ACC/AHA Release Updated Atrial Fibrillation Guidelines for 2023

Jose Joglar, MD
Credit: UT Southwestern Medical Center

The American College of Cardiology (ACC) and the American Heart Association have released new guidance for prevention and management of atrial fibrillation (AF).

In addition to an emphasis on healthy lifestyle habits as well as early and aggressive rhythm control, the guidelines, which were published on November 30, 2023 in the Journal of the American College of Cardiology and Circulation, provide a new staging classification for AF and endorses use of catheter ablation with a Class 1 indication as first-line therapy in select patients.¹

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.² “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.”

Although a focused update was released in 2019, the new guidance represents the first major guideline update released on the topic from the ACC and AHA since 2014. The 171-page guideline, which is endorsed by both the American College of Clinical Pharmacy and the Heart Rhythm Society, is broken down into 11 chapters and based on a comprehensive literature search was performed from May 12, 2022, to November 3, 2022.¹

According to authors, the new staging classification provides benefit, relative to the prior classification, as it does not rely only on arrhythmia duration but recognizes the disease as a continuum requiring multiple strategies at different stages.¹

The new staging classification is as follows:¹

• Stage 1: At Risk for AF
• Stage 2: Pre-AF—evidence of structural or electrical findings predisposing patient to AF.
• Stage 3: AF
  • 3A Paroxysmal AF; 3B Persistent AF; 3C Long-standing persistent AF; 3D Successful AF ablation
• Stage 4: Permanent AF—no further attempts at rhythm control after discussion between patient and clinician.

A major emphasis within the guidelines is placed on the role of early rhythm control, with a Class 1 level of recommendation for use of a trial of rhythm control to evaluate whether AF is contributing to the reduced left ventricular function. A Class 1 level of recommendation was also awarded for catheter ablation as a first-line therapy to improve symptoms and reduce progression to persistent AF in selected patients, generally younger with few comorbidities, with symptomatic paroxysmal AF in whom rhythm control is desired.¹

As with previous guidance, the latest guideline continues to endorse use of CHA2DS2-VASc for recommendations for anticoagulation but encourages incorporation of other risk variables to help inform the decision as well as the use of other clinical risk scores to improve prediction, facilitate shared decision making, and incorporate into the electronic medical record.¹

Guideline authors also called attention to a greater endorsement for left atrial appendage occlusion devices, which now boasts a Class 2a level of recommendation based on additional data on safety and efficacy of left atrial appendage occlusion devices. A reflection of the ongoing interest and research in the arena, the guideline offers updated recommendations for use of detection devices, including wearables.¹

“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,” Joglar added.²

References:

1. Joglar JA, Chung MK, Armbruster AL, et al. 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. Published online November 30, 2023. doi: 10.1161/CIR.0000000000001193
2. Early rhythm control, lifestyle modification and more tailored stroke risk assessment are top goals in managing atrial fibrillation. American Heart Association. November 30, 2023. Accessed November 30, 2023. https://newsroom.heart.org/news/early-rhythm-control-lifestyle-modification-and-more-tailored-stroke-risk-assessment-are-top-goals-in-managing-atrial-fibrillation.