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The Beat Webinar Series - Episode 11 (On-Demand) - ...
The Beat 11 On Demand
The Beat 11 On Demand
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Welcome, everyone, to this Heart Rhythm Society episode of the BEAT webinar series. This we're recording at the Heart Rhythm Society meeting. We're going to be discussing the recent AF guidelines that have been published. We have a number of the guideline authors who are going to be presenting to us, and we have some esteemed panelists who we will introduce as we go for discussion of these guidelines. My name is Crash Sanders. I'm from the University of Adelaide in Australia. My co-chairs for this session is Mike Lloyd and Jason Jacobson from the Digital Education Committee at the Heart Rhythm Society. So it's my pleasure to invite Jose Yorgla, who is the chair of the AF guideline document. He's done a lot of efforts for this document. He's going to present to us what's new in the guidelines. Welcome. Thank you, Crash. Thank you so much, chair, co-chair, panelists. Thank you, everyone, for being here today. I'm going to talk real quick about bird's eye view of what is new. I'm not going to cover everything that is new, just a few highlights. The first thing that we did is we created a new stages and the question is why do we have stages and the reason was we wanted to change the thinking about AFib. We wanted people to start viewing AFib as a complex disease process that takes a lot of multidisciplinary approach to manage, has risk factors, comorbidities, lifestyle interventions, so it's a complex disease a little bit like coronary disease as opposed to just a rhythm abnormality. We also engage heavily on lifestyle interventions that Dr. Russo is going to talk about but I just want to say that we were very prescriptive. We want to tell people these are exactly what you need to do when it comes to lifestyle changes that can improve an AFib or can enhance the probability of success from interventions like ablation or cardioversion. Dr. Russo, Dr. Kusumoto, Dr. Hsu will add to this conversation. I just want to summarize it. We also changed a little bit when it comes to risk score for stroke. This is a big change. We wanted to change the conversation. We wanted to open the door to the possibility of other risk scores when needed. For example, some risk scores like Garfield might use kidney disease, for example, that's not available in the CHAS VAS. We didn't throw the CHAS VAS out of the window because it's still the most validated score but also open the door to other possibilities when needed and also for future research. Maybe in the future by being less rigid we can open the door for investigators to look into other risk factors for stroke like atrial myopathy, for example, atrial fibrillation burden. And some of this comes from the fact that this is a very important paper by Quinn, several years ago, 34 different studies, randomized studies, and you can see, or observational studies, you can see that different cohorts in 34 different studies have different risk of stroke. And they actually go into question the rigidity of CHAS-VASc score 1 or 2 in this publication, 75% of the patients with CHAS-VASc score 1 did not meet a risk that indicated anticoagulation. Thus, we wanted to accept the fact that there's some degree of uncertainty on this and we need to move the needle forward to clarify for our patients. You can see also that we move, instead of a CHAS-VASc score, we talk about magnitude of risk. And that is very important because then there will be some conditions where the risk of stroke is dissociated from historical perception of the CHAS-VASc score will indicate. For example, hypertrophic cardiomyopathy patient with a CHAS-VASc score of 0 might have a risk of stroke of 3%, or a patient with a CHAS-VASc score of 4 with device detected at 8 feet might have a risk of stroke of 1%. So we wanted to start talking about magnitude of risk and that way we'll have more nuance the different disease processes when you're having conversations with your patient. And you can see also the threshold for starting anticoagulation changes a little bit. is indeed a risk factor for stroke, but the threshold for that risk to become evident doesn't start until after CHAS-VASc of 2 where the decision of providing anticoagulation has been already made. So the threshold changes a little bit. A woman with a CHAS-VASc score of 0, you can see it's almost the same risk, it's not a CHAS-VASc score. and you can see still we still don't have a lot of data so we didn't make a lot of comments. We still 2b and it left a drop in the occlusion as an alternative. Mainly the 2a indication patient with bleeding risk. We made some minor changes in case somebody notices for example Sotalol is a 2b and just emphasizes the fact that drugs pose significant risk and this is based on a meta-analysis a Cochrane library analysis that show increased mortality with Sotalol. We didn't do a class 3 recommendation we had a lot of debate on that but we downgraded the class of recommendation for drugs and again emphasizing that drugs are not entirely safe. We upgraded catheter ablation and like I said some of our writing committee members we go into further detail about rhythm control but we have tons of data to support the fact that catheter ablation has gotten safer and the efficacy is superior to antiarrhythmic drugs. So in selected patients selected patients catheter ablation is a class one jumping without the need of trying antiarrhythmic drugs I will use selected patient we didn't want to be very dogmatic but you know the paroxysmal normal heart but we want to you know a lot of people ask me what is selected we didn't want to be very dogmatic it might be that somebody in his 70s is very fit very in good shape. So heart failure has a whole new section that is very prescriptive as well and you can see that we also incorporated all the recommendation which is a single figure a single chapter for the end-user when you open your guideline in your smartphone for example at the bedside at the point of care you have access to all the recommendations pertinent to the patient that is in front of you okay. So we can see for example in patient with heart failure we have catheter ablation upgrade to a class one recommendation for depressed CF for example and then the patients who are not good candidate for ablation we have a bunch of other recommendations and everything is there in a single figure so you guys can navigate this easier. We have other important areas in the guideline I didn't go through all of them because of limited time but for example how to manage anticoagulation in patients undergoing surgery everything you need to know is right there in a nice figure. So in conclusion the new guidelines tries to emphasize AFib is a complex disease and not just a rhythm abnormality. We were prescriptive with lifetime interventions. It's a little bit more flexible in stroke risk estimation and analogous uncertainty. There are updated recommendations compared to past guidelines in important areas such as catheter ablation. There's a lot of useful information also. gave the questions for the panelist discussion at the very end. We've got a lot to get through. It's my pleasure to introduce Andrea Russo, one of my former your incredible leadership on the on this document. Let's see, am I in the right? So as you know, we have three pillars of AFib management now. In addition to thromboembolic prophylaxis, there are also symptom management and management of AFib burden. What we're going to talk about right now is modification of risk factors, modifiable risk factors, things that we can do to prevent AFib onset, prevent the progression of AFib, and prevent adverse outcomes. And this is important to know that it's important throughout the disease continuum, not just when you're first diagnosed, not just for trying to prevent AFib, but throughout the disease process. Dr. Sanders, you'll see, has really published a huge amount in this area, and this is a figure from his group and Dr. Middeldorf in terms of what those modifiable risk factors are. So obesity, physical inactivity, hypertension, sleep apnea, diabetes, hyperlipidemia, alcohol intake, and smoking are all important. These are things that can cause changing of the atrial substrate and can cause adverse outcomes in the setting of atrial fibrillation. So first of all, the guidelines give a class one, you'll see a class one recommendation here that we should, anyone who's at increased risk of atrial fibrillation, we should give a guideline directed management for risk factor modification, including targeting obesity, physical inactivity, unhealthy alcohol consumption, smoking, diabetes, and hypertension. And then as Dr. Juggler already told you, we have very specific recommendations based on the data and based that we have available. A class one recommendation for obesity, so for patients who are overweight or obese with a BMI of greater than 27, weight loss is recommended with an ideal target of at least 10 percent weight loss to reduce AFib symptoms, burden, recurrence, and progression to persistent AFib. And so what data do we have? Well, we know that risk factor modification in terms of weight management with an intervention of specific program or versus general just lifestyle advice, we know that the specific intervention does help. Legacy was another trial by Dr. Sanders and his group looking at the effect of weight loss on AFib recurrence. This is looking at patients who have both with rhythm control strategies, so rhythm control strategies like ablation or anti-arrhythmic drugs, and this is on the left here is without rhythm control strategies. You can see here if you have a 10% weight loss or more, whether you have rhythm control plans or not, this will really reduce AFib recurrence, increases the freedom from AFib over time. And then not only that, weight loss can have an impact on the progression of atrial fibrillation, so this here on the left shows progressing from paroxysmal to persistent AFib. If you have a weight loss of 10% or more, you can see the chance of progression goes way down. It's really much lower than if you don't have any weight loss or any significant weight loss. In addition, reversal of AFib, so having a more persistent AFib pattern, you can become more paroxysmal, more likely to do that if you lose 10% or more. Really interesting data and important data. Stress factor modification, we look at individuals, class one recommendation again, moderate vigorous to vigorous exercise training to a target of 210 minutes per week, very specific recommendations, to reduce AFib symptoms and burden, increases the maintenance of sinus rhythm, increases functional capacity, and improves quality of life. Data to support this. Smoking cessation, we know stopping smoking is important for a lot of things, but in addition, if you have a history of AFib and you smoke cigarettes, we should strongly recommend they quit smoking to mitigate the increased risk of AFib-related cardiovascular complications and other adverse outcomes. In terms of physical activity, again, Dr. Sanders' lab, his group, looked at a very tailored individual patient program. It's a home-based physical activity program, and up to 210 minutes per week of exercise. You can see here that that actually reduced AFib recurrence compared to those who didn't have this very specific tailored program. It also reduced AFib symptom severity, so exercise and physical activity caused improvement. What about other things? For patients with AFib who are seeking a rhythm control strategy, should minimize or eliminate alcohol consumption to reduce AFib recurrence and burden. We all think of caffeine, and this is, I think, good news for us here, but no benefit for patients with AFib, recommending caffeine abstention to prevent AFib episodes is really no proven benefit, so we can drink coffee still. If you have someone who says, caffeine triggers my AFib, obviously we're going to tell them to cut back on that or to stop. What's some of the data? This is a meta-analysis. There are several studies on this, seven prospective studies, over 12,000 AFib patients in terms of alcohol consumption. You can see that alcohol consumption, even at just a moderate intake, is a risk factor for AFib. For example, one drink per day, here's the hazard ratios here, or the risk ratios here. Going up to four drinks per day, you could see, or five drinks a day, it's obviously higher risk with more, but even at just one drink a day. We know it's an increased risk, but what if we stop? This study is randomized, controlled study in Australia, looking at adults who consumed 10 or more standard drinks per week, and they had paroxysmal or persistent AFib, but they were in sinus rhythm at baseline, and they were randomized to abstain from alcohol or just continue what they're doing with six-month follow-up. You can see here that abstinence resulted in improvement in outcome, and this is looking at time to recurrence of AFib, compared to just doing what they were doing already, and that was significant. Also, if you look at the percentage of time in AFib during follow-up, you could see that the abstinence group had a lower percentage of time in AFib at follow-up than those who did not abstain, and that was significant also. What about hypertension, treatment of hypertension? The PS1 recommendation for AFib and hypertension, optimal blood pressure control is recommended to reduce AFib recurrence and AFib-related cardiovascular events. Then sleep apnea. This is only given a 2B recommendation because the data really isn't all that strong in terms of treating sleep apnea to prevent AFib recurrence. Obviously, we want to do it for a lot of reasons. If they have sleep apnea, we want to treat it for other cardiovascular or pulmonary reasons, but among patients with AFib, it may be reasonable to screen for sleep apnea, giving its high prevalence in patients with atrial fibrillation, although the role of treatment of sleep-disordered breathing is not clear in this respect. Really the bottom line is aggressive risk factor management. You can see of all these different factors, patients are in the middle. We need to look at some of these very specific targets. You can see this was really nicely summarized in this figure by Dr. Sanders and Dr. Middeldorp in their group. I think we all know EP docs may not be the focus of the visit all the time. We really need an integrated care approach. It's not just us. This is really a systemic disease. It's affecting a lot of things. We have to get an integrated approach with other healthcare providers and then within our team, an interdisciplinary team to treat these patients because we can't do this alone. Thank you very much. Thank you so much. Thanks for having me here. Delighted to be here with the rest of the writing committee members and speaking on behalf of the many other colleagues who met weekly with all of us through all our nights. The next 10 minutes, I will speak briefly in terms of rhythm control, what has changed. And here we are at The Beat Live in Boston. Perfect. So first and foremost, I will call all of your attention to a paradigm shift. So key in the document is a paradigm shift for early consideration for treatment to reduce atrial fibrillation burden. So what do we mean by that? So this is a focus to minimize atrial fibrillation. progressive disease with the focus now to minimize atrial fibrillation burden early. This further builds on what Dr. Russo has so elegantly already outlined for us, the lifestyle and risk factor modification going hand-in-hand with that, and now the long-term rhythm control strategies include anti-arrhythmic medication and or ablation and we will further discuss those. So the take-home point for the guideline, the very first take-home point in this regard, is that the guideline emphasizes the importance of early and continued management of patients with atrial fibrillation that should focus on maintaining sinus rhythm and minimizing atrial fibrillation burden. So what does this mean? So new for the first time, we have a section on the goals of therapy with rhythm control. With that, this focuses on symptom improvement, improvement of outcome including hospitalization reduction, reduction of stroke, and improvement on mortality, and also in terms of reduction of progression. Again, beckoning back in the concept that atrial fibrillation is a progressive disease. Furthermore, we have a 2B recommendation for consideration in patients with atrial fibrillation where symptoms associated with atrial fibrillation are uncertain. A trial of rhythm control such as cardioversion or pharmacologic therapy may be useful to determine what, if any, symptoms are attributable to atrial fibrillation. A lot of these built on the East AFibNet study where patients with less than one year of atrial fibrillation were randomized to early rhythm control which included anti-arrhythmic or ablation versus usual care. The key thing to point out regarding the primary outcome, which are compositive deaths from CB causes, stroke, or hospitalization with worsening AFib, worsening hospitalization or ACS, included lower recurrence of primary outcome in the early rhythm control group versus usual care, better maintenance of sinus rhythm in the early control versus usual care. In the bottom here, we see that in a subsequent analysis, An up-front triage approach by heart failure. This is new from prior, and we'll talk briefly a little bit more about heart failure toward the end of my talk. This also emphasized shared decision making in the process of rhythm control. And furthermore, I will point out here, we have upgraded recommendation for catheter ablation highlighted in green here in the middle. The strategies of rhythm control broadly includes three possibilities. Antiarrhythmic medication, as we alluded to, of which, as Jose pointed out earlier, the triage. where the recommendation will actually split when you're looking at symptomatic paroxysmal AFib patient versus symptomatic persistent AFib patient and patient with longstanding persistent atrial fibrillation. The data since 2014 have shown consistent efficacious approach with catheterization. What we now have harmonized, divided in a different way, is more a focus on the patient's selection, rather than the duration of the atrial fibrillation itself. Here we see a first-line therapy recommendation that's class one, in select a patient generally younger, with fewer comorbidities, with symptomatic paroxysmal atrial fibrillation, in whom rhythm control is desired, catheter ablation is useful as a first-line therapy to improve symptoms and reduce progression to persistent atrial fibrillation. As a 2A, in patients other than the selected population, with symptomatic paroxysmal or persistent atrial fibrillation bundled together, who are being managed with a rhythm control strategy, catheter ablation as first-line therapy can be useful to improve symptoms. In a selected patient with asymptomatic or minimally symptomatic atrial fibrillation, catheter ablation may be useful for reducing progression of atrial fibrillation and dissociate complications. I want to expand here a little bit more on what we mean by the selected population, as indeed this question has come up many times. should be suspected, and an early and an aggressive approach to atrial fibrillation control is recommended. What else changed? This is what Jose alluded to earlier, that in a harmonized way to approach atrial fibrillation in patients with heart failure, we also provided additional guidance in terms of candidates most likely to benefit from this type of intervention. To summarize, there are two key recommendations here. In appropriate patients with atrial fibrillation and heart failure with reduced ejection fraction who are on guideline-directed medical therapy and with reasonable expectation of procedural benefits, which are specifically highlighted here to the right, which include patients who have atheid-mediated cardiomyopathy, no sign of infection or scar on cardiac MRI, no or mild atrial fibrosis, suggesting earlier in the atrial disease process, prospective of atrial fibrillation, younger patients without significant other comorbidities. in the heart field would preserve ejection fraction with reasonable expectation of benefit. Catheter ablation can be. our failure to reduce the tractor infection now has. including the population likely to benefit and the divide by the ejection fraction. So, in summary, the key changes in rhythm, control, and ablation include a paradigm shift emphasizing early or continuing measurement to reduce atrial fibrillation, a class one recommendation for catheter ablation as first-line control in selected patients who are younger with fewer comorbidity, and a class one recommendation for catheter ablation in appropriate patients with heart failure reduced ejection fraction. Thank you, I'll look forward to further discussions. Thank you very much. And our final speaker before we get to the panel's discussion is Fred Kusumoto from Mayo Clinic Jacksonville, Florida talking about stroke. All right, so my task for the next 10 minutes is to fill in what Jose talked about with regards to stroke prevention, et cetera, and specifically, how do we stratify? As Jose pointed out, one of the big issues or one of the big points with the new AF guidelines is to provide increased flexibility, and why do we need to sort of do that? So I have no disclosures. And you know, Jana spent a lot of time talking about rhythm control, and you know, when we think about managing atrial fibrillation, and arguably, just about anything, right, you want to treat symptoms, and you want to treat really bad things, right? You want to prevent those really bad things. And in atrial fibrillation, the really bad thing is a stroke, and it really is protecting the head. And I always misquote Teddy Roosevelt when I talk with my cardiology and EP fellows. You want to take care of what's going to hurt you the fastest, the mostest. I mean, that's really the most important thing to do. So here, then, is the recommendation that you saw from Jose, that in fact, you ought to use some sort of risk stratification scheme. The question is what to sort of do and what to use. And clearly, when you look at the different schemes that are used, as mentioned, we don't want to throw Chad's VASC and Chad's out of the window. Look at, they've had the greatest majority, right, of studies that have used it. On the other hand, there are a number of studies that have used different schema that have been used more recently that maybe provide some additional value, and why might we need to look at that a little bit more closely. And you know, the key thing to think about, we had this big discussion about whether or not to include the word Chad's VASC in the actual guideline recommendation itself. You know, there's no question that it is used. It's something that we are sort of familiar with. It's something that we all can think about really quickly, but perhaps it's not the one ring that rules them all. I'll bring out just Garfield AF. Remember that in Garfield AF it uses all of the Chad's VASC stuff, but it adds some more. And the question is whether or not, particularly in those patients who have a Chad's VASC score of one, where you're really sort of worried, you're on the fence about deciding whether or not to use anticoagulation or not. In fact, maybe it has a little bit better sensitivity without sacrificing specificity. There's other things too, right? There's biomarkers. You know, there's a host of biomarkers that can be used potentially that can predict risk of stroke in patients with atrial fibrillation. And the most commonly quoted study and the biggest study is the ABC study from Engage Timmy 48, right? So again, it shows there that whether it's troponin, whether it's ProBNP, whether it's growth differentiation factor, in fact, increased risk of bleeding and stroke associated with increased amounts of the biomarkers. So how can we use it? It seems like it increases all the time. Well, in fact, the investigators showed that if you had increased bleeding, it was really the growth differentiation factor which was the most critical. And for increased stroke, it was BNP and troponin. So perhaps we can begin incorporating this sort of data into thinking about our patient's individual risk for stroke. And here then is sort of a table looking at all of the different factors. You can see that just about all of them use age. Now, in some cases, instead of having specific strata, there is a continuous weighting. That's fine. You can see that most use some component of the CHADS-VASc score, particularly the presence of a prior stroke. But you can see some additional clinical variable. So for example, as I mentioned, in Garfield, there's lots of other things like chronic kidney disease, smoking, dementia. There's lab data. I showed you from ABC the use of biomarkers. Remember, there's also Atria that was developed in 2013 that really focused on renal dysfunction as an additional sort of marker and risk factor for stroke. For those of you who are younger and perhaps don't remember, the C in CHADS-VASc was going to be used for creatinine, but it kind of fell out. So interesting that additional studies later suggest, in fact, that we could use renal function as something to help us in this setting, left atrial size for the ABCD. But when you then look at the C factors, right, and you look at the C statistics, in fact, you can see that CHADS-VASc is a little bit better than 50% for sure. And if I magnify this, in fact, by using some of these other scores, in fact, you can increase the C statistic a little bit. But I mean, the question is going to be, is it really just a fancier coin that you're going to flip? So how do we think about this sort of in a more flexible and detailed way that is individualized? And why should we bother? Well, the big question is, you know, when we estimate risk of stroke, you either decide to anticoagulate or you don't, right? I mean, that's it, and that's the issue that we have. And I don't know any of my patients who like to take anticoagulation, but I have to tell them, well, you have to take some. So Jose brought up these recommendations here. I'm not going to repeat it. You can see that the CHADS-VASc score is in parents, but why in parents? He showed you this slide before, the fact that different populations, in fact, had different inherent risks for stroke. So let's take this data put together by Quinn and colleagues and look at it a little bit more carefully. When you then divide each of these studies into their CHADS-VASc score of 0, 1, and 2, you can see that, in fact, the CHADS-VASc score of 0 is really good. Those patients all had a stroke risk less than 1%, as shown by the green dotted line. You can see it begins to fall apart, right, when you look at those patients with a CHADS-VASc score of 1 or 2, where some patients with a CHADS-VASc score of 2, in fact, had a lower risk of stroke than our set barrier of 1 or 2%, and some had, in fact, higher. So again, it begs to the question that we need better data to risk stratify individual patients. So what should we do? We have this two-way recommendation for those patients who have an intermediate risk, we ought to talk a little bit more, right? It really is to discuss this. And we have a little bit of data in these patients. So this is a study from the Danish National Patient Registry, where you looked at a large number of patients who were on anticoagulation. And here's the issue, right? Are all of the ones sort of about the same? Not really. Age, right, is a little bit more important of a risk than others. But in fact, you can see that in the 95% confidence intervals really have significant overlap. So again, it's an imperative that we as clinicians need to talk to our patients. I'm going to finish this so that we have time for our discussants to talk about some of these issues more extensively with this. Jose brought up paroxysmal versus persistent. We know from SPAF 3 that, boy, whether or not you had paroxysmal or persistent atrial fibrillation, at least in this study, in fact, the risk of stroke was the same. When you look at large meta-analyses, however, there is an importance to AF burden. So in fact, those patients with PAF appear to have a lower risk of stroke than those patients with non-PAF, although, again, with broad confidence intervals. So that's why the guideline recommendation is, in fact, that those patients, regardless of whether they have PAF, persistent, or permanent, we ought to think about it as one thing. But we all know that the data is evolving very, very quickly. And I bring you to ARTESIA and NOAAFNET 6. Here are patients with subclinical AF. They had three to four hours of AF if you look at it. They had CHA2DS2-VASc scores of four. So they had higher risk for stroke. You can see that in the placebo or the aspirin group, their percentage of stroke risk was about 1% a little bit over. So again, we were pretty good, I think, in terms of choosing 1% as that area of equipoise where one has to then have that discussion about stroke risk and bleeding risk and begin, you can already see, thinking about integrating some of these new data into our discussion with our patient who has that intermediate risk. I would argue for most of my patients, I'll just stand on the soapbox for a second, they don't want a stroke. They can put up with a little bit of GI bleeding, as it were. They don't want a stroke. So I would like to leave this group thinking about trying to sort of err on the side of what is going to hurt that patient the fastest and the mostest and have more significant issues down the line. So to finish up, use a validated tool to evaluate stroke risk. Just do it. Acknowledge that all of these little schemes are blunt instruments and that we really do have to spend time thinking about this with our patients. And perhaps maybe this is one place where the electronic health record is going to help us. Maybe we can get to an individualized risk of stroke that incorporates anatomy, incorporates biomarkers, incorporates clinical issues. And finally, a personal discussion is absolutely critical. I love AI. We do a lot of AI at Mayo Clinic in Florida. It really is a patient-to-healthcare provider discussion that's absolutely critical. And for this group, thank you for being here. Really looking and actively learning about these issues is critical. And with that, thank you very much. Thank you, Dr. Kusumoto. Now, the fun part. Briefly, let me introduce our dream team of panelists here. Dr. Lentz from Maastricht University. Dr. Huynh-An Pak from Yonsei. Dr. Emma Svenberg from Karolinska. Karolinska? I'm saying that right? And of course, Dr. Hawkins. Hugh Hawkins from Johns Hopkins University. So we're going to take this opportunity for the panelists to kind of lead some of the questioning and discussion with the presenters. Hugh, you've always got questions about the guidelines and what we can and can't do. And I appreciate your comments and questions. Yeah, so first, congratulations to the writing group, to Jose and team. I mean, what a fantastic document. I think this shows the value of bringing in a whole new writing group, a whole new leadership group, the old approach and sort of retuning it. I have to admit, when I first read the document, some of the things I thought were terrible and I thought you guys had lost your mind. But as I hear these presentations and as we reflected on it, I think you're right on target for a lot of things. I mean, one example was the CHADS VASC. I initially said, well, they fabricated their responsibility. They basically said, it's up to you. No longer use the CHADS VASC. It's all on you. And yet, when you think about the 65-year-old with well-controlled hypertension, with one episode of AFib a year before lasting two minutes, where you're saying you have to anticoagulate because they're CHADS VASC is two, without sort of saying in a broader discussion, well, I think this is a 1% or less than 1% group. I mean, I think it's sort of exciting from a stroke prevention where we move it away from the lawyers saying, this was a CHADS VASC two patient who didn't anticoagulate and they had a stroke, opening up your wallet, you're going to be sued, to documentation, having the discussion, talking about these risk factors. I think this also really encourages more research. I mean, I think this document was forward thinking where it set the stage for a new generation of research. And I think when it comes to stroke prevention, AFib burden is incredibly important. This is the first document ever, I think, to include AFib burden or type of AFib in a risk factor consideration. Same with the left atrial size. I think that makes an enormous difference, yet it's not in the CHADS VASC or any of these other score systems. I think this is the first document to call attention to that. So I think there's a lot of really good things in this document. In terms of some of the things that really surprised me, and I'll turn it over to my One was SOTOLOL, where you put SOTOLOL literally behind amiodarone. And it was like, where's the new data that justifies demoting SOTOLOL? Yes, there's a meta-analysis, but that's not a high-quality study. And I think the meta-analysis is relatively old. It's not new news. On the other hand, when I look at my practice, I virtually never use SOTOLOL anymore because I probably think it has some different risk profiles. But anyhow, so it's a remarkable document. Every page you turn opens up other questions, but I'll turn it over to Emma and Jose. Let me tackle a couple of these things real quick. First of all, thank you, Hugh. I appreciate the comments. One thing that you guys don't know, but I knew, is that this guideline is going to evolve faster than in the past. Instead of waiting 10 years, we're going to try to create an update in a more frequent basis. We're going to have an opportunity to change things and evolve faster. And like you said, the idea of changing the CHAS VAS is to get away from the rigidity that did not allow future research. For example, I believe that AFib burden is an important risk factor. When you talk about paroxysmal versus persistent, there seems to be lesser risk with paroxysmal, still high enough to warrant anticoagulation. But when you see patients with isolated AFib events, one, three hours a year, those patients tend to be at low risk. But that's not reflected in the CHAS VAS score. And patients, every physician here in the room knows that the patient said, dog, do I need to take anticoagulation. Dude, I really need it. It's $300 a month. You know, so that's what we wanted to do to enhance the conversations. The other thing in terms of Sotalol, the issue is that these drugs are not safe. They have a lot of inherent risk. Sotalol meta-analysis show increased mortality. Show increased mortality. Some of our writing committee members wanted to ban it outright. They wanted to give a class three, don't use it, period. So this debate had to be, was a compromise, believe it or not. There's some of the internal deliberations that happened. You know, when we're having these writing committee meetings on a weekly basis, they wanted to ban it right because we are evidence-based document. We need to move away from practice patterns, a lot of fighting, a lot of, that's no way I don't do it, but the evidence shows this. That's where we need to go. We need to go with the evidence. And some people wanted to ban it outright. So thank you very much for the talks. And it's an excellent guideline. Congratulations, really. What really intrigued me is this development of the continuum of atrial fibrillation, the disease spectrum. I really enjoyed that, reading that. I always think about atrial fibrillation that way, like hypertension or other diseases. It's not a yes or no. It's really a continuous disease. But I miss the patient group that I commonly see in my clinic, and that's the patients with the wearable devices coming in that have AFib detected, and they come to see you. And yes, they do have AFib. You can see from the recordings that that's there, but where would you place them on this disease? Is that a three little A, or, yeah. So you bring up a really critical point. I mean, that is absolutely the issue that Jose brought up in sort of not a lower level, but even less of a level, right? Because we do have these wearables where people have this little spurt of, card-carrying AFib, there's no question about it. You don't know how long it lasted. You can ask the patient, what was the heart rate, things like that, et cetera, and get some clinical clues. But for my purposes, I kind of still put that in that perspective of subclinical AF, and whether or not you wanna then call it, is it enough to then get into this sort of pre-AF stage or not, I think it's really a discussion. As is noted in the guideline document, in fact, that's when, in fact, thinking about other risk factors, et cetera. And oftentimes, I'll use that then as a call for the patient to maybe cut down from two glasses of Cabernet to one, et cetera. Because even as Prash said, for his abstinence study, when you look at the people who were abstaining, in fact, they were still drinking a little bit. They were Australian. So my point, though, is that I do think it is a call to action. So I agree that I think it's hard, and I think that Jose is correct that as we get more and more data with regards to wearables, et cetera, as more data is clearly going to come up, how are we going to evolve that and be a little bit more prescriptive with regards to the recommendations? I think that that's going to be important. Okay. First of all, congratulations for the new guidelines, and it is impressive and a lot of change. Actually, because the HRS gave me a mission as a panelist, I read the whole guideline in the aircraft. It's a really, really long guideline. So I list up some gray zone or questions. One of the impressive thing is the new guidelines cited many papers with Mendelian randomization. Mendelian randomization. So it is the genetic analysis and support the causal results relationship. It is quite impressive. And second one is the anti-arrhythmic drug downgraded to class 2A indication, anti-arrhythmic drug. So all the anti-arrhythmic drug became a 2A indication. So there is a gray zone who does not have a class 1 indication for catheter ablation for rhythm control. So that is my question. And third thing is the aspirin issue. Aspirin issue. Aspirin is a class 3 indication in new guideline. In the European guideline, it is already downgraded to class 3 a few years ago. However, in practically, many physicians are using aspirin after successful apendicoclosure, right? So there is some LAO, yeah. So there is some discrepancy. And also, after percutaneous appendicoclosure, we are using aspirin, but after surgical appendicoclosure, based on the LAOS 3 trial, 85% of patient is still taking oral anticoagulants. So there is discrepancy between the percutaneous and the surgical LAO. So what do you think about that? Thank you for those questions. I think there are multiple components to that, and I'll try to unpack some one at a time. So I think working backwards, I think in terms of some of the anti-coagulation and deplatelet questions, I think there are a few components related to the aspirin issue. So I think, first off, the point was raised regarding having aspirin as a class three, as in a not to do. And then I think that actually is reflected in our guidelines in several different places. So first off, as a not effective, but increases bleeding risk in patients who have no risk factor. Secondly, I think it's also an opportunity for us to actually just mention here that in patients who are already on anticoagulants, who have no other indications for aspirin or anti-platelet therapy, that's also to be avoided because of the increased bleeding risk. The last components related to the aspirin and anticoagulation has to do with some of the anticoagulation, antithrombotic consideration in the setting of left atrial appendage occlusion. That there is a really great point that currently there is a discrepancy in terms of what's used post-surgical versus post-percutaneous. That's based on the landscape of the data today from a layout three that the majority of the patient continue on Wolfrin subsequent to having received a closure. And I think, again, you know, Jose tasks us to be very much evidence-based and based on that evidence, our recommendations were according to that versus in the percutaneous world, as we know that there's a scale back to anti-platelet therapy after demonstration of completion of the occlusion, that there is no residual leak. And that transition has also gone accordingly to the anti-platelet therapy, which is reflected per data in our guidelines. So things were very much very, very literal, very much evidence-based. Related to the rhythm control strategy, I think that's another area of really, really good question. I think for anti-arrhythmic therapy, I think the key point that a committee recognized here is that even anti-arrhythmics have risk. And so in that sense, I think the strategy is more to think about early rhythm control, but not necessarily pushing for early rhythm control with anti-arrhythmic. So that early rhythm control based on eSAFE-FNAD is allowed with either anti-arrhythmic or ablation therapy. And in select population, catheter ablation is then the preferred strategy for that modality of early rhythm control. Let me say also for the audience, how the guidelines comes out to a class of recommendation in general. It's a risk versus benefit. It's the risk of the intervention versus the benefit. And you consider, what did you get? You get survival advantage, you get a risk of death, no survival advantage, LVF gets better. So it's a risk versus benefit or one intervention versus the other. And the fact is anti-arrhythmic drugs are not that good. That's the bottom line. At the end of the day, when you look at one year, freedom from AFib with an anti-arrhythmic drug, we're talking about 30%. And that's it. And that's what the committee sees, that you see the data and you have side effects, torsade, bradycardia, total of 30% bradycardia rate leading to discontinuation, end up with a pacemaker. So those risks are there, but at the end of the day, when you look at the risk of benefit, the drugs don't work that well. That's the bottom line. Yes, so also from my side, of course, congratulation to the complete. I think here it's a little bit better to understand. So also from my side, of course, congratulation to the complete writing committee. When I had the opportunity to read this manuscript then the first time, well, there were a lot of very, very nice figures, which could actually be really nicely be used on bedside to actually really integrate directly in the care of our patients, which I really, really liked. The ChEDS-VASc part, well, this was a little bit confusing to me because then suddenly the ChEDS-VASc, which we actually were used to use, is suddenly a little bit softened. So what should we do now with this? So I think there's still a lot to learn, of course, also in the next years. But I would actually like to have one comment also about the risk factors to Dr. Russo. So you actually showed, particularly for primary prevention to prevent incident atrial fibrillation, risk factor modification plays a role. I think there it should be initiated early. But then when we think about secondary prevention, so in patients who already are diagnosed with ECG, with atrial fibrillation, then on the one hand we should perform rhythm control as early as possible, best with catheter ablation. But on the other hand, there should be also some time to take care for the overweight, to take care to reduce smoking, to reduce alcohol, and so on, and so on. So how, and this was actually what I was missing a little bit in the guideline, how should we now combine comprehensive risk factor modification, which cannot be performed on one day, we know this, with early rhythm control, which might be possible within one day by a catheter ablation? So what is the sequence? What should we focus first on? Is it actually that we should not ablate until the risk factors are modified? So what are the ideas on the guidelines there? Thank you for that question, and that's a really great question. So I see it as a continuum. So even after catheter ablation, we know that there's still a risk of recurrence. It's not, we're not always perfect with that, right? So to decrease, and there's some data looking at post-ablation, decrease the chance of recurrence of AFib post-ablation, that these are also valuable risk factors. Now, I think the real challenge is, unless we move to Australia, it seems like a lot of people in Australia, it seems like a lot of, it takes a team effort to really modify, it takes motivated patients to lose weight. Might we see some changes with some of the newer drugs for weight loss that might be useful, but I do agree, but it's a continuum. So just because your rhythm control and you can fix things right away, and I don't think you should wait. I wasn't implying that. Don't, it's not wait. It's almost like even, we say heart failure therapy before you get an ICD, right? It's not that you're gonna wait forever. You're gonna initiate that, probably by the time you get them on your ablation schedule, you'll have some of that going on, but it's not all or none, and it's the individual patient. If you're just having brief episodes of AFib, and it's a very low burden, and you may, that patient may be different if their device detected with a watch, and you had your first episode of AFib, that patient might not be ready for an ablation day one, and it takes the patient a while, too, to kind of understand all this, and knowing what they should do, whether they have a procedure or not, but great question. I think one other thing to dovetail on Dr. Russo's message, actually, Dominic pointed out, actually, the importance of involving the patient in this process. I think one thing that our guideline, and I think that's really taken a huge step forward, is a lot of, you will see many areas will really encourage a decision-making, the discussion process, and I think it's being even more important compared to prior guidelines, by now having a focus on therapeutic lifestyle risk factor modification, the role of the patient in the active management of atrial fibrillation, so I just wanted to make sure that that's also loud and clear from the guideline standpoint, as well. Thank you, everyone. Look, there's lots we could be discussing with these guidelines. I want to thank the speakers, thank our panelists for their comments and questions, and look, this will be available on the HRS 365 system, and we'll send out notifications at that point. Thank you.
Video Summary
In this episode of the BEAT webinar series by the Heart Rhythm Society, the focus is on discussing the recent atrial fibrillation (AF) guidelines that have been published. The webinar features various guideline authors and esteemed panelists. Key points highlighted in the discussion include the introduction of new stages in viewing AFib as a complex disease requiring a multidisciplinary approach, emphasis on lifestyle interventions, more flexible stroke risk estimation, and updated recommendations for catheter ablation. There is also a shift in the classification of antiarrhythmic drugs to a 2A indication, the downgrading of aspirin to a class 3 indication, and the importance of integrating risk factor modification with early rhythm control strategies. The guidelines stress the need for personalized risk assessment and a patient-centered approach to management, with a focus on evidence-based practices and ongoing research to improve outcomes for patients with atrial fibrillation.
Keywords
BEAT webinar series
Heart Rhythm Society
atrial fibrillation guidelines
multidisciplinary approach
lifestyle interventions
stroke risk estimation
catheter ablation
antiarrhythmic drugs
aspirin indication
risk factor modification
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