New atrial fibrillation guidelines address underlying diseases

London — Updated Guidelines For Management Atrial fibrillation Recent research published by the European Society of Cardiology revolutionizes the approach to treating this complex, multifactorial disease.

Identifying and treating complications and risk factors is the first and central element of patient management and is crucial for all other aspects of care for patients with atrial fibrillation (AF), explained Isabel van Gelder, MD, professor of cardiology at the University Medical Center Groningen in the Netherlands, at the European Society of Cardiology (ESC) Congress.

Van Gelder, who chaired the ESC-AF guidelines task force, said that giving equal importance to managing comorbidities is not only appropriate but crucial.

Comorbidities contribute to both the onset and recurrence of atrial fibrillation, and a dynamic approach to comorbidities is “central to successful atrial fibrillation management.”

Class I Recommended

In fact, based on overwhelming evidence, Class I recommendations have been made for a number of goals in the complication and risk factor management phase of atrial fibrillation management, including: High blood pressure,component heart failure, obesitydiabetes, alcohol consumption, and exercise.

Sodium-glucose cotransporter-2 (SGLT2) inhibitors “should be offered to all patients with AF,” van Gelder said, making this a new Class I recommendation.

Patients who do not receive aggressive management of the listed comorbidities will ultimately face “treatment failure, poor patient outcomes and wasted healthcare resources,” she said.

Control of sleep apnea was also listed as an important goal, but Van Gelder acknowledged that the supporting evidence only allows for a Class IIb recommendation.

Controlling comorbidities is not a new idea. 2023 Joint GuidelinesIn the latest ESC guidelines, led by a coalition of expert groups including the American Heart Association (AHA) and the American College of Cardiology (ACC), management of comorbidities, which include most of those identified in the new ESC guidelines, is listed second in a list of 10 key messages.

However, the new ESC guidelines prioritize management of comorbidities by listing it first in each of the specific patient care pathways developed to define optimal care.

These pathways are defined in algorithms for newly diagnosed AF, paroxysmal AF, and persistent AF and always begin with an assessment of comorbidities followed by step A (avoidance of complications). stroke — Mainly due to anticoagulation therapy.

Direct oral anticoagulants are used in patients with mechanical or Mitral stenosis“That basically includes all of the patients at CHA,” Van Gelder said.₂DS₂– VASc score ≥ 2, but even a score of 1 should be “considered”.

The ESC framework is known by the acronym AF-CARE, where C stands for comorbidity.

In step A of the framework, identifying and treating all modifiable bleeding risk factors in patients with AF is a class I recommendation. Based on class III recommendations, she cautioned against withholding anticoagulation because of CHA.₂DS₂-Rather than relying on VASc risk factors alone, Van Gelder said the decision to anticoagulate or not, like any other decision, needs to be made individually in consultation with the patient.

Specific pathways for AF symptom relief and rhythm control vary for newly diagnosed AF, paroxysmal AF, and persistent AF. As with all guidelines, specific options for symptom management and AF ablation are color-coded, with green indicating level 1 evidence.

The assessment and dynamic reassessment steps refer to the need to regularly evaluate patients for new modifiable risk factors related to comorbidities, stroke risk, bleeding risk, and AF risk.

Management of risk factors for AF has long been emphasized in guidelines, which have moved from a previous focus on AF with attention to comorbidities to a focus on comorbidities with the hope of more durable AF management. The success of this shift has been based on multidisciplinary care selected in collaboration with patients to reduce or eliminate the risk of AF triggers and its complications.

Route is appropriate for all patients

A very important recommendation (and this is new) is to “treat all patients with atrial fibrillation, regardless of age, gender, black or white, high or low risk, with an integrated, patient-centered AF-CARE approach,” Van Gelder said.

These changes reflect a shared recognition of the close relationship between management of comorbid conditions and management of AF, according to José A. Jogler, MD, professor of cardiac electrophysiology research at the University of Texas Southwestern Medical Center at Dallas, who served as chair of the writing committee for the joint 2023 AF guidelines published by the AHA, ACC, American College of Clinical Pharmacy, and Cardiac Rhythm Society.

“It's becoming increasingly clear that AF is often the result of underlying risk factors and comorbidities that cannot be separated from AF alone,” Jogler explained in an interview.

He put it first “to emphasize the importance of looking at atrial fibrillation not just as a rhythm abnormality but as a complex disease that requires a comprehensive, multidisciplinary treatment approach,” he said.