A new staged framework for atrial fibrillation (Afib) classification was proposed in updated U.S. guidelines.
Afib catheter ablation gained a broader class I recommendation from the American College of Cardiology and American Heart Association (ACC/AHA) for improving symptoms in people with all subtypes of symptomatic Afib when antiarrhythmic drugs have not worked or been tolerated.
First-line use also gained the same class I rank for selected individuals with symptomatic paroxysmal Afib wishing to improve their symptoms and prevent progression to persistent Afib.
- Stage 1 (at risk for Afib): presence of risk factors such as obesity, hypertension, sleep apnea, genetics, and older age
- Stage 2 (pre-Afib): evidence of structural or electrical findings such as atrial enlargement and atrial flutter
- Stage 3 (Afib): substages from paroxysmal Afib (3A), persistent Afib (3B), and long-standing persistent Afib (3C) to successful Afib ablation (3D)
- Stage 4 (permanent Afib): no further attempts at rhythm control or monitoring following a patient-clinician discussion
Across all four stages in Afib, modifiable risk factors should be treated, whether with lifestyle changes or medications. Heightened surveillance may be considered starting in stage 2 pre-Afib, but stroke risk assessment and therapy should not be introduced until stage 3 Afib.
“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 writing committee chair Jose Joglar, MD, of UT Southwestern Medical Center in Dallas, in a press release.
“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,” he continued.
His group put a new emphasis on healthy lifestyle to prevent progression or lessen the burden of Afib. Obese and overweight patients should target 10% weight loss (class I recommendation). People with Afib should perform 210 minutes of weekly moderate-to-vigorous exercise (class I). Also recommended were tobacco cessation for smokers with a history of Afib (class I) and reduced alcohol consumption in people with Afib (class I).
In contrast, abstaining from caffeine was deemed to be of no benefit in Afib, though it may reduce symptoms in patients reporting caffeine as a trigger for Afib symptoms (class III).
The ACC and AHA also upgraded percutaneous left atrial appendage occlusion to “reasonable” (class IIa) for patients with Afib and a moderate-to-high risk of stroke (CHA2DS2-VASc score ≥2) and a contraindication to long-term oral anticoagulation.
The guidelines offered options in how to calculate stroke risk.
Although CHA2DS2-VASc has a class I endorsement for stroke risk assessment, guideline authors acknowledged that this validated risk calculator leaves room for uncertainty by leaving out kidney disease and other risk factors. Patients with Afib at intermediate risk who remain uncertain about the benefit of anticoagulation may consider these outside factors to inform this and other decision-making (class II recommendation).
“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 said.
Future research needs to include better individualization of Afib and stroke risk, as well as more clarity on the role of general Afib screening and the magnitude of subclinical Afib that would merit stroke prevention therapy, Joglar’s group noted.
The authors added that no recommendations could be made for use of upstream therapies such as glucocorticoids, statins, renin-angiotensin-aldosterone system inhibitors, or SGLT-2 inhibitors for the prevention of Afib, due to limited or inconsistent data.
The ACC/AHA guideline was co-developed with and endorsed by the American College of Clinical Pharmacy and the Heart Rhythm Society.
Joglar had no disclosures.
Other guideline committee members had relevant relationships with industry.
Journal of the American College of Cardiology
Source Reference: Joglar JA, et al “2023 ACC/AHA/ACCP/HRS guideline for the diagnosis and management of atrial fibrillation” J Am Coll Cardiol 2023; DOI: 10.1016/j.jacc.2023.10.021.