ACC Updates Guidelines for Treating Patients with Atrial Fibrillation

Francis Alenghat, MD, PhD

The American College of Cardiology (ACC), American Heart Association (AHA), and Heart Rhythm Association (HRS) have announced an updated to guidelines for the management of patients with atrial fibrillation (AF).

The 2019 AHA/ACC/HRS Guideline for the Management of Patients with Atrial Fibrillation recommends 6 new major recommendations for anticoagulation, interventions to decrease the risk of an embolic stroke, and electrophysiologic approaches to convert AF back to sinus rhythm. The update was released for the public on the eve of the ACC 2019 Annual Scientific Sessions in New Orleans, LA, this weekend.

In a podcat interview accompanying the released updates, Francis Alenghat, MD, PhD, an assistant professor and cardilogist at the University of Chicago noted several key updates in the guidelines.

"The guidelines discuss management of anticoagulation for atrial fibrillation and also management of the rhythm itself,” Alenghat explained.

The new guideline was published as an update to the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation. To compose the 2019 guidelines, the ACC/AHA Task Force on Practice Guidelines invited new members and members of the previous writing committee.

The guidelines recommends oral anticoagulants for patients with AF and an elevated CHA2DS2-VASc score, which is 2 or more in men and 3 or more in women.

Despite warfarin being a mainstay of therapy for thromboembolic prophylaxis for years, the guideline recommends novel oral anticoagulants (NOACs) over warfarin in NOAC-eligible patients with AF. Several randomized clinical trials have demonstrated use of NOACs, such as are dabigatran, rivaroxaban, apixaban, and edoxaban, as alternatives to warfarin. These NOACs have been shown to be non-inferior to warfarin in the prevention of stroke and systemic embolism.

In patients where long-term anticoagulation is not possible, percutaneous left atrial appendage closure (LAAC) may be considered. A meta-analysis of randomized clinical trials demonstrated non-inferiority of a LAAC device versus warfarin in the combined end point of cardiovascular death, stroke, and systemic embolism. In this analysis, hemorrhagic stroke occurred less frequently in patients undergoing LAAC. This benefit came at the expense of increased ischemic strokes in the LAAC groups.

For patients with AF or atrial flutter of 48 hours or longer, or when then duration is unknown, anticoagulation is recommended for at least 3 weeks before and 4 weeks after cardioversion regardless of CHA2DS2-VASc score. This recommendation is based on trials that demonstrated efficacy and safety of NOACs for this indication.

Catheter ablation of AF may be reasonable in patients with symptomatic AF and heart failure with reduced left ventricular ejection fraction to potentially lower mortality rate and reduce hospitalization for heart failure. This recommendation is based on findings from an open-label clinical trial that demonstrated catheter ablation was associated with a lower rate of all-cause death or hospitalization for worsening heart failure than medical therapy.

For overweight or obese patients, weight loss, combined with risk factor modification is recommended. These recommendations are based on data showing that weight loss reduces symptom burden, symptom severity, and number of AF episodes.

“There were a lot of practical pieces in this guideline, which for the clinician and the practitioner, is going to be helpful in terms of making decisions,” Gaurav A. Upadhyay, MD, assistant professor at the University of Chicago, Clinical Cardiac Electrophysiologist and Clinical Researcher, added in the podcast interview.

Guideline creators added that there could be an expectation for the use of NOACs to increase but because no blood test exists that proves adherence to NOACs, physicians may need to consider usage of transesophageal echocardiography to exclude the presence of atrial thrombus prior to cardioversion.

LAAC carries procedural risks not associated with medical therapy. In addition to this, catheter ablation can be associated with procedural complications and repeat procedures may be required in up to 20% of patients. Authors recommend further, large randomized clinical trials to compare catheter ablation with medical therapy.