Early rhythm control, lifestyle modification, and a more personalized assessment of stroke risk are the main goals in the management of atrial fibrillation.
The American College of Cardiology (ACC) and the American Heart Association (AHA), along with several other leading medical associations, have released new guidance for optimally preventing and managing atrial fibrillation (AFib). The guideline was jointly published in the Journal of the American College of Cardiology and Circulation .
Atrial fibrillation , or AFib, is the most common type of heart rhythm disorder (arrhythmia), affecting more than 6 million Americans, with the number expected to double by 2030. AFib causes a variety of symptoms, including They include rapid or chaotic heartbeats, fatigue, shortness of breath and chest pain, and cause about 450,000 hospitalizations each year, according to the Centers for Disease Control and Prevention. If left untreated, AFib can cause or exacerbate heart failure and significantly increases the risk of stroke.
The 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Treatment of Atrial Fibrillation (ACC/AHA/ACCP/HRS Atrial Fibrillation Guideline) provides guidance for clinicians on the treatment of patients with atrial fibrillation (AF). The guideline emphasizes a rhythm control strategy similar to that recommended in the most recent European Society of Cardiology (ESC) atrial fibrillation guideline. The recommendations also highlight the need for lifestyle modification and risk factors in addition to medical treatment. In this guideline summary, we highlight practice-changing guideline recommendations to accelerate adoption into clinical practice.
Dissemination of the ACC guidelines is an organization-wide effort overseen by the Solutions Set Oversight Committee, which aims to ensure that guideline content is integrated into all clinical policies, education, registration, membership, and efforts. of ACC promotion. The clinical tools presented here are part of a broader ACC dissemination strategy to facilitate the implementation of key practice changes.
Top 10 Messages for Practice The following top 10 messages are taken from the ACC/AHA/ACCP/HRS Atrial Fibrillation Guidelines. The messages were selected as key themes for this Guideline because they represent the most impactful changes in these recommendations compared to previous guidelines and address known gaps in clinical practice.
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The updated guideline calls for a stronger, more prescriptive focus on healthy lifestyle behaviors to prevent or lessen the burden of AF, as well as earlier and more aggressive rhythm control overall, including improved recommendations for catheter ablation as first-line therapy. line to prevent disease progression. Also detailed is updated guidance on managing heart rate and rhythm medications, use of blood thinners, and when to pause or temporarily stop these therapies.
Additionally, the guideline establishes a new way of classifying AFib, using stages , which reinforces the continuity of the disease and highlights the need to use a variety of strategies at different stages, including prevention, lifestyle modification and risk factors, detection and therapy. Previously, AFib was primarily classified based solely on the duration of the arrhythmia, which, while useful, tended to emphasize specific therapeutic interventions rather than a more holistic, multidisciplinary management approach.
“This is a complex disease. It’s not just an isolated heart rhythm disorder, and we now know that the longer a person is with AFib, the more difficult it is to return to normal sinus rhythm,” said José Joglar, MD, professor of cardiac electrophysiology at UT Southwestern. Medical Center in Dallas and chairman of the writing committee. "The new guideline reinforces the urgent need to address AFib as a complex cardiovascular condition that requires prevention, risk factor modification, as well as optimization of therapies and patient access to ongoing long-term care and treatment." ".
Figure : Management strategies for the new classification of atrial fibrillation. An important message from the latest guidance is the new FA classification system. The previous classification system was based on the duration of the arrhythmia and focused primarily on therapeutic interventions. The new classification identifies AF as a continuous disease that requires a variety of strategies at different stages, from prevention to lifestyle and risk factor modification, detection and therapy. This new classification system is parallel to the idea of disease continuity contained in other guidelines3,4 with the aim of preventing the progression of AF .
There is a clearer focus on modifying risk factors (e.g., weight loss and obesity prevention, physical activity, smoking cessation, limiting alcohol consumption, and controlling blood pressure and other comorbidities) to help prevent AFib or improve any recurrence or worsening of the disease. The recommendations are intentionally prescriptive in nature so that doctors can give patients specific goals and provide them with a clearer roadmap for how they can take steps to live healthier and change the course of their disease.
"Many patients don’t know where to start when they are advised to modify their lifestyle, so we are very specific with our recommendations," Joglar said. "For example, instead of saying ’you need to exercise,’ which largely doesn’t help patients, we recommend talking to patients about what types of physical activity work for them and how many minutes they should be active each day or week." .
The good news for many people, he added, is that morning coffee is fine when it comes to AFib, according to the most recent data, but if people notice that caffeine makes them feel sick, they should skip it.
Catheter ablation received the highest Class 1 treatment recommendation for appropriately selected patients, including those with heart failure with reduced ejection fraction. Catheter ablation is a minimally invasive procedure that deactivates parts of the heart tissue that cause irregular heart rhythms.
"In the past, catheter ablation was considered a second-line option after medications were tried that failed, and we now advise that in selected patients with atrial fibrillation, catheter ablation can be pursued as a first option," Joglar said, adding that recent data showed it is more effective than medications in preventing disease progression in some populations.
Still, he emphasized the need for a multi-pronged approach to achieve greater success. Because AFib and heart failure often overlap, there is a specific section for key considerations for these patients, which reinforces aggressive rhythm control to help cardiac function recover.
Although the guideline continues to support the use of the CHA 2 DS 2 -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 CHA 2 DS 2 -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, anticoagulant recommendations should be based on a comprehensive risk of annual thromboembolic event rather than a specific score.
"The new guideline gives physicians flexibility to use other predictive tools, and we hope this will also improve communication and shared decision-making with patients," Joglar said, adding that there is an increased focus on the use of predictive devices. left atrial appendage closure for stroke. prevention. This device is located in the left atrial appendage of the heart, where blood clots often form, to prevent them from reaching the bloodstream.
As with other chronic conditions, such as high blood pressure or type 2 diabetes, Joglar said, "We now have a better understanding and more tools to prevent, treat and also mitigate the risk of AFib so we can improve patient outcomes." "
The writing committee was composed of cardiologists, cardiac electrophysiologists, surgeons, pharmacists, and lay patient/stakeholder representatives.
