The American College of Cardiology (ACC) and the American Heart Association (AHA), with several other medical associations, have issued new guidelines for the prevention and management of atrial fibrillation (AF). The guideline was jointly published in the Journal of the American College of Cardiology and Circulation.
The updated guidelines call for a stronger, more prescriptive focus on healthy lifestyle habits to prevent or lessen the burden of AF, as well as early and more aggressive rhythm control in general, including upgraded recommendations for catheter ablation as first line therapy to prevent disease progression. Also detailed is updated guidance on the management of heart rate and rhythm medications, use of anticoagulants, and when to temporarily pause or stop these therapies.
Additionally, the guidelines set forth a new way to classify AF, using stages, that reinforce the continuum of the disease and underscore the need to use a variety of strategies at the different stages, including prevention, lifestyle and risk factor modification, screening, and therapy. Previously, AF was primarily classified based only on arrhythmia duration, which, although useful, tended to emphasise specific therapeutic interventions as opposed to a more holistic and multidisciplinary management approach.
“This is a complex disease. It is not just an isolated disorder of the heart’s rhythm, and we now know that the longer someone is in AF, the harder it is to get them back to normal sinus rhythm,” said Jose Joglar (Southwestern Medical Center, Dallas, USA), chair of the writing committee. “The new guideline reinforces the urgent need to approach AF as a complex cardiovascular condition that requires disease prevention, risk factor modification, as well as optimising therapies and patients’ access to care and ongoing, long-term management.”
There is clearer focus on risk factor modification—for example, weight loss and obesity prevention, physical activity, smoking cessation, limiting alcohol, and controlling blood pressure and other comorbidities—to help prevent AF or ameliorate any recurrences or worsening of the disease. Recommendations are intentionally prescriptive in nature so that clinicians can give patients specific goals and provide a clearer road map for how they can take steps to live healthier and change the course of their disease.
“Many patients do not know where to start when they are given advice about lifestyle modification, so we are very specific with our recommendations,” Joglar said. “For example, instead of saying ‘you need to exercise,’ which is largely unhelpful to patients, we recommend talking with patients about what types of physical activity works for them and how many minutes they should be active each day or each week.”
Ablation: Class 1 recommendation
Catheter ablation was given a Class 1 treatment recommendation for appropriately selected patients, including those with heart failure with reduced ejection fraction.
“In the past, catheter ablation was considered a second line option after medications were tried and failed, and now we are advising that, in select AF patients, you can proceed to catheter ablation as a first option,” Joglar said, adding that recent data showed catheter ablation to be more effective than medications in preventing disease progression in some populations.
Although the guideline continues to endorse use of the CHA2DS2-VASc score as the predictor of choice to determine patients’ stroke risk, other risk calculators should be considered when uncertainty exists or when other risk factors need to be included. For example, kidney disease is not included in CHA2DS2-VASc. Patients, especially those at intermediate risk, may benefit from evaluation with more than one risk calculator because some work better than others in different patient populations, or other factors need to be considered. For example, recommendations for blood thinners should be based on a comprehensive yearly thromboembolic event risk rather than on a specific score.
“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, adding that there is enhanced focus on the use of left atrial appendage closure devices for stroke prevention.
The writing committee was comprised of cardiologists, cardiac electrophysiologists, surgeons, pharmacists, and patient representatives/lay stakeholders.
