Well, hi, welcome everybody to HRS online town hall on risk factor modification and stroke prevention for atrial fibrillation. My name is Peter Noseworthy. I'm the division chair for cardiac electrophysiology at Mayo Clinic in Rochester, Minnesota. And we'll be speaking with two of the authors from our most recent guidelines on two key pillars on the treatment of atrial fibrillation. I'm thrilled to be joined by Rakesh Gopinathan Nair and Janice Chu from Mount Sinai. And Rakesh is from Kansas City Heart Rhythm Institute. A note, Janice and I spoke last night and her voice was crystal clear, like a bell, and she woke up with a bit of a hoarse voice, but I really am very thankful that you're sticking it out and you're joining us today. And don't worry, we can understand you just fine. So the way this will be is we're going to start with a brief overview of two of the topics from each of our speakers. Janice is going to talk about lifestyle modification, and then Rakesh will talk about stroke prevention, and then I'll lead us in an interactive Q&A. If you have questions for our speakers, please put them in the Q&A part of the chat. I'll be able to see those, and then I'll introduce them into our conversation. So now I think what I'll do is I'll ask each of our speakers to introduce themselves. Maybe Janice, I'll start with you and then go to Rakesh. Thank you. Thank you, Peter. So hi, everyone. Good evening. I'm glad to be here. Sorry about my voice. It may be a little bit hard to understand, but please feel free to send in any questions and I will be able to view those as well. I'm Janice Chu. I'm a cardiac electrophysiologist in New York. I'm affiliated with Mount Sinai, with Icahn School of Medicine, Mount Sinai. We'll be speaking more very soon. Let me turn the stage over to my colleague here, Rakesh. Hi. Good evening, everyone. My name is Rakesh Gopinathaner. I'm the cardiac EP lab director at the Kansas City Heart Rhythm Institute, and I was honored to be part of the guideline committee and look forward to discussing some of the relevant topics centering on anticoagulation and lifestyle modification with you. Yeah. And Rakesh, your voice is a little bit faint, so I can hear you just fine, but it's a little bit quiet. So if you could be closer to the mic or switch it over, I think it would be beneficial. So Janice, maybe now I'll hand it to you to talk a little bit about what's new, what's interesting, and what are the take-home points as they pertain to lifestyle modification for atrial fibrillation management and prevention. That's fantastic. Thanks so much, Peter. Really delighted to be here with everyone. I know that many of you might also have had a chance to join one of the webinars earlier this fall related to lifestyle modification, so you had a pretty extensive overview or some of the recommendation. I want to spend the next couple of minutes to really just very briefly highlight some of the key points to stimulate some of the discussion. Today's format's really meant to be quite casual and very much conversational. So this first aspect pertains to lifestyle risk factor modification and atrial fibrillation. So for one, I want to frame this as an important paradigm shift. When you compare the 2023 guideline to the prior 2014 or the 2019 update, you will notice that lifestyle risk factor modification is now a key component of atrial fibrillation management. This is a major update from the prior guideline. Specifically, in this guideline, we have prescriptive recommendations for primary and secondary prevention of atrial fibrillation. I want to share with everyone here a key take-home point that's one of the top 10 take-home points for the guideline. That is, this guideline recognizes lifestyle and risk factor modification as a pillar of AFib management to prevent onset, progression, and adverse outcomes. The guideline emphasizes risk factor management throughout the disease continuum and offers more prescriptive recommendations accordingly, including management of obesity, weight loss, physical activity, smoking cessation, alcohol moderation, hypertension, and other comorbidities. So what do we mean by this paradigm shift? So whereas previously, atrial fibrillation management focused more just on stroke risk assessment and symptom management with rate and rhythm control, we now have as a specific pillar optimization of all modifiable risk factors. This rests on shared decision-making, engaging the patient, and really focused on treating risk factor and enacting behavioral change. In this guideline, we have a helpful acronym that I think will be vital for everyone's clinical practice, and this is the head-to-toe acronym, standing for thinking about heart failure, exercise, arterial hypertension, diabetes, tobacco, obesity, ethanol, and sleep. Let's dive in a little bit more. As a primary prevention recommendation, we now have a class-run recommendation that patient at increased risk for atrial fibrillation should receive comprehensive guideline-directed lifestyle risk factor modification for AFib, targeting all the different aspects that we have mentioned. For secondary prevention, overarching is a recommendation for comprehensive care. And I think that as we read the guideline from this document, I want to emphasize to the group one of the key aspects of guideline development. And that is what we call the PICOT format, which is being very specific in what patient is this guideline being recommended for. What is the intervention? What is the expected outcome that we expect of the therapy to be delivered? So in this case, for example, patient with atrial fibrillation, now we're talking about patients who already have atrial fibrillation, should receive comprehensive care addressing lifestyle risk factor modification. So to improve AFib symptoms, risk of stroke, and other associated medical condition to reduce AFib burden, progression, and consequences. The specific medical comorbidity highlighted in the guideline include hypertension, diabetes, and heart failure. For the purpose of this guideline and where we stand today, the sentiment here is a recommendation for guideline-directed medical therapy, where we further leverage the detailed extensive recommendation directed at a targeted medical comorbidity management with dedicated hypertension guideline, dedicated diabetes guideline, and dedicated heart failure guideline. So to ensure that the comorbidity management of patients with atrial fibrillation are optimized. With that, I want to pivot a little bit more to some of the lifestyle modification that I think may be quite new to the audience and very interesting opportunity for us to further engage with the patient. One and center of this is a recommendation for weight loss in individuals who are overweight or obese, specifically in patients with atrial fibrillation who are overweight or obese with body mass index greater than 27. Weight loss is recommended with an ideal target of at least 10% weight loss. It's crucial to reduce AFib symptom, burden, recurrence, and progression. And these are key components, symptom, burden, recurrence, and progression. The data for here came from several important studies to highlight the randomized clinical that comprehensive management with weight loss included a population that had body mass index of greater than 27. And that is the population targeted. Further follow-up data demonstrated that at least 10% weight loss demonstrated most significant impact in reduction of AFib recurrence, that is in freedom from AFib. Therefore, the recommendation rests on that specifically being prescriptive for BMI due to dry BMI less than 27 or with a weight loss of more than 10%. Physical fitness is another area that's very important in patient with atrial fibrillation. A class-run recommendation wherein individuals with atrial fibrillation, moderate to vigorous exercise training to a target of 210 minutes per week is recommended to reduce atrial fibrillation symptom and burden, to increase maintenance of sinus rhythm, and to increase functional capacity and improve quality of life. This rests on a collection of multiple observational study, and most recently with a randomized clinical trial led by the Australian group, the ACTIV-AFib study, wherein randomization with moderate to vigorous exercise training up to 210 minutes per week over a six-month period resulted in improved symptom and improved AFib burden. Two other areas to highlight include smoking cessation, where inpatient with a history of atrial fibrillation who smokes cigarettes should be strongly advised to quit smoking and should receive guideline-directed medical therapy for tobacco cessation to mitigate increased risk of atrial fibrillation-related cardiovascular complication and other adverse outcomes. This is based on observational and population data. So here you see the level of evidence is a non-randomized data. For alcohol consumption, this is an area that's of great interest to many, and this is for patients with atrial fibrillation seeking a rhythm control strategy that is to really to promote maintenance and sinus rhythm. Patients should minimize or eliminate alcohol consumption to reduce atrial fibrillation recurrence and burden. This is an area where much discussion has come about in terms of whether or not people are able to completely eliminate, or is there a more pragmatic halfway? Abstinence is still highly promoted from a pragmatic standpoint, concurrent with the comprehensive protocol initially studied. The threshold for the comprehensive protocol was set as three drinks or less per week. So that's an alternative, although for those seeking rhythm control strategy, complete elimination or abstinence may be even more favorable. The next two that I want to address are sleep and caffeine consumption. I think for many years now, there's an increased awareness of the potential association of sleep disorder and atrial fibrillation. In fact, the prevalence of sleep disorder in patients with atrial fibrillation is quite high. Here we have a 2B recommendation. Among patients with atrial fibrillation, it may be reasonable to stream from obstructive sleep apnea, given its high prevalence in patients with atrial fibrillation. Although the road of treatment for sleep disorder breathing to maintain sinus rhythm is uncertain as an intervention. Lastly, for caffeine consumption, for patients with atrial fibrillation, recommendation for caffeine abstinence to prevent AFib episode is of no benefit. It's no longer a recommendation that really needs to be enforced. It's a recommendation that we sometimes hear being practiced, but it's not a recommendation that needs to be promoted. In fact, abstinence is typically of no benefit for patients with atrial fibrillation, except in those who have specific trigger as caffeine. So for the general population, there is not a need to withhold for caffeine. So this feeds nicely into one of the overarching message from the guideline, where we emphasize AFib as a continuum of disease that spans from being at risk for atrial fibrillation to having pre-atrial fibrillation with evidence of structural electrical finding predisposing patients' atrial fibrillation to clinical atrial fibrillation, and then at stage four to permanent, which is a choice that's made between the patient and the clinician. And I emphasize here, you see the treatment for modifiable risk factor and comorbidity as a continuum that spans the entire cycle. I will summarize our overall take, and as a very pragmatic approach, that this is very much a paradigm shift. As we think about atrial fibrillation as a continuum, and we emphasize lifestyle and risk factor modification through this entire continuum as a new pillar, as a novel paradigm shift, what I think is particularly important now is a new emphasis on patient engagement, where this really becomes a partnership more than ever to really enact the lifestyle risk factor modification. I will pause here and turn this over to my colleague, Rakesh, for the next part of the overview before we engage in our discussions. Thank you, Janice, for that fantastic overview of lifestyle modification in our current guidelines. So I'm going to switch gears here and talk about how to prevent stroke in atrial fibrillation and anticoagulation, also alternatives to anticoagulation. So one of the biggest changes in the 2023 guidelines compared to before is that we are no longer prescribing one risk score. In the prior guidelines, in the update, it was CHATS-2 initially and CHATS-2-VASC. And so the current guideline really emphasizes the annual percentage stroke risk rather than sticking to one particular risk score. It also recognizes that there are other risk scores that can provide additional information to fine tune or better understand the risk profile of the patient. So the guideline clearly says that if there is a 2 percent or increased annual risk of stroke, those are the patients who should be considered for anticoagulation. It also says that if your intermediate stroke, such as, you know, one of the risk factors is just being female or they have like a CHATS-2-VASC or a 1, other risk factors should be considered and shared decision making done in order to better understand and inform whether those patients would benefit from anticoagulation. These include other risk scores include Garfield AF, Atria. These are, they look at different factors that emphasizes bleeding as well as renal disease and some of the things that the CHATS-2-VASC score do not have. And these can, along with other patient factors, could be considered for determining the need for anticoagulation. So that in that particular aspect, the guideline is actually diversifying the risk scoring paradigm in this case. The other, one of the other things that is new with this guideline is that left atrial appendage occlusion receives a class 2A recommendation compared to 2B in the 2019 update. And this is in light of the additive safety and efficacy data that has come across in the past 2 to 3 years. So that would be, we'll go over that as well. So in general, if you have a, if you're a female who has a CHATS-2-VASC or 3 or equivalent at least 2% or more yearly risk or a male with a CHATS-2-VASC or 2 or have a 2% or more yearly risk, anticoagulation should be considered. And the guidelines clearly say that bleeding risk scores should only be used to inform and identify bleeding problems and treat them, but it should not be used as a, you know, if the patient needs anticoagulation, you have to anticoagulate and then the bleeding risk score should not be used to dissuade you from anticoagulation in that case. So there are the other factors in terms of, you know, in patients who does not have valvular AF, which are patients with mechanical heart valves or rheumatic moderate or severe mitral stenosis, and they should preferably receive a direct or anticoagulant compared to warfarin. It is also important to assess the factors that contribute to a higher risk of bleeding, such as previous bleeding or use of drugs that could increase bleeding, to mitigate those factors as much as possible. And as I mentioned, the intermediate risk patient should be further evaluated using other risk scoring, risk scores that are available. So, in terms of, if you look at recommendations in general, in patients who are, have AFib and at risk for stroke, the guidelines recommend that the re-evaluation and need for the choice of stroke risk reduction therapy at periodic intervals should be done. There are modifiable risk factors and their stroke risk can come down, so a periodic evaluation is recommended. What are the other recommendations for antithrombotic therapy? Let's talk about what is not acceptable. In patients with AF who are candidates for anticoagulation and without an indication for antiplatelet therapy, aspirin alone or in combination with clopidogrel as an alternative to anticoagulation is not recommended. Anticoagulation or oral anticoagulation has been shown to be better than the combination of these two. In patients with AFib but without any risk factors, meaning low chance to vascular, aspirin monotherapy for prevention of thromboembolic events is not of benefit. Those are the two that should not do things in there. What about the intermediate risk patients? In this case, the guideline gives a two-way recommendation that it is reasonable to anticoagulate patients with a stroke risk of greater than 1% but less than 2% per year. But again, shared decision-making or individualized decision-making should be done in those cases. In terms of managing anticoagulation, the guidelines clearly emphasize the importance of dealing with drug-drug interactions, especially associated with DOACs, including CYP3A4 or B-glycoprotein inhibitors. In warfarin, again, target INRs between 2 to 3. The guideline acknowledges that there is substantial usage of DOACs, but at times, non-evidence-based doses of DOACs are used. They recommend against using the non-recommended doses to avoid harm and increase risk for stroke in those cases. One of the important topics that has created a lot of controversy in the past few years has been so-called subclinical atrial fibrillation or SCAF or device-detected atrial fibrillation. Before I get into that, what about cryptogenic stroke? In those cases, the guidelines recommend that some form of monitoring should be done in those patients to identify atrial fibrillation. Initial cardiac monitoring, perhaps sometimes followed by an implantable loop record for long-term monitoring is recommended. In terms of subclinical atrial fibrillation, anticoagulation is recommended for patients with a longer duration, at least 24 hours or more of atrial fibrillation, with a chance to have a vascular greater than or equal to 2 or an equivalent stroke risk. It is reasonable to start anticoagulation in those patients as we lack solid outcome data in these situations. Whereas those with 5 minutes to 24 hours, the evidence is not that great. It is given a 2B recommendation, but it is reasonable to initiate anticoagulation. Those who have short episodes, less than 5 minutes of atrial fibrillation that is detected in a pacemaker or loop recorder does not require anticoagulation in this case. Switching gears to just talk about what are the alternatives for anticoagulation in those who cannot take anticoagulation. Left atrial appendage closure has emerged as a very promising therapy in those who cannot tolerate long-term anticoagulation. In the current guidelines, it has been given a 2A recommendation in patients with moderate risk of score, chance to have a score greater than or equal to 2, and a contraindication to long-term oral anticoagulation due to a non-reversible cause. There are examples that have been given for non-reversible causes. Percutaneous left atrial appendage occlusion is reasonable. The guidelines also mention that in patients with atrial fibrillation and a moderate to high-risk stroke and very high risk of major bleeding on oral anticoagulation, LAA occlusion can be a reasonable alternative oral anticoagulation based on patient preference. However, one has to carefully consider procedural risk and understanding that evidence for oral anticoagulation is more extensive. One last thing I would mention is about patients who get surgical AF, surgical appendage closure, especially using Atriclip or ligation on those. In those situations, anticoagulation cessation is not recommended as outcome data is lacking, because many of the large randomized trials in these cases continued oral anticoagulation despite the appendage being closed. The guidelines recommend that in those patients who undergo cardiac surgery and have AF, appendage closure is recommended to reduce the long-term risk. So those are some of the highlights for the anticoagulation thromboembolic therapy. There are some other things that we can discuss in questions, including anticoagulation cessation, perioperative management, etc. So I will stop here and turn it back over to Dr. Noswati. Great. Thank you both for those great summaries. I had said that we would maybe go back and forth between you, but you're both experts on both of these aspects of the guidelines. So maybe what I'll do is I'll pose questions and I'll pose them to one of you, but if the other has an additional point to add, we'll keep it free flowing. You can feel free to comment on any of the questions that are asked. Janice, I'll start with you. There's a lot of recommendations here, and you could imagine going through it with a patient as a laundry list in a discussion, a checklist. Or the other extreme would be to set up a multidisciplinary clinic that has expertise in each of these things and can provide comprehensive lifestyle modification and metabolic care, like has been done in some of these trials. What are you doing in your practice? What do you think is effective? What is practical in our health care system? And I'd actually like to hear what both of you are doing. So Janice, I'll start with you. Peter, thank you. That's such an excellent question. I think many people in the audience are probably thinking the same thing. Now that we have so strongly recommended risk factor and lifestyle modification, how can that be accomplished? This is not previously part of the paradigm of our clinical care. I think for me, the bottom line is, and I'll state a couple of things, for me, the bottom line is this has got to be individualized experience. And this is an individualized experience both for the patient as well actually for the practice setting. So we know many of the fundamental studies that brought so much science to this area came from our colleagues in Australia. And the practice environment may be different in the United States and certainly may be further different in other areas globally. The hope is the recommendation apply to all these people and that we are able to bring forward the risk factor modification for all patients with atrial fibrillation globally. But recognizing that a practice environment may differ, I think the fundamental principle number one is the connection with the patient. I think more than anything else, when I think of this with patient engagement, part of this is actually the physician counseling and a bit of a trust issue. Oftentimes, I think of this, I think this is kind of stepping back just in terms of personal practice. I see a lot of these things very similar to the way that we had gone through many years ago with smoking cessation. Where the physician who's primarily caring for the disease condition is a very powerful advocate for the patient, but also someone that the patient really turns to for knowledge and for next step and guidance. It may be that a specific expert in atrial fibrillation like us, the cardiac electrophysiologist, may not have all the time to deal with every single component of the lifestyle risk factor modification. But I do think that it deserves a conversation. I think even a brief discussion, a brief physician directive, physician-led counseling by the specialist, I think can go a very long way. And I personally incorporate that in my practice. Depending on patient-specific environment, even in an urban area like mine, some people may not necessarily have access or the time to travel to all the different specialists. And this is where things get really individualized, where sometimes they relied on a few providers to really help address all of the many risk factors. Or some other patients actually strongly prefer being referred to different specialists, and that's what motivates them to be able to take the next step. So I think this is a complex question, but in my mind, the most important aspects are individualization to the patient and then the establishment of the relationship with the patient and the physician counseling component to really drive forth the care. Yeah, that's great. It seems like an opportunity that we don't want to miss, especially as a trusted professional. It's easy in our practice to say, you need an ablation. You don't need an ablation and make short visits, but that really is a missed opportunity. Prakash, do you want to comment on how you operate? I completely agree with Janice. I think we love integrated care, multidisciplinary care, but again, our health system at its core is point of care. And there are several barriers to how healthcare delivery is done in the US that prevents a particular patient to get referred to multiple specialists to get that kind of coordinated care. So I think a point of care counseling is so important, and I think if anything, I think weight loss is plenty of data, and I think there could be roles for artificial intelligence and apps. And there are so many technological advances that could help track how they're doing, motivate the patient, and at the same time provide data to the physician. I think in going forward, hopefully those methods can be used to improve the lifestyle and sweat modification in this patient population. Yeah, that's great. I do think that a technological solution might help. We've tried a bunch of things at Mayo over the years. I've been at Mayo for about 10 years, and we've had dieticians that we were working with, but it wasn't quite enough patients for the dieticians. We've tried to bring in, do shared visits where we got a whole bunch of patients together to get sort of the same teaching to find some economies of scale. But it was hard to do that. It's hard to staff a clinic for maybe five or six patients in a day, or two or three patients in a day who might need these kind of detailed recommendations. And the temptation to send them from specialist to specialist all around the institution is also probably not in their best interest. So some way to consolidate this at the point of care, as you both said, is key. I find one thing about the guidelines very helpful is that they're so prescriptive and precise. The fact that you said BMI of 27, and you said 10%. Now, I'm sure there's some false precision there, but how did you choose those numbers? Is there an inflection point, or what is it in the inclusion criteria from trials, or what is it that made you choose those values? I think that's a great point. And I think, you know, Rakesh, great for you to chime into if you want. I will show this as a quick example. I think, you know, this, for example, actually, let me see if we can make this a little bit bigger from current slide. There we go. So, for example, this is part of where the 10% came from. Okay. So, to Peter's point, I would just use this as an illustrative, as an example for where we're more prescriptive. So this, for example, came from a study. This was a legacy study where the figure that I put up here, that graphically demonstrated stratification of those with weight loss greater than 10%, really having more significant benefit of ablation-free, drug-free, aid for freedom versus those without achieving the 10%. So I think, you know, using this as an illustration, I think, you know, broadly, Peter, I would say that, yes, indeed, our guideline very much tried to be prescriptive, because so often people say, okay, we're going to go loose way, but what's the target? Is there a target? We don't always have target because we don't always have data, but where possible, if we have the specific data to substantiate, you know, the specific treatment outcome in the PCOLT format that we write the recommendation, then we will want to try to be as prescriptive as possible. And this was an example of how we got to the 10%, specifically for the benefit that we're looking for with the treatment strategy that we recommend. Great. Prakash, anything to add to that, or? It's, you know, I think everybody's patient is different. I mean, I think it's a good sort of guidance point to, you know, for most people, but then there are people who, that may not work. And I think there is some good data on bariatric surgery and improving AF outcomes. And I think, I mean, we do work closely in our institution with our bariatric surgery folks to help these people, and several have had good outcomes secondary to that. And so I think as a starting point, that's great. But then, you know, there are particular people, there are patients who have comorbidities, and as such, for them, it's difficult to accomplish that kind of weight loss with lifestyle and exercise and all that. So I think, again, it's a comprehensive care paradigm. And I think that other factors should be considered as well. I mean, now it's possible for people to have quite traumatic weight loss, much more than 10% with pharmacologic agents, bariatric surgery. So I understand that maybe that's a reasonable goal for most patients, but if they are significantly obese, would you make an effort to drive them down with more traumatic weight loss? I mean, I was going to ask both of you about that. I mean, what has been your experience with the weight loss drugs, and how is that playing a role in, or currently as well as in the future regarding how we manage those patients? Yeah, I'll let Peter go first. I think that's an interesting question that we're still thinking about, Peter, and then I certainly could chime in as well. Yeah, we're not prescribing them in our clinic, but we're certainly seeing more and more patients on these agents. And in general, we're seeing follow-on benefits outside of weight loss in many cases. We are creating a system to train our nurse practitioners on the initiation and titration of these medications. They're working with our metabolic clinic to sort of onboard and learn about that. So that's a piece of our clinic that we're looking forward to incorporating over the coming months. But right now we're not initiating them in our clinic. How about you, Janice? Yeah, I'm personally not initiating those, but I share your observation that in my practice, I see more and more patients being on it, being started by other providers, being started by a primary care provider, or potentially endocrinologists or general cardiologists. Quite interesting. I think the one thing that I wonder about, and this is, again, as we talk about all of these, the recommendation is based on science, but we need more science, more evidence. One clinical observation is many patients on the weight loss drugs often become dehydrated. They are frequently orthostatic. And this is, again, an observation, not a guideline for the audience. This is purely an observation that sometimes you wonder if some of the fluid shift or the dehydration component, whether there's something more going on. And it's not clear to me whether or not this would be a direct one-to-one correlation, in terms of a specific impact on atrial fibrillation. Because I think these medication can have impacts. They are so meaningful, so multifactorial. So I would be keen to learn more about how this will play out. Yeah, I think we'll probably learn more as time goes on. There's a talk about treating obstructive sleep apnea and screening for it. In my practice, there are also patients who don't have sleep apnea, but have very poor sleep. And to me, the poor sleep in and of itself seems like a risk factor. And I try to teach about sleep hygiene and things like that. But I wonder, you've looked through the data. Are there data for sleep quality independent of obstructive sleep apnea? Or do you think it's all about the physiologic perturbation, high adrenergic tone, sleep apnea, as well as the hypoxia that drives it? I don't know. I've always sort of been curious about that. I don't know if you've come across data on that. I'm not sure about the latest on that. That was a left-field question, more of a curiosity for myself. But the other thing is, the recommendations for alcohol, eliminate if possible. What's the language that you're using? If somebody has one or two drinks a week, what are you telling them? Do you want to drive it to zero? Previously, as a profession, we've been fairly permissive. And I feel like the pendulum is swinging against alcohol. And the data are much stronger that it can be a powerful provoking factor for atrial fibrillation. So how are you talking about it with your patients? Janice? Well, I think for me, I tend to be pretty frank with patients. I think part of it is actually sharing the data, giving them the guidance, but ultimately realizing that they're part of the partnership. So I'm very respectful. I do highlight for them that in patients who are really seeking to maintain sinus rhythm, abstinence or driving the dose as low as possible, it's going to be beneficial to them. Sometimes you have patients who listen to this and say, well, doc, I understand you. I see where you're coming from, but I just can't. And you try to help them along the way to go for as low as they understand. And it's a personal choice, just as with many other things, it becomes almost a shared decision making, as you were thinking, Peter, that some people make the decision that despite their inclination to want to maintain sinus rhythm, that they have lifestyle that they want to maintain as well, and then it ends up being trying to help them achieve a happy medium. There's no clear medium, but it's a shared decision making process. From the pragmatic standpoint, it's certainly I think as low as possible, but for people who are excessive binge shrinkers, the very first step is at least cutting it down to below three. And then that's partly because some of the more comprehensive work that the Australian group had done had used three as a threshold. So there's a little bit of that to go by. And I think the lower probably the better. But I think being able to give people some incremental guidance sometimes can be helpful in making the behavioral change less daunting. Good advice. I just wanted to not add to the alcohol part. I agree with what Janice said, but I also want to put in a plug in saying that coffee is okay. Yes. So the guidelines also say that there are no significant adverse effects with caffeine consumption and atrial fibrillation. So yes, if you switch from alcohol to coffee, and it should be okay. Great. I think we could pivot now to talk a little bit about the anti-coagulation and stroke prevention guidelines. So there's a couple sort of idiosyncrasies or unusual cases that come up a lot in practice. The questions I get a lot. So Rakesh, in patients with very high BMIs, how are you dosing DOACs? And what about patients with gastric bypass surgery? So it's a very interesting question. I think in terms of the very high BMI, we have limited information, but like post-hoc analysis of some of the DOAC, big DOAC trials, looked at the subgroup again. Different trials differed a little bit in terms of how they defined as morbid obesity, but they found that those particular subgroups did not have a significantly higher risk of stroke with the current dosing. So it's a challenge, but I think based on the trial data, it seems like that the prescribed doses should be okay for the patients with large BMI. And so Peter, sorry, can you go to the second part of the question? A gastric bypass. So I think in that particular situation, I think a couple of interaction issues come up, and there is sometimes there could be malabsorption, there could be P-glycoprotein deficiency issues, and that could impact some of the, because almost all the DOACs are metabolized through the liver, and some have renal excretion as well, and I think typically, you know, there is no clear evidence for guidance based on, you know, factor 10A levels, although that's the only way you can kind of understand how much is going on, but I think I personally have just continued the way the guidelines are prescribed, or the package inserts are prescribed, the dosing for the patient in those cases, again, unless there is substantial issues with absorption or, you know, other significant drug interaction that are associated with those patients. Great. Jess, anything to add to that, or? I agree with, I actually agree with Rakesh's approach. Not much to add. I think in the interest of time, happy to. I'll remind the participants that if you have questions, please put them in the Q&A. I'll be sure to bring those up. Rakesh, you did mention, of course, that we're not using the DOACs in patients with mechanical valves or significant rheumatic mitral stenosis, but are there other populations where you would still favor Warfarin, and which of your patients are still on Warfarin? I mean, obviously, you know, they, in the post-surgical patient with a bioprosthetic valve or something, I mean, there is some surgical recommendation. They typically tend to prefer Warfarin in those cases, and obviously, if you have an additional risk factor, such as a clotting disorder, or, you know, they also frequently tend to be more on Warfarin and underlying hereditary conditions, and I think those are some of the scenarios. Obviously, you know, mechanical valves, of course, they need to be on it, and in general, you know, for the vast majority of the people, DOACs is what's recommended, but again, you know, one also has to consider that a good proportion of patients have substantial challenges with affording them, and so there is some drop-off that is noted, and people stopping it, but again, hopefully, several of them will become generic here soon, and that could potentially alleviate those concerns. Yeah. Do you have any other special cases? What about, like, dialysis in patients with renal failure? I mean, you know, there are a couple of scenarios, like apixiban is currently the agent that is preferred in those situations, and then the roveroxaban is not, and dabigatran also is not recommended in those scenarios, so I think the, although one should also say that the indication for apixiban was not based on a large randomized trial, but a lot of it was based on pharmacokinetic data, but I think that's something that apixiban is actually favored in that particular scenario. You talked a little bit about risk stratification in those patients with a borderline indication at the low end of the CHA2DS2-VASc risk factor profile, and that you could either use a different scoring system or look at other clinical factors. Can you just tell us a little bit about what some of those factors are and what sort of things would tip you towards anticoagulating somebody with a low score? Yeah, so that's an excellent question. So, I think there was a lot of discussion in the guideline and the meetings and all that regarding this. I think if we have, you know, one of the challenges with some scoring systems are that they are very good at differentiating very low risk versus very high risk, but those intermediate risk patients can be a challenge, and in these scenarios, these are patients who are, you know, CHA2DS2-VASc, one for male and two for females, but they may, in those scenarios, using the other risk factors, the two that the guidelines mention, one is the atria scoring system, and which actually looks at anemia, it's a bleeding parameter, and also looking at renal failure and uncontrolled hypertension, including that, and so there are certain factors there that actually could be additive if that particular intermediate risk patient based on the CHA2DS2-VASc score has other risk factors, and then Garfield actually looks at different age groups and has a lot of other factors. Yeah, Janice has a slide that she can kind of walk us through in that case. Yeah, Janice, why don't you take us through this? Sorry, my audio was a little slow. I was actually going to bring this up since Rakesh was discussing it so that it can be up for everyone as well. I'm sorry, I seem to still be, my slideshow mode is, yeah, so this is a little bit bigger, so hopefully it's easy for everyone to see, but this is actually exactly what Rakesh was talking about for the group that's thinking about some of the modifiers. Our committee really spent a lot of time thinking about what are some of the ways we can further risk stratify. I think part of it is thinking about going beyond just CHA2DS2-VASc, where traditionally we know about the CHA2DS2-VASc, which is equivalent to about 2% per year by the traditional parameter, and then the intermediate parameter that Rakesh described is about 1 to 2% per year, and whereby we have specific populations that would pick out, which we briefly discussed already, in terms of people with rheumatic mitral stenosis, mitral stenosis of moderate or greater severity, who need Wolfram, hypertrophic cardiomyopathy, other forms of congenital heart disease, that's beyond the scope of today's discussion, but then for the intermediate and low-risk patients to really go into thinking about expanded risk modifier using the atria, which highlights kidney disease, smoking, and proteinuria beyond CHA2DS2-VASc, and the Garfield that highlight these, as well as dementia, and using these to compute percentage score that can then feed back into the percentage risk model that goes beyond just CHA2DS2-VASc and paving ways for new ways of thinking as more risk scores become validated and new scores are developed. So, this is a tool that the audience may be interested in, and I will just briefly show this. This is from the AHA guideline on the Go app that was developed specifically to accompany our guideline. We're respectful and recognizing of the legacy of CHA2DS2-VASc that has established much of clinical practice, including efficacy data on anticoagulation. We started with CHA2DS2-VASc, and the CHA2DS2-VASc links to a CHA2DS2-VASc calculator similar to the way we traditionally compute it, but for patients whose CHA2DS2-VASc score does not bid them into the high-risk category where you answer no in an interactive fashion, you can proceed with the rest of the consideration that we discussed earlier, where you can consider if patient has one of the many categories that we discussed earlier. If the patient doesn't have these additional categories to separately, where in anticoagulation, this can open up an H.Y.R. Garfield score that can simultaneously compute the risk score for both of them, yielding the percentage risk that would be able to provide further guidance in terms of the annual percentage risk. So, this is a helpful tool that can be leveraged for the audience who are watching. You can scan the QR code or take a picture of this and be able to access this off the AHA guideline on the Go app to support the thought process and as part of the algorithm. That's great. Thank you very much. I do like putting this in more concrete terms in terms of atrial fibrillation or stroke risk as a percentage. I think that's much more about the way we think where these arbitrary scores. Maybe we'll just end. These guidelines come out only so often. What are the big unanswered questions that you hope are answered by the time you're asked to return for the next guideline? Is it around burden? Is it around screen-detected AFib? What's keeping you up at night? I'll say two or three things. One is regarding thromboembolism. One is that we don't have clear guidance on patients who get surgical either AF ablation or just getting left atrial appendage closure with a clip. It's been proven to reduce stroke risk if you have left atrial appendage closure, but there are no clear studies on whether or not anticoagulation can be stopped and if so, when and what parameters you look for. There is substantial practice variation. People are stopping it. Some people are not. It's kind of all over the place. That's one thing that there is another LAOS trial that's ongoing, but that's going to be a little while before we have the results of that. Second is about, I think in the next year or two, there's going to be at least a couple of major left atrial appendage clinical trials that will be published. I think the option trial will be presented at AHA, which is comparing continued anticoagulation versus left atrial appendage closure in patients with intermediate chest vascular three or above as an option. We may see, and then there's Champion and Catalyst are two trials that are going to look at left atrial appendage closure as an alternative, just as an option without even having a contraindication to anticoagulation. These three trials will inform us as to how that field is going to look like and what kind of evidence base are we going to think about it. Peter, you mentioned about the burden and how we're going to deal with the subclinical AFib. That's getting pretty muddled up late. On one hand, we know that subclinical AF is a much lower stroke risk compared to clinical AF, at least based on the Artesia data. But then also that low burden AF was associated with some adverse outcomes. It's just a little bit of a conflicting scenario. I think hopefully future studies will guide us in that regard. Those would be my three things. Dennis, I'll give you the final word. What's coming? What are you looking for? I share Rakesh's excitement in terms of thinking about new data forthcoming related on thromboembolic prophylaxis for patients with atrial fibrillation that really spans a gamut, ranging anywhere from device-mediated approach, as Rakesh has outlined, to new medications that are coming out. And again, the jury's still out in terms of what to do with Factor XI inhibitor. I think there's just an example of the way that even medication aspect was still shaped too. So I think there's a lot of unanswered. I think a really important and central part of the way that we are starting to approach atrial fibrillation going forward, it's more burden-based. And by thinking about burden, we're having new ways to think about anticoagulation. We're having new ways to think about early, you know, one thing we didn't talk about is the early approach. How early? Can we ever be too early? You know, what is early? And what does that mean? And I think, Peter, as you noted, I think there's a lot of promise with technology, digital technology, digital health. I think I anticipate seeing a lot more evidence coming on this space, supporting new recommendations that may be more related to how we use technology in our practice. And I think the last thing, I think it's a full circle from the way we started. I think lifestyle risk factor modification is going to be a space that we have to learn a lot more about. I think this is a very first foray for a major guideline in atrial fibrillation to have this much extensive and prescriptive recommendation to really guide lifestyle risk factor modification. But a lot more will need to be done in seeing how this can be implemented. So I think this will also be another area that I anticipate seeing a lot more before we have our next round of update. That's great. Well, I thank you both. I think it's an optimistic note. We've gone from a field of treating atrial fibrillation to one with a much more comprehensive view and a much more nuanced approach to stroke prevention and management and all of that. So I think it's a great time to be in electrophysiology. I thank you both for highlighting the work that you've done on the guidelines and for joining us tonight. And with that, we'll sign off. Thank you, Janice. And thank you, Rakesh. Thank you. Thanks so much, everyone. Thank you. Thanks, everybody. I am taking out participants. One second. Just takes a lot of clicks. Dr. Nelser, they already left. Janice, Rakesh, thank you all so much for doing this. Absolutely. That's what I wanted to say as well. I just wanted to say thank you. I know it can be hard. I mean, I've been a professor and I know it's hard when the class isn't talking. Sometimes you're like, I need you to talk to me. So I know it can be disheartening when they're not speaking up, but you did an amazing job. And thank you. Very much appreciate y'all doing this format with us, experimenting with this town hall. As I said, this is our second one. Last week was the first one. So thank you all so much for taking this leap with us, trying out this format with us and just doing the webinars and working on this grant with us. We so, so, so, so appreciate it. And we're done. So have a good evening. Dr. Chu, I hope so rests your voice. I hope you feel better. I have a whole bag of lozenges. So feel better. Have a good rest of y'all's Thursday and a good weekend. And Ashley, Stephanie and I will touch base with you when you're back. Awesome. Sounds good. All right. Have a good night, everyone. Wonderful. Thanks so much. Great to see you guys as well. Good night.

atrial fibrillation

AFib management

lifestyle modifications

stroke prevention

2023 guidelines

risk assessment

anticoagulation

patient-centered care

technology in healthcare

therapeutic advancements