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AF 2023 ACC guidelines half atrial fibrillation
- 1. Atrial Fibrillation ACC guidelines 2023 Dr Rajesh Ponnada Cardiology Resident Apollo Hospital, Visakhapatnam
- 2. Incidence and prevalence Increasing Increase in Aging Population Increase in Obesity Increased Survival in AF patients Multi factorial Increased Detection
- 4. Mortality 12% Stroke 14% dementia 8% Heart failure 30% MI 8% CKD 8% PAD 8% SCD 12% SEQUEL OF AF 0 1 2 3 4 5 6 Mortality Stroke dementia Heart failure MI CKD PAD SCD Risk Probability
- 5. Age-Standardized Global Prevalence Rates of AF and Atrial Flutter per 100,000, Both Sexes, 2020
- 6. Risk Factors for Diagnosed AF
- 13. Consider Increased Surveillance Treat modifiable risk Factors Monitor AF burden clinically throughout Risk of stroke Assessment, Pathophysiological changes, Treatment of symptoms S.O.S
- 14. S.O.S
- 15. Definitions Term Definitions AF A SVT with uncoordinated atrial activation and ineffective atrial contraction Clinical AF Subclinical AF Atrial high-rate episodes AF burden First detected AF Paroxysmal AF Persistent AF Long-standing persistent AF Permanent AF
- 16. Risk Stratification and Population Screening CHARGE-AF (Co- horts for Heart and Aging Research in Genomic Epidemiology model for atrial fibrillation Total points 0-8. For the C2HEST score, the C statistic was 0.749, with 95% CI of 0.729–0.769.10 The incident rate of AF increased significantly with higher C2HEST scores.
- 17. Newly diagnosed or suspected AF Assess other electrical abnormalities • Basic laboratory tests, CKD, LFTs and hyperthyroidism. electrolyte abnormalities, • clinically relevant disorders , Bleeding/Stroke risk • Transthoracic Echocardiogram Chamber size, Valve Functions, RV pressure, LVEF, Impacts decision on Antiarrhythmic medication, Rhythm control therapies Strain Imaging,( for infiltrative disorders Amyloidosis) LA size and function, stronger predictor of recurrence after ablation • Ambulatory electrocardiographic monitoring, may be pursued based on the results of these initial evaluations
- 18. The initial clinical evaluation of the patient with newly diagnosed or suspected AF
- 19. Monitoring options for AF standard 12-lead ECG, continuously recording loop-recording electro- cardiographic monitors implantable loop recorders handheld ECGs, and smartwatches (Photoplethysmography) RCTs have demonstrated that implantable cardiac monitors exhibit the highest sensitivity in detecting AF compared with external ambulatory monitors, likely related to the longer duration of monitoring
- 21. LIFESTYLE AND RISK FACTOR MODIFICATION (LRFM) FOR AF MANAGEMENT Obesity and physical inactivity each independently increase the risk of newly diagnosed AF But avoid pursuing years of regular, high-volume (>3 h/day) high-intensity endurance training , J curve Phenomenon Bariatric surgery in Class III obese individuals (BMI >40 kg/m2) with AF was associated with improved sinus rhythm maintenance after catheter ablationand reversal of AF
- 23. In patients with AF and diabetes undergoing catheter ablation, optimal glycemic control preablation may lessen the risk of AF recurrence postablation.3
- 24. Comprehensive Care RACE 3 (Rate Control versus Electrical cardioversion for persistent atrial fibrillation) trial (SAFETY [Standard versus Atrial Fibrillation specific management study])
- 25. PREVENTION OF THROMBOEMBOLISM Risk Stratification Schemes patient’s absolute risk of stroke is central to recommendations about anticoagulation Category Rate Low < 1% per year Intermediate 1 to 2 % per year High >2 % per year Net Clinical Benefit Patient preference Bleeding risk Ischemic stroke risk Scores are problematic to use in clinical decision-making because they incorporate several clinical factors that increase the risks of both stroke and bleeding HEMORR2HAGES HAS-BLED
- 26. CHA2DS2-VASc score Original CHADS2 suboptimal performance in selected populations, Renal diseases Newer risk scores may modestly improve risk discrimination (c-index) compared with CHA2DS2-VASc and may offer potential advantages in specific populations ATRIA (Anticoagulation and Risk Factors in Atrial Fibrillation), GARFIELD-AF3 (Global Anticoagulant Registry in the Field-Atrial Fibrillation) risk scores
- 27. A higher risk of bleeding without predicting higher risk of stroke Factors previous bleeding, anemia, and certain medications Population-based studies suggest that the benefits of stroke prevention with oral anticoagulation generally outweigh the risks of bleeding, even in patients determined to be at high risk for bleeding Decision-making about oral anticoagulation should be based on consideration of both benefits and harms, not by using bleeding risk scores in isolation,
- 28. CHA2DS2-VASc of 1 (CHA2DS2-VASc of 2 in women) Additional Risk Factors discussion with patients 1-point-concept of risk estimation in the subgroup of patients with a CHA2DS2-VASc score AF burden, can be considered when interpreting a stroke risk score Degree of Hypertension Control ARISTOTLE (Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation) trial, a single elevated BP measurement during the study was associated with a 50% increased risk of stroke patient-specific risk factors, such as certain biomarkers (eg, proBNP), LA or left atrial appendage (LAA) function and anatomy, or ECG features, among others
- 29. Additional Risk Factors That Increase Risk of Stroke Not Included in CHA2DS2-VASc Risk Factor Definitions for CHA2DS2-VASc Score as in the Original Article2
- 31. Risk-Based Selection of Oral Anticoagulation: Balancing Risks and Benefits Risk of stroke should inform the decision Regardless of the pattern of AF Periodically Reassessed
- 33. High risk for stroke or systemic embolism is about 2% per year DOAC trials Re-LY [Randomized Evaluation of Long- Term Anticoagulation Therapy ROCKET AF [Rivaroxaban Once Daily Oral Direct Factor Xa Inhibition ARISTOTLE Vitamin K Antagonism for Prevention of Stroke and Embolism Trial in Atrial Fibrillation] ENGAGE AF-TIMI 48 [Effective Anticoagulation with Factor Xa Next Generation in Atrial Fibrillation – Thrombolysis in Myocardial Infarction 48 intermediate risk (1%-2%/y) can also benefit from anticoagulation, and the RE-LY1 and ARISTOTLE3 trials
- 34. IMproved ICH and mortality risk of DOACs compared with warfarin in meta- analyses of the DOAC trials,5-7 it is appropriate to designate a lower stroke risk threshold if a DOAC is utilized Markov state transition decision model16 concluded that anticoagulation was preferred for a stroke rate of 1.7%. AVERROES trial (Apixaban Versus ASA to Prevent Stroke In AF Patients Who Have Failed or Are Unsuitable for Vitamin K Antagonist Treatment) Aspirin was studied compared to apixaban Trial was stopped early due to the benefit of apixaban over Aspirin to prevent stroke or systemic embolism, while major bleeding was similar between the 2 arms.
- 35. ACTIVEW (Atrial fibrillation Clopidogrel Trial with Irbesartan for prevention of Vascular Events) combination of clopidogrel and aspirin was compared to VKAs trial was stopped prematurely due to T he superiority of anticoagulation with VKAs to prevent stroke, non–central nervous system systemic embolus, MI, or vascular death
- 40. Thank you…..
Editor's Notes
- Atrial fibrillation (AF) is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the globally .The increasing burden is multifactorial; causes include the aging of the population, rising tide of obesity, increasing detection, and increasing survival with AF and other forms of cardiovascular disease The estimated global prevalence was 50 million in 2020 with majority underdiagnosed
- SDI was made up of the geometric mean of 3 common indicators: the lag distributed income per capita, mean educational achievement for those aged $15 y, and total fertility rate <25 y. SDI ranged from 0 to 1, where 0 represents the theoretical minimum level of development, whereas 1 represents the theoretical maximum level of development
- AF is associated with a 1.5- to 2-fold increased risk of death; studies suggest that the mortality risk may be higher in women than in men.6 In meta-analyses, AF is also associated with increased risk of multiple adverse outcomes, including a 2.4-fold risk of stroke, 1.5-fold risk of cognitive impairment or dementia,1.5-fold risk of myocardial infarction 2-fold risk of sudden cardiac death, 5-fold risk of heart failure (HF), 1.6-fold risk of chronic kidney disease (CKD), and 1.3-fold risk of peripheral artery disease (PAD). In Medicare beneficiaries, the most frequent outcome in the 5 years after AF diag- nosis was death (19.5% at 1 year; 48.8% at 5 years)11; the next most common diagnosis was HF (13.7%), followed by new-onset stroke (7.1%), gastrointestinal hemorrhage (5.7%), and MI (3.9%
- Other atrial arrhythmias are often encountered in patients with AF
- Altered LA compliance is known to be associated with AF11 and progression toward persistent-type AF
- The initial clinical evaluation of the patient with newly diagnosed or suspected AF should be focused on con- firming the diagnosis and identifying relevant clinical factors that will impact management. A targeted history and physical examination should be performed at the initial assessment and repeated during periodic follow- up, especially given the evolving risk of thromboembo- lism and the cadence of symptoms in response to therapy n ECG can assess other electrical abnormalities, including possible substrates such as Wolff-Parkinson-White (WPW) syn- drome, coexisting atrial arrhythmias, as well as abnor- malities that may affect decision-making in pharmacological management (eg, bradycardia, QT dura- tion)
- However, caution should be considered in pursuing years of regular, high-volume (more 3 h/day) high-intensity endurance training given observational data linking it with increased AF risk
- Almost all patients with AF have multiple conditions that either increase AF risk or are exacerbated by AF. Pa- tients with AF are also at risk of developing thromboem- bolism, stroke, and HF, so a comprehensive approach tailored to the needs of the individual patient should improve outcomes. Randomized trials have shown the efficacy of many individual components of patient-centered care for AF, as discussed earlier in this section. Several randomized and nonrandomized studies have utilized comprehen- sive programs for patients with AF The RACE 3 (Rate Control versus Electrical cardioversion for persistent atrial fibrillation) trial3 found that multifac- eted treatment for patients with AF and early HF (with mineralocorticoid receptor antagonists, statins, ACE inhibitors and/or angiotensin receptor blockers [ARBs] helped maintain sinus rhythm SAFETY [Standard versus Atrial Fibrillation specific management study]), a posthospital discharge management program specific to AF was associated with proportionately more days alive and out of hos- pital but not prolonged event-free survival relative to standard management.
- Currently used bleeding risk scores—HAS-BLED (hypertension, abnormal renal/liver function, stroke, bleeding history or predisposition, labile international normalized ratio [INR], elderly [age >65 years], drugs/alcohol concomitantly]), HEMORR2HAGES (hepatic or renal disease, ethanol abuse, malignancy, older age [>75 years], reduced platelet count or function, re-bleeding risk, hypertension [uncontrolled], anemia, genetic factors, excessive fall risk, stroke), and ATRIA (Anticoagulation and Risk Factors in Atrial Fibrillation: anemia, renal disease, elderly [age >75 years], any prior bleeding, hypertension) discriminate poorly between patients with and without bleeding
- risk discrimination is improved by including more predictors The CHA2DS2-VASc score is considered the most validated score, most therapies have used that score to prove efficacy, and thus CHA2DS2-VASc is generally the preferred score. Yet, despite its extensive use, CHA2DS2-VASc has shown suboptimal performance in selected populations, Renal diseases and also CHADVAS2 score of 2 had annual rates of stroke that ranged from low to high: <1% in 4 cohorts, 1% to 2% in 6 cohorts, and >2% in 5 cohorts,4 although higher scores were associated with higher stroke risk in each cohort
- periodic assessment should be performed once a year but might need to be performed more frequently in the context of changes in clinical status, such as reduction in renal function or development of additional risk factors
- Patients at intermediate risk (1%-2%/y) can also benefit from anticoagulation, and the RE-LY1 and ARISTOTLE3 trials included this population
- Unless there is an indication for antiplatelet therapy, such as coronary artery disease (CAD) or vascular disease, patients with AF should not be prescribed antiplatelet therapy to reduce stroke risk.
- APT is the recommended treatment of choice for patients with cryptogenic stroke, including embolic stroke of undetermined source.6,7 For patients with AF in general, however, anticoagulation has been shown to be superior to APT for stroke risk reduction