New arrival Atrial fibrillation European Heart Association (ESC) management guidelines call for the need to streamline diagnostic confirmation and structured characterization of AF and integrated treatment with the Atrial Fibrillation Better Care (ABC) pathway.
“It’s as simple as CC to ABC,” blamed one Task Force member during the virtual unveiling of guidelines ESC Congress 2020..
This guideline was created in collaboration with the European Association of Cardiothoracic Surgery (EACTS) Release At the same time August 29 European Heart Journal..
The document supports opportunistic screening for AF by pulsing, recognizing the large number of currently available screening tools and their reported proportions of sensitivity and specificity. electro-cardiogram (ECG) Rhythm strip for patients age 65 and older, Class 1 recommendation, Level of evidence B
Systematic ECG screening should also be considered to detect AF in individuals at least 75 years old, or in individuals at high risk. stroke (Class IIa, Level B).
Other new Class I screening recommendations inform individuals being screened about the importance of detecting AF and its implications for treatment, as well as a structured referral platform for physician-led assessment. To introduce.
A clear diagnosis of clinical AF is only established after confirmation by conventional 12-lead ECG or single-lead ECG strips for at least 30 seconds.
Match ESC 2016 AF guidelinesIn a new iteration, AF is first diagnosed and is classified as paroxysmal, persistent, long-lasting, and permanent. However, classifying the clinical profile of AF is also important, said Task Force member Giuseppe Boliani, MD, of the University of Modena, Italy, in his first five presentations.
“The novelty of the 2020 guidelines is that the 4S-AF for the structured characterization of atrial fibrillation considers stroke risk, symptom severity, atrial fibrillation burden severity, and substrate severity. It is related to the scheme proposal.”
This is a paradigm from the traditional classification of a single domain of AF to a structured characterization that streamlines assessment, informs treatment decisions, and facilitates communication between physicians of various disciplines. The shift is represented by Tatjana Potpara, MD, PhD, Co-Chairs of Guidelines, and Director of Intensive Arrhythmia Care, Serbia Clinical Center., Belgrade.
“The good thing about this approach is that evaluation of the “S” component is currently performed using the available tools, but in the future, 4S-AF will provide a more accurate evaluation. It has great potential to incorporate what is available. Substrate or symptoms or arrhythmia burden, etc.”
ABC pathway
The guidelines advocate the previously described ABC path for integrated care management. It consists of “A” for anticoagulation/stroke avoidance, “B” for better symptom management, and “C” for comorbidities/Cardiovascular risk Factor optimization.
This document describes the formal risk of bleeding risk for all patients, including the treatment of modifiable bleeding risk factors and the use of the HAS-BLED score to help identify patients at high bleeding risk (HAS-BLED score ≥3). Strengthen support for score-based assessments Early and more frequent follow-up.
Potatopara emphasized that these assessments should be done regularly, given that the risk of stroke and bleeding is dynamic and changes over time with age and comorbidities. For AF patients who are initially at low risk of stroke, the next assessment is optimally performed in 4-6 months.
Guidelines also target weight loss Obese Good blood pressure management in patients with atrial fibrillation, especially those undergoing ablation and those with atrial fibrillation High blood pressure To reduce the risk of AF recurrence and stroke and bleeding (both from Class I, IIa).
It is particularly important to address these risk factors and to address and communicate with patients the variable risk factors associated with the increased incidence and persistence of AF, Dr. Grhard Hindricks, Co-Chairs of Guidelines for Rhythm Co-chairs. And the Medical Director, Heart Center Leipzig, Germany.
“I have to confess that I’m an interventional electrophysiologist. There were times when I didn’t appreciate these risk factors strong enough,” he said. “But we also Catheter ablation, That weight loss is an essential basis for a good procedure. If we can motivate patients to lose weight and then intervene with better outcomes, that is a real benefit for them and address their values. Therefore, I am particularly pleased to introduce it to the guidelines with such strength. “
Rate and rhythm control
This guideline does not recommend one new oral anticoagulant (NOAC) over another. However, in patients already receiving vitamin K antagonists with short duration of treatment range, it is recommended to switch to a different NOAC, but the duration of treatment (class I recommendation) or treatment range (class IIa) Efforts to improve ensure good adherence and sustainability.
Catheter ablation plays a more important role in rhythm control and failure of antiarrhythmic drug therapy does not improve symptoms of paroxysmal AF or AF recurrence in patients with persistent AF with or without major risk factors for recurrence Recommended if. The class I recommend is CAPTAF And Cabana According to Carina Blomström-Lundqvist, MD, PhD from Uppsala University in Sweden, a member of the Task Force,
Catheter ablation is also a first-line treatment for patients with atrial fibrillation who are likely to have tachycardia-induced cardiomyopathy, regardless of their condition. “In this subset of patients, catheter ablation may offer a lot in terms of restoring left ventricular function,” Hindricks observed.
Complete electrical isolation of the pulmonary vein is recommended for all AF catheter ablation procedures (Class I).
“Even as a medical conservative, it is perfectly reasonable to move to catheter ablation after a failed clinical trial,” said John Mandrolla, MD, Baptist Health, Louisville, Kentucky, who was not involved in developing the guidelines. I think.”
Although the second drug may work later One failure is low, He’s a US operator Dofetilide, It’s not used much in Europe, but it works surprisingly well sometimes.
“However, it should be noted that the appropriate transition to catheter ablation after a drug disorder is all appropriate risks such as sleep apnea, weight loss, lack of fitness, blood pressure control, and alcohol overload. Only when dealing with the factors,” he said.
For tachycardiomyopathy, this may also be valid, Mandola said. “I often “get people out of the hole” Amiodarone plus Defibrillation After a few months, proceed to ablation. “
Especially in the 2020 iteration, amiodarone was heart failure Decreased ejection fraction given extracardiac toxicity (increased from class I, IIa).
Quality count
In response to increasing evidence that adherence to guidelines is associated with significantly better outcomes for atrial fibrillation, the 2020 ESC/EACTS guidelines require the measurement of quality of care to identify opportunities for improvement. Recommendations were explicitly included.
With this framework in mind, a task force of 23 people, including members of the ESC, US, Asia-Pacific, and Latin American Heart Rhythm Society, was created with patient representatives to produce a list of quality indicators (QI), Ultimately, it will be resolved with 17 major QIs and 17 secondary QIs, says Elena Arbelo, MD, PhD, and MSc of the University of Barcelona, Spain.
QIs fall into six domains: patient assessment, anticoagulation therapy, rate control, rhythm control, risk factor modification, and, importantly, outcome measurement. The complete list is accessible on paper at the same time Release To EP EuroPace.
The five patient-reported outcomes fall into the outcome domain, but the only quality indicator is health-related quality of life. The remaining results are still significant, but are listed as side effects due to a lack of evidence to maintain or defend systematic implementation, especially as to how to properly measure them.
“Hopefully, [class I] The recommendations of the 2020 ESC Guidelines for the periodic collection of patient-reported results will allow more evidence to be gathered, and in the future there will be sufficient evidence to include these as key outcomes. Will be done.”
Hindricks said the QI work was in parallel with the guidelines and had a significant impact on development, including the inclusion of clear recommendations on how quality was measured. “I do not believe we can overestimate the overall quality control issues in treating patients with a focus on patient values.”
Disclosure information for all writing committee members is included in the report. Mandrola is a Medscape writer and podcaster.
European Heart Association (ESC) Conference 2020. Announced on August 29, 2020.
Euro Heart J.. Published August 29, 2020 Online. Full text
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