The latest guidelines address rate vs rhythm control, anticoagulation, and how to respond to device-detected AF.
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I'm Dr Neil Skolnik. Today we are going to talk about the 2023 American College of Cardiology/American Heart Association guidelines for atrial fibrillation (AF). AF is common and is often first identified in the primary care office. AF substantially increases the risk for stroke, dementia, myocardial infarction, and heart failure.
When AF is detected, three areas of care need to be addressed: symptoms, stroke risk, and modifiable lifestyle factors. Patients with AF should have an echocardiogram done as well as laboratory tests (CBC, CMP, and TSH). Stress testing is not routinely needed unless the patient has other indications for a stress test.
When someone presents with AF to the office or emergency department (ED), the first decision typically concerns rate control, aiming for a heart rate of 100-110 beats/min or less. For acute rate control in the setting of rapid ventricular response - as well as long-term rate control - either a beta-blocker or a nondihydropyridine calcium channel blocker (verapamil or diltiazem) is recommended. Whether the patient needs to be sent to the ED for acute treatment is a matter of clinical judgment.
If the patient has heart failure with reduced ejection fraction, then calcium channels blockers should not be used. A third-line agent in this situation is digoxin, and if used, long-term serum levels should be checked periodically, with a goal of 1.2 ng/mL (note that this is different from the previous goal of 2.0 ng/mL). Intravenous magnesium sulfate is an option if further rate control is needed in the ED. For patients with decompensated heart failure in whom beta-blockers or calcium channel blockers are not effective, consider amiodarone.
The next decision concerns anticoagulation for stroke prevention. Calculate the patient's risk for stroke using a validated stroke risk score such as the CHA2DS2-VASc score, taking into account the risk for bleeding. Decisions about stroke prevention must be balanced against the risk for ischemic stroke or bleeding. If the patient's annual risk for stroke is 2% (CHA2DS2-VASc score of 2% in men and 3% in women), the guidelines recommend anticoagulation to reduce the risk for stroke in both paroxysmal and persistent AF. For a 1%-2% annual stroke risk (CHA2DS2-VASc score of 1% in men and 2% in women), anticoagulation is reasonable. Use clinical judgment for patients at intermediate risk for stroke as well as those with an increased bleeding risk.
Direct oral anticoagulants (DOACs) are recommended over warfarin unless the patient has moderate or severe mitral stenosis or a mechanical heart valve. In patients who cannot take DOACs, surgical and percutaneous procedures to occlude the left atrial appendage are now options to reduce the risk for ischemic stroke without the use of anticoagulation. For patients with AF and chronic coronary disease (less than 1 year after revascularization) without a history of stent thrombosis, antiplatelet therapy should not be used in conjunction with anticoagulation due to an increased risk for bleeding without any reduction in important outcomes.
Among patients with device-detected AF (no symptoms; detected by a watch or other device), stroke risk is lower than that of patients with symptomatic AF. The recommendations for device-detected AF vary by duration of AF as well as by CHA2DS2-VASc score. See the guidelines if you are interested in more information on this fascinating topic.
Finally, what about restoration of sinus rhythm vs rate control alone? The guidelines call this a nuanced decision. The benefits of rhythm control include improved ventricular function, decrease in symptoms, and improved quality of life. One large study (the EAST-AFNET 4) showed that an early rhythm control strategy was associated with a 25% reduction in the combined endpoint of mortality rate, stroke, and hospitalizations due to HF or acute coronary syndrome.
Characteristics that favor a rhythm-control strategy include younger age, shorter history of AF, higher symptom burden, smaller left atrium, greater left ventricular dysfunction, and more atrioventricular regurgitation. The specific treatment for rhythm control, which can be pharmacologic or by catheter ablation, is discussed in detail in the guideline. This is a decision that will be made by our cardiology colleagues. Recent trials have shown a significant reduction in recurrent AF with catheter ablation compared with antiarrhythmic drugs.
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