The American College of Cardiology (ACC) and the American Heart Association (AHA), in collaboration with other medical associations, have released a new comprehensive guideline for the prevention and management of atrial fibrillation (AFib). Published simultaneously in the Journal of the American College of Cardiology and Circulation, the guideline addresses how doctors should treat patients with AFib, a condition that is increasingly prevalent and already affects more than six million people in the United States.
The updated recommendations emphasize a multifaceted approach, integrating lifestyle modifications, early rhythm control strategies, and advancements in therapeutic interventions. If left untreated, AFib can lead to exacerbated heart failure and also significantly increase a person’s risk for stroke.
A notable shift in the new guideline is a new classification system for AFib based on stages, moving away from solely relying on arrhythmia duration. This change emphasizes the continuum of the disease and promotes a holistic, multidisciplinary management approach. The guideline recognizes AFib as a complex cardiovascular condition requiring diverse strategies at different stages, including prevention, lifestyle modification, screening, and therapy. It also provides guidance on medications that regulate the rhythm and rate of patients, the use of anticoagulants, and at which times to pause or stop the use of these medications.
“This is a complex disease. It’s not just an isolated disorder of the heart’s rhythm, and we now know that the longer someone is in AFib, the harder it is to get them back to normal sinus rhythm,” said Jose Joglar, MD, professor of cardiac electrophysiology at UT Southwestern Medical Center in Dallas and chair of the writing committee. “The new guideline reinforces the urgent need to approach AFib as a complex cardiovascular condition that requires disease prevention, risk factor modification, as well as optimizing therapies and patients’ access to care and ongoing, long-term management.”
The new guidelines detail some specific approached to managing and treating AFib including:
Lifestyle Modifications and Prevention-The guideline underscores a stronger focus on healthy lifestyle habits to prevent or alleviate the burden of atrial fibrillation. Jose Joglar, MD, chair of the writing committee, highlights the need for prescriptive recommendations, stating, “Many patients don’t know where to start when they are given advice about lifestyle modification, so we are very specific with our recommendations.” This includes targeted advice on weight loss, obesity prevention, physical activity, smoking cessation, limiting alcohol, and controlling blood pressure and other comorbidities. The aim is to empower clinicians to provide patients with clear, actionable goals for healthier living.
Catheter Ablation as First-Line Therapy-Based on recent data supporting its effectiveness over medications in preventing disease progression, the guideline has elevated catheter ablation to a Class 1 treatment recommendation for appropriately selected patients. This is a change to the traditional approach of considering it as a second-line option after medication. Catheter ablation, a minimally invasive procedure that disables irregular heart tissue, is now advised as a first option in some AFib patients, particularly those with heart failure with reduced ejection fraction.
Stroke Prevention and Risk Stratification-While endorsing the continued use of the CHA2DS2-VASc score for assessing stroke risk, the guideline allows for flexibility in incorporating other risk calculators when uncertainty exists or additional risk factors need to be considered. Kidney disease, for instance, not included in CHA2DS2-VASc, may be assessed using alternative tools. The guideline encourages clinicians to evaluate patients at intermediate risk using multiple risk calculators to make informed decisions about blood thinner prescriptions.
Left Atrial Appendage Closure Devices-The guideline also advises for a greater use of left atrial appendage closure devices for stroke prevention. These devices, positioned in the heart’s left atrial appendage, prevent blood clots from entering the bloodstream. This recommendation reflects advancements in technology and the potential benefits of these devices in certain patient populations.
The new ACC/AHA atrial fibrillation guideline is intended to provide advice to physicians on newer treatment modalities without being rigid, Joglar noted. “The new guideline gives clinicians flexibility to use other predictive tools, and we hope this will also enhance communication and shared decision-making with patients,” he said.
Similar to other chronic conditions, such as high blood pressure or Type 2 diabetes, Joglar added we “now have a better understanding and more tools to prevent, treat and also mitigate the risk of AFib so that we can improve patient outcomes.”