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Risk factor management can be ‘fourth’ pillar of AF treatment
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Ablation does not always prevent adverse outcomes in patients with atrial fibrillation, nor do the established three pillars of AF management: rate control, rhythm control and anticoagulation. Given that clinicians are targeting the risk factors for recurrence, many of which are related to lifestyle.
Predictors of AF include hypertension, obstructive sleep apnea, obesity and diabetes as well as markers such as left atrial size, aortic stiffness and epicardial fat, and ameliorating these factors can lower risk for AF recurrence, Dennis H. Lau, MBBS, PhD, FHRS, said during a presentation at the Heart Rhythm Society Scientific Sessions.
“When we treat AF with catheter ablation, we have not finished our job,” said Lau, a cardiologist at Royal Adelaide Hospital in Australia. “We have to look at the risk factors that contribute to AF in our patients.”
The risk management philosophy
In Australia, candidates for AF ablation must wait for upward of 1 year, compared with the United States where the procedure is readily available, Lau said.
Because of that waiting period, clinicians focus on aspects such as weight management, increasing physical activity and smoking cessation and alcohol use.
“Risk factor management has been shown to reduce AF burden, reduce the need for ablation, improve outcome for rhythm control strategies and is indeed an essential component of your AF care,” Lau said. “We need to improvise a model of care delivery, as this is not possible in your usual 15-to-20-minute consultation of patients.”
Lau said a collaborative effort is needed when managing patients with AF.
“When you have a patient with AF, as an electrophysiologist, you’re just a small piece of the pie,” he said. “We need to involve multiple specialists, from dietitians to exercise physiologists to sleep physicians to pharmacists, to help us improve the care of AF patients.”
The ‘fourth’ pillar
In the United States, risk management for AF is endorsed by the American College of Cardiology, American Heart Association and Heart Rhythm Society guidelines along with the traditional three pillars of AF.
U.S. experts said there are benefits to implementing a risk management plan in patients with AF.
Joseph Marine, MD, said risk management can go beyond treatment of AF.
“The risk factors for AF are also risk factors for coronary artery disease and congestive HF,” Marine, a cardiologist at Johns Hopkins Hospital, told Cardiology Today. “Most patients would like to prevent disease rather than taking daily medications or undergoing invasive medical procedures. Most of my patients are eager to know what they can do to reduce their burden of AF beyond drugs and procedures.”
John D. Day, MD, FACC, FHRS, cardiologist and medical director of heart rhythm services at Intermountain Heart Institute, and former president of the Heart Rhythm Society, said the option for risk factor management is something patients should be aware of in order to not have to take medication for the rest of their lives.
“I think the biggest payoff is that studies show that approximately 50% of AF cases can be put into remission without drugs and without any procedures,” Day told Cardiology Today. “That is huge. You basically have to have ... lifestyle optimization and biomarker optimization. But by making a concentrated effort to live as healthy as you can, you’ve got a 50-50 chance of putting this disease, which can lead to HF, stroke and other devastating complications, in remission.”
Despite the benefits to risk management, there are some concerns about the negative effect if patients lack the necessary tools to complete the process or are noncompliant.
“Lifestyle changes are difficult to undertake,” Marine said. “By the time most people reach middle age, habits of eating, exercising (or not) and alcohol use are deeply ingrained and difficult to change without determined effort. Some patients do not like existing treatments for obstructive sleep apnea and will not use them, especially if they do not have symptoms of obstructive sleep apnea. Adherence to a program to achieve good control of hypertension and diabetes is still another challenge.”
Day said when risk factor management is properly executed, there are no drawbacks.
“The only side effect of lifestyle optimization and biomarker optimization are the good side effects,” he said.
In nonadherent patients, Marine said it is important to establish a therapeutic alliance between the patient and the referring physician.
“Even if a patient is not likely to take advice to engage in risk factor modification, it is important to discuss the subject, even if only to plant an idea that a patient may act on at another time,” Marine told Cardiology Today. “Patients may act on some suggestions and not others, so even a partial success should be sought. What I think would be most helpful for compliance would be establishing an AF pathway within existing cardiac rehabilitation programs. This would probably require studies showing a significant reduction in important endpoints in AF patients undergoing cardiac rehab.”
Among some patients who fall back into old habits or are nonadherent, they may have no other treatment options, Day said.
“Many patients can do it, but not all patients can do it,” Day said. “Unfortunately, patients who are unable to do it or don’t have the right tools or don’t have the right resources will generally be treated medically or with ablation.”
Application ahead of ablation
In Australia, ablation is an expensive form of therapy, according to Lau, meaning risk factor management can be essential in limiting the need for the procedure.
Day said the lengthy wait time in Australia can make risk management an appealing option.
“These are patients who have already failed medical management,” Day said. “They don’t have anything more that you can offer the patient, so it makes sense to do everything you can from a lifestyle standpoint since they have to wait up to a year for their ablation.”
Although there are no lengthy wait times in the U.S., Day said some electrophysiologists may wait for ablation to implement a lifestyle optimization plan.
However, he said, there are cases where ablation needs to be performed before risk factor management can be fully implemented.
“Sometimes a patient may not be able to exercise until you can get rid of the AF because every time they try to exercise, their heart’s gone into AF,” Day said.
Day said risk factor management is starting to become a more common strategy in the U.S.
“We are seeing more and more physicians focus on lifestyle optimization, at least within the electrophysiology community,” he said. “I suspect a lot of general cardiologists and primary care physicians are totally unaware how effective lifestyle management is for treating AF.”
Although risk factor modification alone may not eliminate symptomatic AF, it should be an adjunctive therapy in all patients, Marine said.
“I discuss risk factor modification to some extent with all my AF patients,” he said. “I can think of several patients referred to me for ablation who postponed having their procedure to pursue aggressive risk factor modification alone.”
Growing momentum
Marine said some U.S. electrophysiologists are emphasizing risk factor management in patients with AF, but “most invasive electrophysiologists, however, do not have the time, bandwidth and programmatic resources to lead such preventive efforts, and we depend on our general cardiology and primary care colleagues to implement these programs. An additional barrier is that AF is not a qualifying diagnosis for cardiac rehabilitation programs in the U.S.”
Day said a benefit of risk factor management is its ability to effect substantial lifestyle changes.
“You can make these conditions totally go away without medication, which, at least in our practice, changes the calculus as far as who requires lifelong blood thinners,” he said. “So, there’s really a lot that’s within the power of the patient to change their health destiny.”
Lau said being able to lower AF recurrence after initial ablation through risk factor management reduces the likelihood of repeat ablations, which carry an approximately 1% risk for complications.
“Is it ethical use of our resources to ablate this patient knowing full well that a year or two, they’re going to get recurrence?” he said. “If you have leaking roof and rotten timber, do you just replace the timber or fix the leak?” – by Earl Holland Jr.
Reference:
Lau DH. Session S-AF03. Presented at: Heart Rhythm Society Annual Scientific Sessions; May 8-11, 2019; San Francisco.
Disclosures: Day reports he wrote a book on lifestyle modification. Lau reports he received honoraria, speaking and consultant fees from Abbott, Bayer/Schering Pharma, Biotronik, Boehringer Ingelheim and Pfizer. Marine reports no relevant financial disclosures.