Gregory Weiss, MD: Guidelines on Quality Measures for AFib

Gregory Weiss, MD

It is common from time to time for our flagship organizations to issue guidelines and standards of care based on the latest peer-reviewed research. While most societies and colleges of medical science generate blanket updates to guidelines on approximately ten-year cycles, as evidence emerges it is prudent to intermittently update the updates.

More than ever modern medicine requires, not only strong guidelines for diagnosis and treatment, but also strong measures intended to provide practitioners and institutions that deliver cardiovascular services the tools they need to evaluate the quality of care provided. The American College of Cardiologists (ACC) and the American Heart Association (AHA) have taken the lead in a worldwide effort to provide performance and quality measures based on evidence to ensure that we provide the highest quality cardiovascular care to all our patients.

Performance measures serve as benchmarks for clinicians and institutions to strive for and provide a looking glass into areas where improvement can be made. This update looks at the 2016 ACC/AHA quality and performance guidelines and provides guidance following the emergence of new evidence in the interim. In this update the Task Force:

• Provides a clarification that valvular atrial fibrillation is atrial fibrillation with either moderate or severe mitral stenosis or a mechanical heart valve.¹
• Establishes a separation of a male and female threshold for the CHA2DS2-VASc score. This separation applies only to the PM-5: Atrial Fibrillation/Atrial Flutter: Anticoagulation Prescribed.¹

The CHA2DS2-VASc score is the most commonly used method of predicting the risk of stroke in patients with atrial fibrillation (Afib).² The acronym stands for Congestive heart failure, Hypertension, Age (greater than 65 = 1 point, greater than 75 = 2 points), Diabetes, previous Stroke/transient ischemic attack (2 points). VASc stands for vascular disease (peripheral arterial disease, previous myocardial infarction, aortic atheroma), and sex category (female gender) is also included in this scoring system for a total of seven criteria and potentially 9 points.

A patient’s annual risk for stroke with Afib increases as the CHA2DS2-VASc score increases. Annual stroke risk can be described based on the CHA2DS2-VASc score in the following way³:

• 1 point = 1.3%
• 2 points = 2.2%
• 3 points = 3.2%
• 4 points = 4.0 %
• 5 points = 6.7 %
• 6 points = 9.8%
• 7 points = 9.6%
• 8 points = 6.7%
• 9 points = 15.2%

Guidelines suggest that patients with a score of 1 may choose to take aspirin alone or go on full anticoagulation. This decision should be made after a discussion of the pros and cons of each therapy. Patients with Afib and a score of 2 or greater are recommended to undergo full anticoagulation with warfarin, dabigatran, rivaroxaban, or apixaban.¹ The recent guideline changes regarding different CHA2 DS2 -VASc risk score treatment thresholds for men (>1) and women (>2) are now incorporated into the performance measures.¹ Left unchanged is the suggestion that when Afib is due to a heart valve problem, full anticoagulation should be utilized.

As clinicians, we rely heavily on our professional organizations to guide us in making decisions that are in our patient’s best interest. It would be impossible for each of us to review the myriad of studies hitting the journals on a daily basis. These performance measures and guidelines provide excellent information that we can use to educate our patients about Afib and their risk for stroke. I have found many patients reluctant to undertake anticoagulation for their Afib and there are valid reasons to worry especially in elderly patients who are prone to falls. It is our task to take these quality measures and set the bar for our patients while weighing the risks and benefits.

References:

1. Paul A. Heidenreich, MD, N. A. Mark Estes III, MD, Gregg C. Fonarow, MD, et al. 2020 Update to the 2016 ACC/AHA clinical performance and quality measures for adults with atrial fibrillation or atrial flutter a report of the American College of Cardiology/American Heart Association Task Force on performance measures. Circ Cardiovasc Qual Outcomes. 2021;14:e000100. DOI: 10.1161/HCQ.0000000000000100
2. Gage BF, et al. Selecting Patients With Atrial Fibrillation for Anticoagulation Stroke Risk Stratification in Patients Taking Aspirin. Circulation. 2004;doi:10.1161/01.CIR.0000145172.55640.93
3. https://www.ahajournals.org/doi/epub/10.1161/CIRCULATIONAHA.119.041303