ESC guideline on AF emphasizes shared decision-making
Click Here to Manage Email Alerts
A new atrial fibrillation guideline from the European Society of Cardiology advocates collaboration between clinicians and patients for AF treatment options.
The guideline, presented at the virtual ESC Congress and published in the European Heart Journal, recommends the “ABC (Atrial Fibrillation Better Care)” pathway of anticoagulation, better symptom management, and CV and comorbidity optimization, and contains an algorithm with four strategies to characterize AF to help determine the best course of treatment.
“Patients want to be involved in decisions about their care and their preferences should be respected,” guideline task force co-chair Gerhard Hindricks, MD, medical director of the rhythmology department at Leipzig University Heart Center in Germany, said in a press release.
The guideline represents “a paradigm shift from single-domain classification of atrial fibrillation toward a comprehensive, structured characterization of patients with atrial fibrillation, streamlining the comprehensive risk assessment of AF patients, facilitating the communication among physicians of various specialties at different health care levels and supporting shared treatment decision-making,” guideline task force co-chair Tatjana Potpara, MD, PhD, assistant professor at Belgrade University School of Medicine in Serbia, and cardiologist and head of the department for intensive arrhythmia care at the Clinical Center of Serbia in Belgrade, said during a virtual session on the guidelines.
The first pillar of the ABC pathway is to avoid stroke through anticoagulation, task force member Gregory Y.H. Lip, MD, the Price-Evans Chair of Cardiovascular Medicine and director of the Liverpool Centre for Cardiovascular Science at the University of Liverpool, said during a presentation. He noted that “the default is stroke prevention unless [the patient is] low risk.” The first step is to identify low-risk patients by a CHA2DS2-VASc score of 0 in men or 1 in women, then offer anticoagulation to the others after bleeding risk is assessed, preferably by the HAS-BLED score. Non vitamin-K-antagonist oral anticoagulants are preferred, but if used, a need to consider with vitamin K antagonists is well managed time in therapeutic range, he said.
The second pillar is improved symptom control, using “patient-centered, symptom-directed decisions on rate and rhythm control,” Lip said.
The third pillar is CV risk factor and comorbidities optimization including lifestyle changes.
The guideline recommends the 4S-AF scheme for characterizing AF. This scheme consists of the following:
- stroke risk, as assessed by the CHA2DS2-VASc score;
- symptom severity, as assessed by quality-of-life questionnaires and the European Heart Rhythm Association Symptom Score;
- severity of AF burden, as assessed by the temporal pattern (paroxysmal, persistent, long-standing persistent or permanent) and total AF burden (total time, longest episodes and number of episodes in a given period); and
- substrate severity as assessed by CV risk factors, comorbidities and imaging results, including data from incident AF risk scores, AF progression risk scores, biomarkers and imaging modalities such as echocardiography, CT and MRI.
The guideline strongly endorses lifestyle improvements in patients diagnosed with AF, including regular physical activity, BP control and weight loss.
The guideline was developed in collaboration with the European Association of Cardio-Thoracic Surgery and the European Heart Rhythm Association of the ESC.
Reference:
Perspective
Back to Top
Jonathan P. Piccini, MD, MHS, FACC, FAHA, FHRS
There has been a lot of emphasis on catheter ablation and some of the data being presented at ESC will focus this discussion even further. The new ESC guidelines elevate two important recommendations for catheter ablation. No. 1, they recommend ablation as a Class I recommendation for persistent AF that is symptomatic and refractory to antiarrhythmic therapy (the American Heart Association/American College of Cardiology/Heart Rhythm Society guidelines counsel a Class IIA recommendation). No. 2, they assign a IIA recommendation for ablation in HF with reduced ejection fraction to improve survival and reduce HF hospitalization. The AHA/ACC/HRS guidelines only give this indication a IIB recommendation. This is a notable difference.
Almost all of the elements of the ESC guideline are in U.S. practice, at least to some degree. Many of them are not universal (like using patient-reported outcomes) but will likely now get more attention and emphasis.
The new guidelines emphasize the ABC (anticoagulation, better symptom management, CV and comorbidity optimization) pathway for managing AF. All three of these core management principles are important and bear emphasis. Emphasizing these principles through this mnemonic may help facilitate physician and patient education and improve outcomes. It is also notable that there is a new Class I recommendation that specifically states a diagnosis of AF requires an ECG. This of course is like saying the sky is blue and the Earth is round, but it is a really important recommendation. With the advent of screening tools and smartwatches that do not use an ECG-based method of detection, making sure the health care community relies upon ECG recording for definitive diagnosis is very, very important.
Collapse
Hindricks G, et al. 2020 ESC guidelines on atrial fibrillation. Presented at: European Society of Cardiology Congress; Aug. 29-Sept. 1, 2020 (virtual meeting).
Click Here to Manage Email Alerts