New atrial fibrillation guideline highlights early rhythm control, prevention strategies
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Key takeaways:
- An updated atrial fibrillation guideline proposes a classification system to “stage” the disease.
- Recommendations include tailored prevention strategies and first-line catheter ablation for some.
An updated guideline on the prevention and management of atrial fibrillation includes a new staging system to emphasize disease progression, along with updated recommendations for catheter ablation and left atrial appendage occlusion.
Of note, catheter ablation is now recommended as a first-line therapy in certain patients with AF, and lifestyle and risk factor modification are now deemed to be a key component to prevent onset of AF, progression of AF and poor outcomes from AF.
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The guideline, a joint effort of the American College of Cardiology and the American Heart Association, was developed in collaboration with and endorsed by the American College of Clinical Pharmacy and the Heart Rhythm Society and was published in the Journal of the American College of Cardiology and Circulation.
“The full AF guideline was first published in 2014. Over the last decade, there have been many changes in technology and a lot of new science,” Jose Joglar, MD, FAHA, the Elizabeth Thaxton and Ellis Batten Page Professor in Cardiac Electrophysiology Research, and director of the clinical cardiac electrophysiology fellowship program at UT Southwestern Medical Center in Dallas, and chair of the writing committee, told Healio. “This is a field that has grown very fast. To reflect that, we also wanted to prepare the guideline for the future, update and modernize it.”
AF affects 2.7 million to 6.1 million people in the U.S., according to the AHA, and that burden is expected to rise substantially in the coming years. As Healio previously reported, as many as 23% of 5.6 million to 6.6 million presumptive AF cases are undiagnosed in the U.S., with many undiagnosed patients likely eligible for oral anticoagulant treatment.
The guideline notes AF is associated with a 1.5- to twofold increased risk for death and studies suggest the mortality risk may be higher among women compared with men. In meta-analyses, AF is also associated with a 2.4-fold risk for stroke, a 1.5-fold risk for cognitive impairment or dementia, a 1.5-fold risk for MI, a twofold risk for sudden cardiac death, a fivefold risk for HF, a 1.6-fold risk for chronic kidney disease and a 1.3-fold risk for peripheral artery disease.
Among Medicare beneficiaries, the most frequent outcome in the 5 years after AF diagnosis was death, followed by HF and new-onset stroke, according to the guideline.
New AF classification system
The classification of AF was previously based only on arrhythmia duration, Joglar told Healio. The new proposed classification using stages aims to recognize AF as a progressive disease, requiring different strategies at different stages.
“What the old classification system did was emphasize the rhythm abnormality,” Joglar said during an interview. “What we wanted to emphasize with this new staging system is that AF is a complex disease that requires understanding, similar to coronary artery disease. It requires a multidisciplinary approach. We need to approach AF in a more holistic way, from prevention to screening and then intervention. Patient management should include a multidisciplinary approach as well, including weight loss and physical activity. This goes beyond the heart rhythm.”
The classification system includes stage 1, defined as at risk for AF; stage 2, defined as pre-AF; stage 3, which is AF across a range of four substages (paroxysmal AF, persistent AF, long-standing persistent AF and successful AF ablation); and stage 4, defined as “permanent AF,” where there are no further attempts at rhythm control after discussion between the patient and clinician.
“Once AF develops, there are three important care processes that must be specifically addressed with all patients and aligned with their goals of therapy: Stroke risk assessment and treatment, if appropriate, Optimizing all modifiable risk factors, and Symptom management using rate- and rhythm-control strategies that consider AF burden in the context of an individual patient’s needs (SOS),” the guideline states. “The overarching principle for AF management is Access to All Aspects of care to All (4 As).”
Recommendations for AF prevention, treatment
The updated guideline emphasizes risk factor management throughout the disease continuum, including recommendations for weight loss for people with overweight or obesity, BP control for people with hypertension, moderation of alcohol intake and smoking cessation.
The guideline also includes specific recommendations on the quality and quantity of physical activity for people at risk for and living with AF.
“We wanted to be prescriptive,” Joglar told Healio. “We wanted to tell the patient, ‘This is what you need to do.’ Not just telling someone to exercise, but, how much and what type of exercise? How many minutes per day? We define this in the guideline. If you lose a certain amount of weight, it can make a real difference in AF disease progression.”
The guideline also recommends clinicians consider moving beyond the CHA2DS2-VASc clinical risk score for prediction of stroke and systemic embolism, noting that clinicians consider other risk variables or other clinical risk scores to help inform treatment decisions for patients with an intermediate annual risk score where there are uncertainties about the benefit of anticoagulation.
“The new guideline gives clinicians flexibility to use other predictive tools, and we hope this will also enhance communication and shared decision-making with patients,” Joglar said in a press release.
Catheter ablation-first strategy
For select patients with AF, the guideline recommends catheter ablation with a class 1 indication as first-line therapy. The authors note that recent randomized controlled trials demonstrated the superiority of catheter ablation over drug therapy for rhythm control in appropriately selected patients. Additionally, catheter ablation of AF is recommended as a class 1 indication for appropriate patients with HF with reduced ejection fraction.
“There have been many high-quality, randomized controlled studies, especially in recent years, showing that catheter ablation is superior to pharmacologic therapy, especially in ideal candidates such as those with fewer comorbidities, for example,” Joglar told Healio. “The data are clear now. Additionally, we need to be more aggressive with intervening early to prevent disease prevention with early rhythm control. This is logical; we don’t want BP to progress to the point of affecting the kidneys or a patient having a stroke. The same thing happens with AF; the disease progresses and becomes more persistent.”
The authors also upgraded left atrial appendage occlusion (LAAO) to a class 2a recommendation, noting additional data now are available on the safety and efficacy of LAAO devices.
“Newer technology, perhaps a decade old now, has evolved,” Joglar told Healio. “LAAO devices are safer and the risk/benefit analysis is now tilting in favor of the procedure. Complications have come down over the years and we have better quality data to support giving a higher-class recommendation for these devices.”
References:
- Early rhythm control, lifestyle modification and more tailored stroke risk assessment are top goals in managing atrial fibrillation. https://www.acc.org/About-ACC/Press-Releases/2023/11/30/17/47/Early-Rhythm-Control-Lifestyle-Modification-and-More-Tailored-Stroke-Risk-Assessment-Are-Top-Goals-in-Managing-Atrial-Fibrillation . Published Nov. 30, 2023. Accessed Nov. 30, 2023.
- Joglar JA, et al. Circulation. 2023;doi:10.1161/CIR.000000000000119
For more information:
Jose Joglar, MD, FAHA, can be reached at jose.joglar@utsouthwestern.edu.
Perspective
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This is a nicely done guideline with many important updates, the most important being catheter ablation receiving a class I indication to treat AF in select patients. This is a huge win for electrophysiology. It is important to note that not every patient who walks in with AF needs an ablation. This class I indication supports the notion that you can have a reasonable discussion about catheter ablation with anyone who walks into your office with symptomatic AF. The bottom line is early rhythm control. There is now a well-defined alternative, supported by randomized controlled trials, that ablation can be first, and importantly, it can be first-line for select patients with AF and HF.
The guideline also includes a new staging system for AF. We now recognize that AF exists on a continuum, and there are now more prescriptive strategies to reflect that. It also highlights the importance of early recognition of comorbidities like obesity, hypertension and risk factors like smoking, alcohol intake and lack of physical activity. These factors must be evaluated across all AF stages. This guideline also notes the importance of including the patient in these discussions with concrete recommendations for weight loss and physical activity. The new “SOS” goals of therapy outlined in the guideline are a clever way to help educate primary care physicians and cardiologists. If we can turn these recommendations into goals, everyone will buy in a bit more.
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