a GAl-3 Inhibitor)

We know, for example, that High Blood Pressure (HBP) often triggers or causes A-Fib, probably because of the pressure and strain HPB puts on the Pulmonary Vein openings in the Left Atrium.

Can therapies like Angiotensin Receptor Blockers, Ace Inhibitors or Hypertensive Therapy (Upstream Therapies) lower HPB and keep someone from developing A-Fib?

Dr. Eric Prystowsky slide 2

Dr. Eric Prystowsky Slide 2: Can “upstream” therapies like Angiotensin Receptor Blockers and Ace Inhibitors help patients “steer clear” of A-Fib?

six Potential Upstream Therapies

Dr. Prystowsky discussed six potential Upstream Therapies which might show promise in A-Fib.

1.  ACE-I/ARBs. ACE Inhibitors and Angiotensin Receptor Blockers may potentially prevent A-Fib by:

• Limiting Substrate Modification such as dilation, fibrosis and conduction velocity slowing

• Improve Hemodynamic Function by lowering atrial and blood pressure and reducing heart failure

• Reducing Initiators of A-Fib by decreasing stretch-activated ion channels Dr. Prystowsky showed how in one study the angiotensin II receptor blocker Irbesartan lowered A-Fib recurrence. But other studies (ACTIVE I) were not so conclusive.

2.  Statins. In one study Atorvastatin significantly lowered the rate of recurrence of A-Fib. But other studies didn’t show statins having much effect on A-Fib.

3.  PUFAs (Polyunsaturated Fatty Acids). He discussed two studies in which PUFAs weren’t very effective.

4.  Acupuncture. In one study persistent A-Fib patients after Electrical Cardioversion were randomized to acupuncture or sham acupuncture for 10 sessions of 15/20 minutes weekly starting 48 hours after the cardioversion. Acupuncture was effective, but the sham acupuncture wasn’t (no placebo effect). This indicates the acupuncturist must be very knowledgeable, experienced and hit the right spots for acupuncture to be effective.

5.  Renal Denervation. In a small study PVI combined with Renal Ablation resulted in less recurrence than just a PVI. (See also: the disappointing news about Renal Denervation in the satellite case Renal Denervation and Pulmonary Vein Isolation for PAF from Siberia, Russia in which it was announced that the Medtronic Symplicity HTN-3 trial didn’t reduce blood pressure)

6.  Tarantula Peptide Inhibits A-Fib.

Alternative Therapies for Atrial Fibrillation

Dr. Prystowsky offers scientists and researchers the thought-provoking concept of “Upstream Therapy”. Divert the contributing factors that contribute to Atrial Fibrillation. What a worthy goal.  Stop A-Fib from developing in the first place!  (See also, Dr. Jalife’s presentation at this year’s Symposium “http://europace.oxfordjournals.org/content/early/2013/02/28/europace.eut038.full.pdf )

Editor’s Comments:
In addition to upstream therapies which reduce high blood pressure, we might also consider therapies that:
reduce or cure sleep apnea which is a trigger or cause of A-Fib
reduce or cure diabetes, another trigger or cause of A-Fib
• keep people from excessive alcohol consumption “holiday heart” which triggers A-Fib.
In a limited study acupuncture was effective to some extent, but right now we don’t have enough data to say acupuncture can make people A-Fib free like a successful catheter ablation. More scientific studies need to be made of acupuncture. And effective acupuncturists need to be identified and listed in a directory similar to the listings of EPs (and surgeons) in A-Fib.com. Acupuncturists need to go through a certification process to verify they can effectively treat A-Fib patients.
For A-Fib patients today, statins, polyunsaturated fatty acids, and Renal Denervation aren’t very effective.
The most promising, exciting upstream therapy for A-Fib is the Galectin-3 inhibitor which prevents fibrosis from developing in the heart and reduces fibrosis already in the heart (See Dr. Jalife’s presentation at this year’s Symposium http://europace.oxfordjournals.org/content/early/2013/02/28/europace.eut038.full.pdf” )

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Last updated: Tuesday, April 18, 2017