Well, good morning. It's our pleasure to welcome you to San Diego and Heart Rhythm 2025, the 46th Annual Meeting of the Heart Rhythm Society. I'm Deepak Bhakta from Indianapolis, Indiana. I serve as the Vice Chair for the Clinical Guidelines Committee for Heart Rhythm Society. And I'm joined by Dr. Yongmei Cha from Mayo Clinic in Rochester, Minnesota, who serves as the Chair of the Clinical Guidelines Committee. If you haven't already done so, please download the HRS 2025 mobile app from your preferred app store. That's how you can participate in the sessions and submit questions for today's session. Please note that visual reproduction of Heart Rhythm 2025, either by video or still photography, is strictly prohibited. We're at today's session, From Guidelines to Practice, Comparing New Guideline Directions in Global Atrial Fibrillation Management. We have some exciting presenters today who've contributed to these documents. We'll start out with our first presenter. So our first presenter is Dr. Jose Hoagler, and he is the Chair for the ACC AHS-AF Guidelines. So I'm glad we have him today to present what's new in the 2023 AHS-ACC-AF Guidelines. Thank you so much to the Chairs, to the audience for being here this morning. I'm Jose Hoagler from UT Southwestern. And I'm going to present some of the highlights of the Atrial Fibrillation Guidelines. Nothing to disclose. So important changes have been incorporated in the 2023 ACC-HA, ACC-PHRS Guidelines for Atrial Fibrillation Diagnosis and Management. So I'm just going to discuss the most important changes that I consider within 15 minutes for my talk. I'm just going to talk about the highlights, the things that are clearly different. There are a lot of things in the guideline. I encourage the audience to go to the ACC Guideline app and open the guidelines and also have the app so the audience, the providers can use the guideline at the point of care, can access the guideline at the point of care. So just start with the new classification. So compared to the prior description of atrial fibrillation that was based just on duration, the new guideline uses a classification that includes a risk for AFib, pre-AFib, AFib, then paroxysmal persistent, long-standing persistent, and after successful ablation and then permanent AFib. And the reason we did this, it was not to confuse anybody or anything, but we wanted to change the conversation. We wanted to start talking about atrial fibrillation as a complex cardiometabolic disease as opposed to just a heart rhythm abnormality. So that's the first big change. And like I said, we engage in addressing the cardiometabolic risk factors. For example, alcohol consumption, lifestyle intervention, management of risk factors, and that's what the message we wanted to bring to the public. Of course, we're not naive enough to believe that everybody was gonna start exercising with AFib immediately. We were aware of that, but we wanted to change the conversation. You're starting to see a lot of research already going on, for example, Osempic, GLP-1 agonist for atrial fibrillation and things of that nature. So we were heavy about primary and secondary prevention. I'm not gonna talk too much about it, just saying that we were also very prescriptive when it came to lifestyle intervention. The guideline, the chair of the Joint Committee for Clinical Practice Guideline would tell me, well, why do you need to put in a guideline for AFib that you need to exercise and lose weight? Everybody knows that. And that applies to any cardiovascular illness. The answer was because we have specific data, clinical studies, randomized data that addresses the specific criteria needed to achieve those targets when it comes to lifestyle interventions that Megan is gonna talk to us about. We were able also to dispel some myth. One of the myth that the writing committee brought up was the issue of caffeine. As you all know, providers of heart rhythm problems, the caffeine gets blamed for everything, but the bad weather, that's the first thing every patient does when they have a rhythm abnormality. They stop caffeine, and we wanted to dispel that myth. So not only we're telling the providers how they should approach atrial fibrillation, but also things that are not helpful accordingly. Of course, some patients don't feel well when they take caffeine. That's fine, but in general, there's no evidence that caffeine triggers or worsens AFib. So the first thing, another important change that this guideline includes is we are more open to the possibility of using other risk scores for estimation of stroke, for stroke prevention in the setting of atrial fibrillation. CHAS-VAS score is the most utilized score, is the most validated score, but it's not a perfect score. So we wanted to open up the conversation to allow, to open up the conversation that other scores are available when clinically necessary. It's not about abandoning the CHAS-VAS, but if it's necessary, also open the door for future research that the development in the future of scores that add additional nuance to estimation of risk. For example, atrial fibrillation duration might be an important risk factor that is not included in the CHAS-VAS. This is an example of the table that we added to the document, talks about the CHAS-VAS, as you can see here, is the most validated score. But then there's a possibility of other scores when clinically, when it's clinically effective, when it's beneficial to the patient and the provider relationship. This is an example of the Garfield score that we include here. It's a web-based tool, for example, that includes not only stroke, but also risk of bleeding and mortality within a single calculation, and also has different advantages. Atrial score has additional risk factors not included in CHAS-VAS, for example, renal insufficiency proteinuria. So we left that for, there's some more scores used in Asian cohorts. So for example, if you tell a patient, some patient might be reluctant to take anticoagulation, you can pull a Garfield score, calculate, and you can inform better the patient. So it's not only about estimating risk, but also tools to be able to communicate with your patients. This is an example of a Garfield estimation that tells you mortality, risk of stroke with anticoagulation, no anticoagulation, as well as bleeding. So when clinically necessary, when clinically being beneficial, those scores are available. This is one of the reasons we wanted to be more dynamic with the score, more flexible, that's the right word, more flexible. This is a paper by Queen, they studied 34 different cohorts. And you can see that in 34 different cohorts, the risk of stroke was very variable. And in fact, for a CHAS-VAS score of one, 76% of the cohort patients reported stroke rates less than 1%, which is below what the guidelines recommend for anticoagulation. And only 18% of those had a stroke risk greater than 2%. And with a CHAS-VAS score of two, 27% of the patients reported stroke rate less than 1%. So the issue, so what the authors here, Queen say, they put into question the generalizability of current guidelines recommendation. So what this translate into the fact that the scores are not necessarily absolute, there is some degree of nuance, it's not an exact science, if you will. So we wanted to provide flexibility accordingly. We also have this 2A recommendation that allows for nuanced conversations in patients who are reluctant to take anticoagulation. For example, if you have a CHAS-VAS score of one, that's a 2A recommendation for anticoagulation, CHAS-VAS score of one, two in women. But you can add additional factors to the conversation that are not included in this score, but might worry you accordingly. So again, we're trying to be more flexible accordingly. For example, somebody with evidence of atrial myopathy, you might be worried also if the patient has permanent AFib as opposed to persistent or paroxysmal hypertrophic cardiomyopathy has always been deemed, for example, a high risk of stroke condition independent of the risk score. Another change that is important to the prior version of the guideline is that instead of recommending anticoagulation based on a score number, we use magnitude or risk. And we estimated 2% or greater for a 2A recommendation, and between one and 2% ... I'm sorry, for a class one recommendation, 2% or greater, and then between one and 2% for a 2A recommendation. And that is for the same reason we talk about in case you're using other scores, I'm going to show you also something else. But also you can see that the threshold for anticoagulation changes in woman. The CHAS-VASc score equivalent for a class one is three if you include gender. And for a 2A, it will be a CHAS-VASc score equivalent in woman of two. And the reason is because this data, just a reminder that our guidelines is an evidence based document. The writing committee meets, analyzes the data, and since 2014 when the first guideline was published, there have been a lot of new evidence, new changes, new studies that we had to take into consideration. And what you can see here in this study by Nielsen is that the risk of woman of five years and one year compared to men, dark blue and light blue, is clearly increased the risk of stroke accounting for the additional point value in the CHAS-VASc score, but that doesn't become evident until after a CHAS-VASc score of two, at which time the decision of anticoagulation has always been, the criteria for anticoagulation has been met already. So this is one of the benefit of having magnitudes of risk, for example, as opposed to use a CHAS-VASc score, and like I mentioned, there are different case scenarios, different conditions. I mentioned hypertrophic cardiomyopathy, but for example, device detected AFib. This is a result of the study, NOAA, AFinet, and Artesia randomized trials of anticoagulation in patients with device detected AFib, not clinical AFib. And you can see that historically the annual risk, if you consider the original CHAS-VASc score, a CHAS-VASc score of three accounts for a risk, annual risk of stroke of about 3%, CHAS-VASc score of four, 4%. Whereas in these two studies, the average patient score was four, but the risk of stroke was only 1%, 1.1, 1.0%. So now you have a better assessment on how to interpret this result and what is the class of recommendation accordingly for this specific population. An important change compared to the prior guideline, you can see that we downgraded Sotalol to a 2B recommendation because of a meta-analysis of Sotalol increased the risk of mortality in patients who took it for atrial fibrillation. Please bear in mind also that no drug is upgraded to a class one. The writing committee didn't feel that drugs are effective enough. And you can see that there are significant side effects as portrayed in this meta-analysis. So we didn't want to give it a class three, allows tools for the provider when clinically necessary, but we downgraded this drug for sure. When it comes to catheter ablation, one of the speakers is going to tell us a little bit more, but I just want to say that we upgraded catheter ablation as a first-line therapy with a class one recommendation without the need to having to try pharmacological therapy, which was the class one recommendation on the prior version of the guideline. We used the word selected patients, generally young and fecal morbidities. And you can see we wanted to be a little bit open-ended about the word selected to allow for flexibility for the practitioners at the point of care, but what does that mean? Generally younger with fecal morbidities. The studies, but in general, the studies that inform this recommendation are stated here in this table. And you can see the patients generally had normal left atrial diameter, generally tended to have normal ejection fraction. You see the age. They tended to be generally younger. It doesn't mean that you cannot do it as a class one in a 72-year-old. That's why we didn't want it to be too prescriptive. But the point is fecal morbidity, generally younger, better hearts. They tend to respond better for ablation, class one recommendation. For heart failure, also we emphasize a lot the issue of tachycardia-induced cardiomyopathy in patients with atrial fibrillation, and which atrial fibrillation seems to be driving the cardiomyopathy of the patients who will benefit the most. So we included all the heart failure management within one chapter, chapter 10, and also which in one figure, like I said, to benefit the providers who use the guideline at the point of care. You pull out your app and you can see heart failure. And then we can see here then the patients who tend to, I'm sorry, it's kind of small lettering, but the patients who are likely to benefit are those patients in whom heart failure, AFib seems to be driving the heart failure. The hearts are not exceedingly dilated, exceedingly fibrotic, whereas in the patient in whom atrial fibrillation seems to be a manifestation of an end-stage substrate, those patients tend to do worse from ablation. And then we include a recommendation for AV node ablation by B, for example. So in conclusion, the new guidelines trying to emphasize AFib as a complex disease, and not just a rhythm abnormality, we're prescriptive with lifetime intervention, it's a little bit more flexible in stroke risk estimations, and acknowledging uncertainty. There are updated recommendations compared to past guidelines in important areas, such as catheter ablation, and there's a lot of other useful information, tables and figures to help clinicians at the point of care. Thank you so much. Thank you, Dr. Ardlar, for that great summary. I remind you to add questions via the App Lab a few minutes at the end of the presentations to answer some questions. We'll now call Dr. Tom DePotter to the podium from Aalst, Belgium. Dr. Potter will be presenting to us what's new in the 2024 European Society of Cardiology Atrial Fibrillation Guidelines. Thank you very much, dear chairs, dear friends and colleagues. It's indeed my pleasure to share with you some of the changes in the 2024 ESC guidelines for management of atrial fibrillation. And obviously, these are disclosures relevant to this presentation. Obviously, what I'm going to say is based on the published 2024 guidelines, there's also the very interesting 2024 joint EHRA, HRS, and APHRS, and Latin American Society consensus document on management of atrial fibrillation, from which some pointers can be taken. And most of what I'll say is summarized, or I shouldn't say summarized, is expanded on in this overview article, which highlights a few of the essential changes in the 2024 guidelines. And I urge you, it's a document we wrote, first author Michiel Rienstra, I urge you to have a look at it and to read it in more detail, expanding on what we'll cover in the next 15 minutes. So, key new aspects for the 2024 ESC guidelines are the, first and foremost, the concept of patient-centered and integrated AF care. And AF care was defined as an acronym which stands for Comorbidity Management, Avoidance of Stroke, Reducing Symptoms by Rate and Rhythm Control, and then Evaluation and Dynamic Reassessment. And the chronological order of these letters is not by chance, is meant to be seen in this order, meaning comorbidity and risk factor management should absolutely come first in our holistic approach of patient-centered AF care, after which stroke prevention, of course, follows, and then management of symptoms. And at the end, but at the end of the first cycle of this algorithm, which then continuously needs to be reassessed, comes dynamic reassessment, because atrial fibrillation, of course, is not a static phenomenon, it's not a static given. For the aspect of comorbidity and risk factor management, also the ESC guidelines have chosen to dedicate a significant portion on stressing the importance of optimization and management of AFib risk factors, most notably, of course, those factors that can be modified, that can be addressed using patient counseling. One example of an acronym to remember these risk factors is the head-to-toes algorithm, as you see on this slide. It's not my intention to go over each and every one of these risk factors in individual detail, but as also the previous speaker already mentioned, there is good, solid, randomized data showing a specific benefit of management of many of these risk factors in the evolution of atrial fibrillation. With respect to diagnosis, the ESC guidelines recommend a routine, recommend that there is value in routine assessments during healthcare visits over the age of 65 years. That means clinical assessment. And then based on some data, and most notably the stroke stop study, there seems to be an argument to be made for population-based ECG screening to be at least be considered in patients over 75 years based on the data of stroke stop showing a benefit in the combined, primary combined endpoint of ischemic stroke embolism, and that from any cause in the population that was randomized to screening. Of course, the counterargument to this observation is that you need to screen fairly large amounts of patients to derive a benefit, and therefore the guidelines also highlight that the target population and the duration of this screening, and importantly also the impact of wearables is currently unclear, because of course there is an impressive spectrum of tools and devices and technological means that are already today enabling the detection of atrial fibrillation, and this most likely will only evolve further in the direction of more and more detection of what we have become, of what we have come to call subclinical atrial fibrillation. A subclinical atrial fibrillation, of course, introduces several new questions. One of the important ones is what to do with these patients in terms of stroke prevention. Stroke prevention in subclinical atrial fibrillation is not a completely unanswered question. There is randomized data, but as you know, the randomized trials that have been performed have not delivered the exact same message. I think they go in the same direction. The important trials in subclinical atrial fibrillation, the NOAAFNet6 trial and the ARTESIA trial randomized patients to either DOAC treatment or control arm subtle differences in both trials, whether this control arm was placebo or aspirin, and if you look at the outcomes, if you look at pooled analysis of these trials, I think the results are not surprising. Both trials show the same direction of benefit in terms of ischemic stroke. DOAC performs better than placebo or aspirin for the prevention of ischemic stroke. The NOAA trial was not significant in this regard. The ARTESIA trial was significant. The pooled meta-analysis shows a benefit of DOAC. And on the other hand, of course, the downside of introducing anticoagulation treatment is, of course, exposure to bleeding risk, and this is also clear from both trials. There is an increased bleeding risk for patients exposed to DOAC where a benefit is seen for patients randomized to aspirin or placebo. And this means in the meta-analysis of both trials, you can appreciate that for the composite endpoint of stroke or systemic embolism, DOACs perform better than placebo for prevention of ischemic stroke, the same is true, however, at the expense of a clear increase in major bleeding risk, which leads to a more or less neutral effect on cardiovascular death and all-cause mortality. In addition to that observation, there is also the observation that there is a difference in time to manifestation of this benefit or risk. There is a difference in time to benefit or harm. If we look at patients with device-detected atrial fibrillation, it is clear, yes, that they are at a increased risk of stroke. It is clear that if patients with device-detected atrial fibrillation receive DOAC, they are at an increased risk of bleeding. So I should have said there is a decrease in the risk of stroke if they receive DOAC, of course. So there is a benefit in terms of stroke prevention and a cost in terms of bleeding risk, but the time difference is not the same. It takes about one year for the stroke prevention benefit to materialize, whereas the bleeding risk occurs almost immediately, which is another argument to consider in the discussion with your patient, of course. And this pooled analysis clearly states that the time to benefit strongly lags the time to harm when you initiate treatment in these patients. For all these reasons, the guidelines have offered a 2B, level B recommendation to consider anticoagulation therapy in these patients with asymptomatic device-detected atrial fibrillation, excluding those patients where the bleeding risk is perceived to be very high. And importantly, as fundamental to the care paradigm, this needs to be reassessed, of course, at periodic intervals to ensure that those patients in which a start of anticoagulation is not yet offered at some point in time to ensure that these patients do receive anticoagulation at a later point in their life at which, for example, the atrial fibrillation may have become clinically apparent. With respect to treatment of the atrial fibrillation itself, a simple case as a vignette to illustrate the changes in the guidelines is a simple patient with paroxysmal atrial fibrillation who presents to the ER with the first diagnosis of atrial fibrillation. And then in the R arm of the care paradigm, the arm of reduction of symptoms by rate and rhythm control, the guidelines offer specific treatment pathways for each stage of atrial fibrillation, whether it is first diagnosed AF, paroxysmal atrial fibrillation, persistent or permanent atrial fibrillation. What the guidelines clearly state is that the care pathway applies to all stages of atrial fibrillation, and rate control and stroke prevention in those patients where stroke prevention is applicable are nearly universally indicated, regardless of the stage of the atrial fibrillation of the patient. And also what is relatively new in the 2024 guidelines is that there is, besides the role for cardioversion in patients where a hemodynamic instability is present, which has always been a recommendation, there is a role for cardioversion as part of a rhythm control approach in those patients with persistent atrial fibrillation, most importantly for diagnostic aspects, and also in those patients with early stages of atrial fibrillation, a wait-and-see approach to see if spontaneous cardioversion occurs within 48 hours seems to be rational based on the RACE-7 study where no effect was seen, no change was seen between patients randomized to early cardioversion versus delayed cardioversion in the evolution of their atrial fibrillation. With respect to stroke prevention, the risk scoring, probably one of the changes that received significant attention, despite the fact that the impact is low to none, is that the ESC guidelines have changed to using the CHATS-VA risk score based on mostly the observation, as we heard from the previous speaker, that, first of all, female sex is a risk modifier, not necessarily a risk factor, and this risk modifier is particularly strong in elderly patients that are indicated for anticoagulation anyway. So for the purpose of simplification, the ESC-24 guidelines have moved to using the CHATS-VA risk score, which eliminates the need to use different thresholds based on the sex of the patient. However, also as seen in the US guidelines, if the CHATS-VA risk score is clearly not the only useful risk score, and a locally validated and or individual approach can be preferred if such risk scoring system is available. Again, here, periodic reassessment is essential, and for the specific phenomenon of stroke, despite adequate anticoagulation, the 24 guidelines specifically state that there is no benefit for adding antiplatelet therapy to those patients. The guidelines also warn against the routine reflex of switching DOACs in patients with stroke on anticoagulation, for which there is very little evidence that this strategy offers benefit, and there is a possibility of surgical clipping. There is no good data either in this setting. There is the LAOS-III data, of course, which does not specifically look at patients with stroke despite oral anticoagulation, but the LAOS-IV study, which has been initiated, will inform on feasibility of LAA closure. However, because of the very convincing outcome data of LAOS-III in a surgical data setting, the guidelines do recommend LAA occlusion in all concomitant surgery procedures. So there is class one level B recommendation of closure, surgical closure of the left atrial appendix as an adjunct to treatment in those patients undergoing cardiac surgery, and then there is a level C expert opinion recommendation to consider this treatment in those patients with contraindications to long-term anticoagulation. With respect to ablation, classification of atrial fibrillation did not significantly change in the guidelines. What I want to highlight in the decision trees for the patient pathways between persistent and paroxysmal atrial fibrillation is the central role of shared decision making. The recommendations for antiarrhythmic drug treatment are identical in persistent and paroxysmal arms, and the ablation recommendation is strongest, of course, in paroxysmal atrial fibrillation, where the 24 guidelines offer a class one recommendation in paroxysmal atrial fibrillation in drug-naive patients, and an equal strength of recommendation as antiarrhythmic drug treatment in those patient populations. These are the recommendations specifically for antiarrhythmic drug treatment in paroxysmal atrial fibrillation, class one indications for amiodarone, dronedarone, or flaconide, based on the underlying disease state of the patient, and an equal class one recommendation for catheter ablation, again, in paroxysmal symptomatic atrial fibrillation patients, whether they have been treated with drugs before, yes or no. In persistent atrial fibrillation, slightly different pathway, because there is very little strong evidence to support catheter ablation in drug-naive patients, so the class one recommendation is antiarrhythmic drug treatment first, and then later catheter ablation, and the other difference is, of course, as indicated earlier, the role of electrical cardioversion in those patients where you think it may have benefit as a rhythm control strategy. I'm going to go over this in the interest of time, and so the key new aspects, the final key new aspects is that rhythm control can indeed improve prognosis. Rhythm control is advised within 12 months of diagnosis based on EAST-AFNET4, as has been well-published, and has received a class two A level B recommendation based on the trial, next to the very well-established class one indication, also as seen in the US guidelines, in those patients with tachycardia-induced cardiomyopathy. Areas of research is, does indeed atrial fibrillation impact mortality? We've seen the CASTLE-HTX trial as the most recent example. The other area of recent research is, of course, LA closure outcome data. We have option published, LAWS-IV is initiated, and a champion trial is expected, and finally, the concept of on-demand DOAC treatment, which, of course, is being studied in the reactive AF. None of these strategies are present in the guidelines. So as take-home message, symptom control is the primary indication for treatment in atrial fibrillation. There is a mortality reduction indication in selected populations based on the context, can be a class one or class two A indication. There is a central role of shared decision-making in the 2024 guidelines, and catheter ablation and antiarrhythmic drugs are equivalent first-line choices in symptomatic paroxysmal atrial fibrillation. In persistent atrial fibrillation, catheter ablation is class one. After failed antiarrhythmic drugs, surgery is class two A in that particular context. Dynamic reassessment is crucial, and bleeding issues remain unresolved, for example, in subclinical atrial fibrillation. Thank you very much. Thank you. That's a great summary on the EIC guideline. So we're going to the next speaker is Dr. Megan Stewart. Yeah, Dr. Stewart is at the University of Washington, and she's going to talk about lifestyle and the risk factor modification in atrial fibrillation management. Hi, thank you to the chairs for the invitation to be here today and to the audience as well. I'm Megan Stewart. I'm a nurse practitioner. I work clinically in our electrophysiology department, managing AFib patients, and I'm also a professor in our School of Nursing. And my role today is to talk about lifestyle and risk factor modification in atrial fibrillation management. And I'm going to highlight some of the similarities and differences between the 2023 ACC AHA HRS guideline and the ESC guideline. So this is the first time that the, I'll just refer to it as the HRS guideline, has included a section on lifestyle and risk factor modification, so that's great. We have this document, or sorry, this figure that was included, and you see at the bottom that kind of the, the base that holds up all the rest of AFib management is treating risk factors and helping our patients to enact behavioral changes. And this was one of the top 10 takeaways from that guideline. And you can see that in our efforts to present atrial fibrillation as the progressive chronic condition that it is, we tried to highlight that risk factor modification starts pre-AF and continues throughout the course of treatment. And as you've already been shown by our prior speaker, the ESC guideline has actually had integrated or comprehensive risk factor management as part of the guideline. Actually, this is their third iteration that I'm aware of that's included it. So in 2016, they had what they called a five-step integrated care approach. In 2020, that was updated to the ABC pathway, AFib Better Care, and now they've reorganized into the atrial fibrillation care model to be even more comprehensive. And so really, there's an increased focus on the importance of lifestyle and risk factor management to improve patients' prognosis, reduce their symptoms, reduce the progression of AFib, and their burden. So in the ESC guideline, I think you saw this, or a similar figure as well in the last talk, but these are the key targets that are outlined in their lifestyle and risk factor management section. So some of the differences between the HRS guideline is that you have the inclusion of heart failure here where if you're looking at our comprehensive care section in the HRS guideline, you're not gonna find that in the comprehensive care section. You're gonna find heart failure in its own section. And we didn't make specific, I don't think we had a specific recommendation, or yeah, recommendation for diabetes, although we did discuss it in that section. We didn't call out a unique recommendation. The sleep apnea is similar to ours, so it's the class B recommendation. And in the HRS guideline, the only additions to what you see here are gonna be the recommendation related to caffeine, and that is that we don't need to recommend our patients to limit their caffeine intake based on the evidence that's available, which is based primarily on normal quality of caffeines, not our monster and really very high level of caffeine drinks for the most part. So I think that could be one area to take a little more of a look at. And the other thing is that in our section, we do specifically call out a recommendation about smoking cessation. I'm saying our because we're at HRS, so. But when I say that, I mean the HRS guideline. So this is the physical fitness recommendation from the HRS guideline. And I wanted to put this up here because it's a little different than what is recommended in the ESC guidelines. So in the ESC guideline, it is recommended that patients have regular moderate to vigorous intensity exercise, but there's not a number of minutes prescribed or recommended. So in the HRS guideline, it is recommended that patients with atrial fibrillation train towards a target of 210 minutes per week, and that's higher than the general AHA exercise recommendation, which is a minimum of 150 minutes a week. And this can help reduce symptoms, reduce AFib burden, and basically slow progression. That recommendation, in terms of the 210 minutes, was based primarily off the ACTIV-AF trial. So this trial enrolled 120 patients with symptomatic paroxysmal or persistent AFib. They had a tailored exercise plan, or they were in routine, the control group, okay, they had the recommendation of 150 minutes a week, and just some education on physical activity. Between zero to three months, there was an approach to exercise, then kind of a reduced number of visits for supervised exercise from three to six months, and then patients were then encouraged to exercise up to 210 minutes per week. And primary outcomes of that study that I would like to present today are the reduced recurrence of AFib, and you can see that folks who were in the 210 minutes exercise arm did have a reduced time to recurrence, and they also had a reduced AFib symptom severity. The other difference in terms of how prescriptive the lifestyle recommendations get is related to alcohol. So the ESC guideline does specifically recommend that patients have three or less drinks per week, or abstain, whereas the HRS guideline focuses on either minimizing or eliminating alcohol consumption. But there's not a number assigned to this minimize. And in the U.S., our guidelines kind of for general health are that men should have no more than seven drinks, or sorry, 14 drinks per week, two per day, and women, seven drinks per week, one per day. So this is a lot less than that, and so people who think they're within a healthy range still need to receive guidance on reducing their alcohol or completely stopping their alcohol. So I usually provide guidance to patients based on the ESC guideline for this. I think it can help a lot of patients to have a specific number and a specific target, and that recommendation was based off of this study here. This was a randomized controlled multi-center trial that was conducted in Australia. They enrolled folks who were drinking more than 10 drinks per week who had paroxysmal or persistent AFib, and the intervention arm was asked to abstain from alcohol, and the control arm was to continue alcohol as usual, and they had six months of follow-up. And they measured AF recurrence through cardio recordings or seven-day cams if people weren't adhering to the cardio recordings. And so the primary endpoints were AFib and AFib burden. And you can see that folks who were in the abstinence arm did have a lower AFib burden and a longer time till recurrence. And I just wanna point out that folks in the abstinence group, their alcohol intake was reduced from an average of 16.8 to 2.1 standard drinks per week, so that's less than or equal to three drinks per week, with 61% of those folks achieving abstinence. So abstinence is best, but reduction helps too. So I'm not gonna touch every single one of the recommendations that was so nicely presented in the ESC guideline in a single figure, but there were the recommendations related to hypertension, and I just don't have time to go through each one individually, so I wanted to focus on the differences, and then I wanted to focus on comprehensive care. So in the HRS guideline, we also have a recommendation for comprehensive care, we just don't have it in the AF Cares framework, but we have a level one recommendation that AFib patients should receive comprehensive care that includes addressing guideline-directed lifestyle and risk factor modification, as well as treating their symptoms, reducing their stroke risk, and treating their other conditions that contribute to atrial fibrillation. And we have a 2A recommendation that suggests ways in which to do that, including the use of clinical care pathways, nurse-led clinics, as reasonable approaches to achieve these goals. So I'm gonna talk about some of the key trials in those areas. This is an older study done by Dr. Hendricks in the Netherlands and published in 2012. This was a nurse-led comprehensive care approach. There were 712 patients enrolled in this trial, and it was nurse-led outpatient care at a single center. They used a guideline-based decision support software, and they had cardiologist supervision, and they provided comprehensive AFib care. This wasn't as much about lifestyle and risk factor modification, but kind of screening, diagnostics, is echocardiogram done, are other labs done as appropriate? And they found that, oops, sorry. Nurse-led care was more beneficial in terms of the primary endpoint, which was a composite of cardiovascular death and hospitalization than usual care. They did meet with patients more often and had 30-minute appointments. So 30-minute appointments at baseline, three months, six months, and 12 months, and then every six months thereafter, compared to under usual care with a cardiologist. At that center, patients got 20 minutes for their baseline appointment and 10 minutes thereafter without quite as of a structured approach to the after appointments. So more care more often led to better results. This is another trial, the AREST-AF cohort study. They followed folks for about 42 months on average. They did aggressive risk factor reduction. It was a physician-led approach, and this was post-ablation. And their control was individuals who declined the risk factor modification post-ablation. And they enrolled folks who had either a BMI greater than 27 and one of these risk factors, high blood pressure, diabetes, hyperlipidemia, sleep apnea, or smoking, or alcohol consumption. And the folks in the lifestyle risk factor modification arm had a 33% reduction versus about a 10% reduction in the control arm in terms of freedom from AFib. The RACE-III trial, this was a trial out of Europe. So they had about 245 participants, I believe. This was routine care versus aggressive risk factor early prevention trial for folks who had heart failure. And the folks in the aggressive risk factor control arm did have a higher, they were more likely to be in sinus rhythm at one year based on Holter. And then the RACE-IV was a follow-up trial to that. This had nearly 1,400 patients, and it was a nurse-led versus usual care for AFib. This was multi-center, and specialized nurses used a decision support tool in consultation with a cardiologist. And they met with patients at baseline three, six, 12 months and then every 12 months thereafter. And then they covered comprehensive lifestyle and risk factor modification. Usual care was with a cardiologist at baseline and then every 12 months thereafter with coordination with the PCP at the discretion of the cardiologist. And the primary endpoint was cardiovascular death and hospitalization. And in this trial, you can see in the figure A that nurse-led care was not superior to usual care. However, when you looked at experienced centers versus less experienced centers where the nurses had more experience and more time and practice providing this level of comprehensive care, in the experienced centers, nurse-led care was superior. And so I think that's important because I think that shows that we can use this approach if we provide folks with the right training and hire the right people and the right level of experience. So how do we get patients to engage with us in keeping this as a patient-centered approach? We need to have patients that are in strategies for goal setting so that we can really, truly engage the patients in this care. So this is a figure from the ESC guideline and it just shows different strategies to help patients become engaged with behavioral change. So shared decision-making, using that to focus in on key risk factors that they are ready and willing to address, being careful to provide information but not overload with too much information at once, and then setting achievable targets. So for example, if I'm encouraging someone to increase to 210 minutes per week, I make sure that I give a couple examples on that would be this many minutes four days a week or this many minutes six days a week. I talk to them about what they're currently doing. If they are interested in achieving that 210, we talk about strategies for getting there, either adding one more day per week, adding 10 minutes on to each session that they do, thinking about people that they could engage in the exercise with them. So I try to talk through not just what I want them to do but how they might be able to achieve it and help them think through those things. And then just a takeaway from the four trials or three trials that I did, I think four, that I did discuss related to comprehensive care. So in looking at them all, some of the takeaways for me are that it takes a multidisciplinary team. Having either a nurse or an advanced practice nurse leading these clinics can be beneficial if done properly. It is important to engage primary care providers, general cardiology providers, electrophysiology. Sometimes it may require referral to a weight management center. It requires patient engagement, so patient-centered strategies, motivational interviewing, shared decision-making, and helping patients set achievable goals. And really key, in my opinion, is considering a restructured approach for comprehensive care. So being that a lot of us are in the EP world, if we are doing post-ablation appointments at three, six, and 12 months, maybe we need to restructure that to add in some more appointments or some longer appointments. I think this is where APPs come in. We are able to bill for that time. We are able to do this work. Electrophysiologists need to do ablations. I do not need to be in the ablation lab. So let us help you. I think it makes sense. I think we can do this together, but it does require more frequent follow-up, longer appointment times, and the use of clinical care pathways or decision support tools can be very beneficial. Thank you. Dr. Schreuer, thank you. I'd like to invite Dr. Ed Gerstenfeld from the University of California, San Francisco to discuss a case-based approach to atrial fibrillation ablation. Dr. Gerstenfeld. Thanks. Good morning, everyone. Thanks for your interest in guidelines. So my charge is mainly to illustrate some cases where the guideline may be helpful, and hopefully they're a little provocative as well. I do have some ARS questions, so I think this will hopefully come up. So if you don't have ARS, you can scan the QR code, and that way you can reply to the questions. So I was asked, since we didn't have a separate talk on it, to give a few highlights from our document, which was the EHRA, HRS, APHRS, LHRS document. I have to give kudos to Stelio Sayas, who was the EHRA lead and just put a ton of work into this document. I was the lead for HRS and John Coleman for APHRS, and Eduardo Saad for LHRS. And when I give that talk, this is my final slide, so I thought I'd just hit the highlights, which you've heard some already. So the main, you know, one of them was that catheter ablation should be preferred over antiarrhythmic drugs as first-line therapy. That's a new recommendation. That rhythm control is preferred therapy for presumed AF-mediated cardiomyopathy, and that ablation is preferred. Routine ultrasound guidance. Sorry, let me go back here. Routine ultrasound guidance for vascular access is preferred. PVI, as we know, remains a cornerstone, and no consistent evidence in favor of other adjunctive ablation strategies. For outcomes, reporting AF burden, as opposed to just the 30-second end point, is strongly encouraged. One of the major changes, also based on data, was reducing the blanking period from three months to eight weeks. And then, finally, in selected patients, reduce healthcare costs at same-day discharge is advisable. And again, as we've heard, I think one of the uniform recommendations from all the guidelines is that catheter ablation has been elevated to a class one indication for AFib, which I think, again, is due to a lot of data that's been collected by our colleagues over the years. So this is a first case. I have two 55-year-old, coronary disease, status post-CABG, obesity, and persistent AF. He initially was detected with paroxysmal AF, started on a DOAC, presented with shortness of breath, and his ECG in 2025 showed AF with rapid ventricular rate. His EF was down to 30 to 35% with severe left atrial enlargement. He was cardioverted, but his AF recurred about seven days later. He's on a Pixaban, Clopidogrel, Carvedilol, Glipizide, Erbisartan, Jardians, and Aldactone. Blood pressure is 142 over 68. He weighs 150 kilos, or 352 pounds, with a BMI of 47. And so we've heard a lot about this, but what's the next best step? There's no right answer here. I'm just kind of curious of what people think. So risk factor modification, we just heard a lot about. Weight loss, blood pressure control, sleep study. We've heard a lot about catheter ablation. It's a class one indication. Amnio and outpatient cardioversion. Admit for dofetilide and a cardioversion. Or option E, which is A and B, both risk factor modification, advise weight loss, and also schedule a catheter ablation. So if everyone would scan the code, go ahead and vote, and we'll see what people think. I know you're not allowed to have multiple options like A and B on the boards, but this isn't the boards. So. I don't know if I, do I have to hit forward to get the poll results? Let's see. There we go. OK, so 73% said A and B, advise some risk factor modification and schedule the ablation. 7% are anxious to go right to ablation, and then a few for AMEO and outpatient cardioversion. Again, there's not a absolute right answer, but I'm just going to give you my take. First, I do realize, because I've been criticized for this before, that he has an AF-mediated cardiomyopathy, and that's a class one indication for ablation. But the question is, and I think Naseem Maroosh criticized me for this, do you need to drop everything and do it right away, or do you have time to work on other things while you're awaiting ablation? In terms of weight loss, I think that's the biggest issue for this patient. And there are some differences in the guidelines. So ACC AHA does give it a class one recommendation to lose, as we heard, about 10% of your body mass. Doesn't really say the when in the process to do that. In the ESC guidelines, it does say weight reduction should be considered, and that is a 2A indication. So perhaps less strong, based, again, on observational data. And in our document, we kind of gave it a more general recommendation that comprehensive management of AF risk factors is recommended. Again, a class one indication, but based on observational data. And there is data on both sides of this. There's obviously data of weight loss being helpful. There's some data, at least in the short term, of weight loss not necessarily affecting outcome. But for me, as someone who does these procedures, I think we do have to realize, in addition to long term benefits to the patient for multiple reasons, there is an increased incidence of complications in multiple studies of AF ablation in patients who are obese. Twice the incidence of vascular complications, major procedural complications, prolonged hospitalization, and 30 day readmission. And so the question is, do you need to rush? I mean, we all know this patient would potentially benefit from ablation. But what I did is, I mean, I increased his COREG. I know in the US, some of us don't want to step on our cardiology colleagues toes, but I finally see their cardiologist and their blood pressure's high, and no one adjusts their meds. So I decided, let's just go up on the COREG. We talked about weight loss. I sent him back to his PCP. I'm not that familiar with lingliptin, but I guess it's a diabetic medicine that also helps with weight loss. We sent him for a sleep study, which was positive, and started on CPAP. I admitted him for duophetalide and a cardioversion, to at least while we're working on these things, get him back in sinus rhythm and prevent adverse remodeling. So his EF, after three months had recovered, back up to 55%. He had a monitor with a burden of AF of about 6%, but felt significantly better. When I saw him then at six months, his weight was down to 151 kilos, or 332 pounds. We had lost about 20 pounds, which is pretty good. But again, he's motivated, and I said, let's continue to work on the weight. We'll check in again, and maybe when you're under 300, think about an ablation. And again, I think this comes down to, you know, patients are gonna come back. They're gonna need it. But being a doc, as opposed to an ablationist, and I don't think there's necessarily a rush for these patients. And I mean, I've struggled with weight, honestly. And a lot of these patients will say, I can't exercise because of my AFib, right? But you fix their AFib, and there's just no incentive to lose the weight. I find if you have a carrot of the ablation, getting off meds, people are much more motivated to lose weight, and it's gonna be better long-term. There's also this study that I like from John Coleman, where he randomized a group of 100 patients to either immediate ablation or delayed ablation. This isn't obese patients, just in general. And he found, actually, the one-year outcomes after ablation, either way, was essentially the same, about 70% freedom from AF. But the key was, throughout that 12 months of waiting, the patients were actively managed to maintain sinus rhythm on antiarrhythmic drugs. And I think that's the key, not to just leave the patients in AF, but to get them in sinus, keep them in sinus, even with short-term MEO if needed. And then, as they're losing weight, and getting to a safer weight, and a weight that's better for their long-term prognosis, then I think about the ablation. And I just think it's a strategy I found more useful for long-term management. Second case is a 43-year-old, paroxysmal AF. At 43, he's had three prior ablations, a PVI in 2009. Then, 2014, a redo, re-isolation of the left veins, complex signals in the posterior wall, so he had roof and floor lines to isolate the back wall. Third ablation in 2019, re-isolation of left inferior, and it was, I guess, a trend at the time, this firm, you know, rotor ablation also. But basically, continued to have AF without much change on Sotolol. Was advised to have a maze surgical procedure, kind of saw me for second opinion, but on Sotolol, still having a 9% burden. I did an MRI to look for other disease, which was negative. We did genetics that were negative. But eventually, did bring him to the lab. This was after about a year. He really was still tired of his AF. This is his baseline voltage map. So you can see some signals by the right superior, some signals on the posterior wall. And the question is what to do, what's the next best step in the lab? Are you gonna re-isolate the posterior wall with RF? Re-isolate the posterior wall with PFA? Vein and martial alcohol ablation, isolate as appendage? Or go on a search for non-pulmonary vein triggers? Let me know to go ahead here. And 15 seconds, so go ahead and give your vote. Okay, so most people are going to go ahead and re-isolate the posterior walls, the next step, 27% triggers, and then some other choices. So it's interesting, this was really, I think it was only our document, because it was an ablation document that got into the weeds of how to approach these redo procedures. I think it's interesting there are only two class one indications. One is that if you do deploy linear lesions to make sure you have block across them, the other is that if a reproducible trigger is found to ablate the trigger. Obviously, other things, you know, venom martial alcohol ablation does have a role in persistent AF, but other strategies are more uncertain. So what I did is I brought him to the lab under conscious sedation. We did find, when we looked at triggers a lot, that general anesthesia tends to suppress them. Again, there's a lot of presentations about using one catheter for an AF ablation, but in this case, we put multiple catheters in, one in the SVC, there's a multipolar catheter over this area in the posterior wall that could be a trigger, and then a CS catheter. And under conscious sedation, gave him isoprol initially, 20 mics, and then came off and nothing happened. And then again, went on 20 mics, and washing off isoprol this time, you can see that he goes into AF and it's coming from the distal tip of this catheter in the SVC, and that's shown here. That actually then kind of organized and terminated, and then he kind of had this pattern again of SVC triggers, and this is where I do find PFA helpful. You know, you don't have to worry about the phrenic, I haven't seen sinus node issues with a basket catheter, and so we did use the PFA to isolate the SVC. I did then put him under GA because of the muscular contractions to isolate the SVC, and then we did, since we're there, touch up the posterior wall, no inducible AF with 30 mics of isoprol, stopped the sotolol, and at least three months, he's finally not having AF. So again, the message here is use our electrophysiology, just ablating more and more and more of the LA empirically, I think, isn't always the best solution when you have these young patients, you got to look for triggers, and I think that's an important thing. And then the last question, which again, may have, I think was mentioned, but I thought was useful for lifestyle modification, so elimination of which of the following would not be expected to reduce the burden of atrial fibrillation, alcohol, marijuana, caffeine, or obesity? And we'll take a poll there. Yeah, so excellent, so 80, more than 80 got the correct answer. A lot of my partner, Greg Marcus, has done a lot of work on this, but I find you're telling patients they got to lose weight, they got to cut out their alcohol, but you can actually give them a positive. Good news, everyone stops caffeine for AFib. Lots of data now that caffeine does not increase the incidence of AFib, so you can tell patients at least you can go ahead and have your cup of coffee and some patients appreciate that. So to summarize, again, I think risk factor modification and weight loss does need more prospective randomized data, particularly now with the use of SGLT2 inhibitors, but I think it's reasonable to consider prior to ablation for morbidly obese patients. It makes the procedure safer, and I think it's better for their long-term outcome. Delayed ablation doesn't necessarily mean worse outcome if you're maintaining the patient's and sinus rhythm on antiarrhythmic drugs, even if you're using a drug like short-term ammio. For initial ablation, PVI remains the cornerstone. For repeat ablation, look for triggers, inducible flutters, rather than just empirically, I've just seen people expanding and expanding their left atrial ablation, and mega, make electrophysiology great again rather than just empiric substrate ablation, so thank you. Thank you. So great case presentations reflecting our clinical practice. So our last speaker is Dr. Janice Cho from Mount Sinai Hospital. She's going to present the gaps in evidence and our understanding of atrial fibrillation. Thanks so much, Yangmei. Thanks everyone. I'm delighted to be here to join the group. I think this is truly being a fantastic session. I think to do due acknowledgment to my colleague, Rakesh Gopinathaner, this is actually his talk and his slide. We worked together on a guideline together, and I'm delighted to deliver this on his behalf and look forward to some of the question and answer that will come about sooner. So I think so far, we heard quite a bit in terms of our 2023 American guideline as well as the 2024 ESE guideline. Both of these have been massive steps forward, including multiple domain and considering atrial fibrillation management as a much more comprehensive practice. However, as we heard today, there are still several gaps in our understanding of atrial fibrillation. The first gap that I'd like to highlight is that there's a gap in further understanding pathophysiology and progression. And specifically, I would back this back to what Jose likely spoke about, that AFib in our guideline is now noted and emphasized as a progressive disease. However, we don't have great predictors for progression. Multiple risk scores are out there, but I think more work still needs to be done in this domain. Longitudinal studies, biomarkers, genetic data, imaging predictors, and better models are needed as one of the next steps. Another important gap to highlight is in the risk stratification models. So far, we heard greatly in terms of consideration for anticoagulating patient with atrial fibrillation. And by this, I would differentiate this from the device-detected atrial fibrillation, here focusing specifically on people who have a diagnosis of atrial fibrillation by the traditional means in terms of ECG, in terms of duration. And here, in the past, we had used a CHADS-VAS model, which had been now agreed to be too simplistic and unfortunately imperfect. It was a huge step forward when it was developed. I think more work's needed, keeping up with the contemporary practice. In our American guideline, the focus is now shifted to risk stratification by percentage, as Dr. Holt-Glahr has highlighted earlier. In the European guideline, we also heard about new ways of thinking, dropping the female in the consideration, now going toward a model of CHADS-VAS. However, additional consideration must still be integrated. This includes not only thinking about other risk models, such as Garfield, such as Atria, but also in terms of other biomarkers and other indication of increased risk. Here we've listed a couple. This includes consideration for afer burden, an issue that's separately needing attention in and of itself, consideration for fibrosis, consideration for LA remodeling, atrial myopathy. And these are all different important factors. I would also point out, both in the American and the European guideline, we now call for repeat evaluation. So there is a need to re-evaluate a patient in terms of his or her risk, both for stroke as well as for bleeding. The third gap is in the area of device-detected a-fib. I think this is an area that many of us have puzzled over and continue to crave more data. Atrial hybrid episode, also known as subclinical atrial fibrillation, is an area that's being expanded with the advent of the NOAD study as well as the Artesia study. And these have informed some of the recommendations, both in the American and the European guideline. I think what we also recognize coming out of these data are twofold. Number one, there's both a consideration for the population itself, that subclinical atrial fibrillation is inherently a slightly different population than those with clinical atrial fibrillation. And we saw in the data presented for NOAA and for Artesia that the percentage stroke risk by their patient comorbidity were much lower than what we are used to seeing for the population in clinical a-f. And by the comorbidity and by the patient substrate, I'm referring to, again, to familiar models such as CHADS-VAS, that for a given CHADS-VAS, the percentage anticipated in the clinical a-f population differ from the percentage that we saw in the subclinical a-f population. Furthermore, one of the sub-study from the subclinical analysis demonstrated that the sweet spot for anti-coagulation for subclinical a-f with device-detected a-f may be closer to the marker CHADS-VAS of four rather than a two that we had used in clinical a-f. The next gap in evidence in the area of early rhythm control, I think today's talks beautifully highlighted some of these area. For example, the EASE-AF net study, highlighted by our European colleague, has been a landmark study that really brought our attention to early rhythm control as a practice. And I think, as Dr. Gersenfield beautifully explained in his case study, that this actually included both rhythm control by way of medication or cardioversion in a combination fashion, as well as ablation. So I think it's important to consider two folds. Number one, when we talk about early rhythm control, which is also a key message in our 2023 American guideline, we are trying to move toward early, earlier rhythm control. And so far, by early, people often ask, how early? What are we talking about? Is it within 48 hours? Which we know from data is not necessarily the case. Is it within three days, within five days, within one month? The data so far, as we think about early, is within the first 12 months. This may, of course, change, as this is indeed an area that we highlight as a gap. And in terms of how to do it, so far, both ablation as well as a facilitated medication approach with cardioversion are acceptable options. And we definitely look forward to more data in this area. Gap number five is in the area of lifestyle and risk factor management. And I think Megan beautifully reviewed this area for us. And specifically for this, there are several issues there, quite outstanding, both in terms of weight loss. How do we think about weight loss and its efficacy in terms of what modality of weight loss is being used as an intervention? Second, a really important thing in this area is the area of implementation science. And I think several of the behavioral challenges that's being highlighted in today's session definitely speak to that. The next gap is thinking of a left at appendage, a left atrial appendage occlusion. I would say that both in our guideline, the European guideline, there's much more discussion on this compared to the prior iterations. I think this also needs to be balanced in terms of potential new ways of anti-coagulating factor XI inhibitors, as we saw in some of the late breakers over the recent years. There are some positive studies, but also some that need to further explore. But very importantly, in addition to this potentially being an option, be that as adjunct or to supplement anti-coagulation, for example, as being studied in the Layouts 4, there's also the question in terms of what to do with these patients long term. One specific example in this area that very much needs more evidence is the question of what to do in terms of cardioversion in patients who already have a left appendage occlusion device. And pertinent to this is the consideration for whether these people need to be imaged. For example, a transit fossil atrial cardiogram is one that's frequently adopted across the globe to look for two things, whether there's device-related thrombus that could be sitting in a left atrial appendage occlusion device, or a persistent leak. Or in some cases, a leak may actually open up as well in the surgical cases. So there are several nuances of consideration that will guide our decision in this direction as well. The next gap is in terms of thinking diversity and health equity. It is well known that atrial fibrillation prevalence differ by different races. There are also access issue in terms of access to anti-coagulation, prescription tendency. Much is needed to be understood in here. And also specifically, zooming out in terms of the contact of a clinical study, this speaks to the need for increasing generalizability in many of the clinical trials that are being performed for atrial fibrillation. Precision medicine and genetic is another area that needs more research. Genetic risks are well understood, but there are also additional models and also additional association. They are still being teased out. In our American guideline, we describe for patients who are young, less than age 40, genetic testing may be considered to look for potential association. The special populations were an additional consideration. Already today, we heard about those with morbid obesity, a very challenging population in terms of pharmacology, in terms of risk profile, vascular complication. There are also other populations such as patients with advanced kidney disease, and also in the situation of atrial fibrillation after acute hospitalization or in the setting of acute illness. There are multiple population where we have some scientific statement or guidance to provide, but I think further targeted study are still needed. Lastly, I think this is an issue of great conundrum, and I think hopefully by staying far upstream and being able to get to patients earlier, early in the stage of the disease progression, earlier in terms of risk factor modification and lifestyle intervention, and in terms of rhythm control, we will hopefully see less and less of patients with persistent atrial fibrillation. For these patients, both in terms of symptom, symptom determination by trial cardioversion is important, but also in terms of long-term quality of life. And tied with that is the chicken and egg question of atrial fibrillation and heart failure. We heard about an excellent case in terms of tachycardia and arrhythmia-related cardiomyopathy, and also the potential role for atrial fibrillation in improving mortality in patient with atrial fibrillation. Additional gaps also include long-term monitoring, what is the ideal frequency and modality for atrial fibrillation surveillance, especially in the post-ablation period, how frequent, how continuous, and how consumer-facing and how patient-centric. Many of these, at least in today's environment, standing on U.S. grounds here, that it very much lacks a built-in reimbursement model from a very practical side in terms of how these can be implemented. I will conclude by saying that there are several gaps that exist in our understanding of atrial fibrillation, although we have come a very long way. There are targeted studies that are needed to address these specific areas and gaps of knowledge, so to further advance how we can provide better atrial fibrillation care. I will pause here, and I will join the panel here and look for your questions. We don't have much time. Maybe give answer one audience question. What is your practice for checking surgical left atrial appendage closure post-operation? We assume they were, you know, all closed, but not always the case. So do you stop OAC if the appendage is completely closed? Well, in the guidelines, in the 2023 guidelines, the problem with appendage closure, the studies that show benefit in stroke prevention, 70% of the patients were kept on anticoagulation. So the problem with this issue of surgical closure, so I'm talking about surgical closure, is that we don't know what to do if the patient is not taking anticoagulation because the studies didn't do that. I don't know if anybody wants to comment, but, and there's a possibility with surgical closure, actually, that you can have little larger holes, larger gaps that could be very thrombogenic. So essentially, you will have to look at the quality of your closure if you want to stop anticoagulation. I feel strongly about that. But the fact is that the data is the combination of closure plus anticoagulation. And I agree, so the last three kept people on anticoagulation. I think Jeff Healy is planning already the last four, which will answer that question of appendage closure without anticoagulation. But I agree with Jose that I do, because some patients, you know, I went through the surgery, I really want to get off, their risk overall maybe is lower. So I'll do at least one, either a CTA or TEE, just to see if it's closed, because if it's not closed, which happens, then, you know, you need to leave them on anticoagulation. If it is closed, I tell them it's safest to stay on anticoagulation. But if patients are motivated and really want to get off, their risk is low, then sometimes they take that option. I think we'll conclude this session. Thank you all. Can I make a comment real quick? Oh, please. One comment real quick before everybody. I'd like a couple observation between the Europeans and the American guideline that we didn't have a chance to talk about. You can see that the Europeans recommend class one recommendation for antiarrhythmic drugs and ablation, whereas we recommended ablation as a class one and drugs as a second line. They did too. I just want to say that the reason for that, there is a methodology when we do guidelines. I'm not a stickler to methodology, those who work with me. I stick to the methodology because the process drives what we do. And basically, the way the guidelines are created, we sit down with a writing committee of over 20 people and analyze the data. What is the data telling you? And based on the data, we assess risk versus benefit or relative benefit of one interventions versus the other. Okay? And the fact is, in every study that we included as a recommendation for ablation as a class one, randomized studies, many of them that I pointed at, ablation is superior to pharmacological therapy. That's the bottom line. That's why we had to pick one over the other. Of course, we do agree that the patients have a saying, patient doesn't want ablation, then you can do drugs. The other thing is, drugs are not entirely safe. You know, you can have, and ablation has gotten safer over the years, the risk of catastrophic complications are very, very low. You can have catastrophic complications with drugs like torsades de pointes. There's cases of sudden death in flaconide during exercise, for example. Those are catastrophic rare events. So I just wanted to point that, highlight differences between the guidelines. And that's the reason, the methodology drove us to write those recommendations. I just wanted to point that, because that was kind of the only difference. Yeah, I just want to very briefly reply to that by saying, I agree. I think the methodology is fairly similar. One crucial difference is there are subtle differences in how we define the target patient population. So if I speak, for example, about paroxysmal, symptomatic, drug-naive patients only, then I would argue, yes, there is data obviously supporting first-line catheter ablation, that's why we made it a class one recommendation, but the vast majority of data you just referred to stating that ablation is superior to drugs is not in drug-naive patients, it's in patients already having failed drug treatment. So for the very specific patient population that we mentioned in our pathway, we felt it was appropriate. But I completely agree with the observation you make, that drugs are not without risk, and the evolution we are seeing most likely will continue in that direction, favoring catheter ablation in more and more indications. Thank you all for attending. This won't be your last chance to interact with folks. So we have the 10 o'clock roundtable discussion, so if you have questions, please go to the exhibit hall roundtable to continue your questions and discussions.

Heart Rhythm 2025

atrial fibrillation

American Heart Rhythm Society

guidelines

lifestyle interventions

stroke risk assessment

European Society of Cardiology

patient-centered approach

comorbidities

catheter ablation

risk factor management

genetic research