ACCEL | Reflections on the New ESC Atrial Fibrillation Guidelines

CardioSource WorldNews | The 2014 Guideline for the Management of Patients with Atrial Fibrillation (AF) from the American College of Cardiology/American Heart Association (ACC/AHA) contained several new significant recommendations.1 Among them: use of the more comprehensive thromboembolic risk calculator, known as CHA2DS2-VASc, that was developed and first adopted in Europe.

Now, a new set of European Society of Cardiology (ESC) AF guidelines have been published online ahead of print,2 and this time they are adopting an approach that is now part of all ACC/AHA guidelines: the heart team. According to Stefano Benussi, MD, PhD, the co-chair of the task force that developed the new document, “These are the first guidelines to target every atrial fibrillation specialist.”

They were developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS). Dr. Benussi added, “They were written by clinical cardiologists, electrophysiologists, cardiac surgeons, a neurologist and a cardiovascular nurse.” His co-chair, Professor Paulus Kirchhof, MD (UK and Germany), said, “Integrating input from the different specialties can improve outcomes in patients with atrial fibrillation.”

No argument here. In the United States, the 2014 ACC/AHA AF guidelines writing committee was composed of clinicians with broad expertise related to AF and its treatment, including adult cardiology, electrophysiology, cardiothoracic surgery (including a representative from the Society of Thoracic Surgeons), and heart failure (HF). According to the vice chair of the ACC/AHA AF guidelines, L. Samuel Wann, MD, MACC, such broad-ranging expertise is critical when developing guidelines: “The American College of Cardiology has long embraced the concept of cardiovascular team-based care, which is particularly important in the care of chronic conditions such as atrial fibrillation, but also important in many other areas, including heart failure, valvular heart disease, and prevention.”

Dr. Wann noted that the 2015 ACC Health Policy Statement on Cardiovascular Team-Based Care gives details of this approach, which is now recommended (but not repeated) in each of the ACC’s Practice Guidelines.3 “We are in full agreement that the best care for patients with atrial fibrillation is delivered by a coordinated team consisting of both physicians and non-physicians with training and specialized experienced in different aspects of patient care.”

The ESC is now taking the same approach, promoting the development of AF Heart Teams with experience in antiarrhythmic drugs, catheter ablation, and surgery to make difficult decisions on rhythm control and hybrid therapy, especially in complex cases. Dr. Benussi said, “There is growing awareness that we need teams to treat complex patients with atrial fibrillation. Putting patients at the center of the treatment algorithm should improve the chances of getting rid of the arrhythmia, with the lowest possible risk. AF Heart Teams should be deployed particularly when the results of treatment are unsatisfactory.”

Changing Emphasis in AF

The new ESC document places greater emphasis on the early diagnosis of AF, before the first stroke. The guidelines committee that developed the new document found sufficient evidence to support opportunistic and targeted electrocardiography (ECG) screening, for example, in people over 65 years of age and in high-risk groups such as patients with pacemakers. “Many people have atrial fibrillation and don’t know it, and will only find out when they develop a first stroke,” said Professor Kirchhof. “Early diagnosis enables us to prevent strokes with anticoagulation.”

Dr. Kirchhof noted that previous guidelines focused on which patients should receive anticoagulation, “and that issue is largely settled.” One important aspect of the new guidelines, he said, is that they “address the long-term challenges in anticoagulated atrial fibrillation patients that all too often lead to discontinuation of anticoagulant therapy despite prognostic benefits in the long term.”

Toward this end, the new ESC guidelines encourage clinicians to provide tailored information and education to AF patients to empower and support them, such as emphasizing lifestyle changes to make management more effective. This can be achieved, in part, through the use of goal-based follow-up. For example, for comorbidity control this might include paying attention to obesity, hypertension, HF, coronary artery disease, diabetes, and valvular heart disease. The performance indicators during follow-up would include weight loss; blood pressure control; HF therapy; statin and antiplatelet therapy or revascularization, if necessary; good glycemic control; and valve repair or replacement.

Overall, the ESC is promoting an integrated approach with structured organization of care and follow-up for all patients with AF, with a goal of improving guideline adherence and reducing hospitalizations and mortality.

Finally, like the AHA/ACC guidelines, the new ESC document recommends catheter ablation as a first-line treatment in select patients. Pulmonary vein isolation is recommended as the preferred first target of ablation, with more extensive ablations reserved for repeat procedures in patients with recurrent AF. It’s an important issue, given that recurrence rates after catheter ablation are high in the long term, and hybrid therapy with antiarrhythmic drugs and catheter ablation or AF surgery are reasonable treatment option in patients who fail conventional rhythm control therapy.

In this ACCEL interview, Christopher B. Granger, MD, FACC, a professor of medicine and director of the cardiac care unit at Duke University Medical Center in Durham, NC, discusses what’s new in the new ESC guidelines, including:

  • A preference for the nonvitamin K oral anticoagulants (NOACs) rather than warfarin in patients who are eligible.
  • A preference for NOACs even in patients already on warfarin.
  • A deliberate decision to make no recommendation to use a bleeding risk score, based on a concern that too much emphasis on bleeding risk in previous guidelines has led to undertreatment and too few patients on oral anticoagulation.
  • There is no use of the term nonvalvular atrial fibrillation in these guidelines, acknowledging that moderate-to severe valvular abnormalities are common in patients
    • with AF and these patients can benefit from oral anticoagulation.
  • Aspirin is now given a Class III recommendation, acknowledging that in this setting of AF, aspirin is either ineffective or harmful.

References

  1. January CT, Wann L, Alpert JS, et al. J Am Coll Cardiol. 2014;64:e1-e76.
  2. Kirchhof P, Benussi S, Kotecha D, et al. Eur Heart J. 2016;doi:10.1093/eurheartj/ehw210 [Epub ahead of print]
  3. Brush JE, Jr., Handberg EM, Biga C, et al. J Am Coll Cardiol. 2015;65:2118-36.
Read the full December issue of CardioSource WorldNews at ACC.org/CSWN

Clinical Topics: Arrhythmias and Clinical EP, Atrial Fibrillation/Supraventricular Arrhythmias

Keywords: CardioSource WorldNews, American Heart Association, Atrial Fibrillation, Disease Management, Surgeons, Thoracic Surgery


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