Guideline Updates for Atrial Fibrillation

Educational Objectives

The goal of this program is to improve management of atrial fibrillation. After hearing and assimilating this program, the clinician will be better able to:

1. Promote the benefits of lifestyle modification for atrial fibrillation.
2. List the indications for left atrial appendage occlusion and catheter ablation in patients with atrial fibrillation.

Summary

Stages of atrial fibrillation (AF): have been introduced in a recent guideline update; patients with stage 1 do not have AF but have risk factors (RFs), eg, obesity, hypertension; it does not need to be documented for every patient, but emphasize that RF modification lowers risk; stage 2 is not clinical AF but features frequent premature atrial contractions or short episodes of atrial tachycardia; patients are at higher risk for AF, and it is uncertain whether treatment can prevent AF; patients may require intensive monitoring, especially if they are at risk for stroke; stage 3 is classified into paroxysmal, persistent, and longstanding persistent AF; stage 3D is after successful ablation; stage 4 is permanent AF and requires ongoing rate control

Lifestyle modifications (class 1 recommendation): can be implemented before or after developing AF in patients with obesity, hypertension, or alcohol use; losing ≈10% of body weight is recommended for those who are overweight or obese; Pathak et al (2015) — demonstrated that patients with a body mass index ≥27 with paroxysmal AF who lost ≥10% of their body weight, regardless of treatment with antiarrhythmic medications or ablation, had better freedom from AF than those who gained or lost less weight; Peigh et al (2021) — found that patients who lost weight prior to ablation had better results; however, patients of normal weight did not show any benefits with weight loss; emphasize to these patients that it is important to maintain their current weight; Goldberg et al (2023) — showed that adding liraglutide (ie, weight loss) to RF modification increased freedom from AF; substances — any amount of alcohol increases risk for AF; caffeine was previously considered to increase risk, but abstaining from caffeine does not prevent AF; however, encourage those for whom caffeine is a trigger to stop drinking coffee; sleep apnea — management is the lowest (2B) recommendation; data show mixed results; although there are benefits to treating sleep apnea, there is no strong evidence that using continuous positive airway pressure reduces AF burden

Left atrial appendage (LAA) occlusion (LAAO): used in patients at high risk for stroke in whom long-term oral anticoagulants (OACs) are contraindicated; percutaneous LAAO devices (eg, Watchman, Amulet) are now a 2A recommendation; a new 2B recommendation is for patients who are at high risk of bleeding and who prefer the procedure over lifelong OAC use; this decision should be made mutually between the patient and clinician by weighing the risks of the procedure (eg, leaks, late device-related thrombus) vs OAC use, as there are good data supporting OACs; surgical exclusion of the LAA during cardiac surgery has a higher recommendation; Connolly et al (2023) found that patients with LAAO were at significantly lower risk for stroke than patients who did not; however, most of these patients continued taking OACs after the procedure, which is in contrast to common clinical practice; the new 2B recommendation clarifies that it is unclear whether excluding the LAA prevents strokes without continuing OACs; the speaker recommends using imaging before stopping OACs to confirm adequate exclusion of the LAA, as the surgical techniques used to exclude LAA vary and may leave residual tissue

Catheter ablation: patients with symptomatic AF who have previously tried antiarrhythmic medications or prefer not to use them can benefit from catheter ablation to improve their symptoms (class 1 recommendation); another class 1 recommendation states that catheter ablation is recommended as first-line treatment for select patients for symptom relief and to reduce progression to persistent AF; Andrade et al (2023) showed that catheter ablation is more effective than antiarrhythmic medication for maintaining sinus rhythm and for lessening progression of AF from paroxysmal to persistent; currently, early ablation for younger patients, especially those with symptomatic AF, is recommended regardless of type; early catheter ablation for asymptomatic young, healthy patients (particularly those with paroxysmal AF) to prevent persistent AF is a 2B recommendation; complications — overall rate is ≈3.8%; the most common complications are vascular injuries from femoral vein access; most complications are repairable and resolve over time; serious complications are less common, and mortality is rare; pulmonary vein stenosis, atrial-esophageal fistula, and permanent phrenic nerve injury are extremely rare, especially with newer technologies

Indications for patients with AF and heart failure (HF): earlier rhythm control (preferably with catheter ablation) is recommended, particularly when HF is related to AF; patients with HF unrelated to AF (eg, due to multiple heart attacks) may benefit from ablation, but based on Marrouche et al (2018) trial, it is not necessarily a class 1 recommendation

Readings

Andrade JG. Ablation as first-line therapy for atrial fibrillation. Eur Cardiol. 2023;18:e46. Published 2023 Jul 27. doi:10.15420/ecr.2023.04; Andrade JG, Deyell MW, Macle L, et al. Progression of atrial fibrillation after cryoablation or drug therapy. N Engl J Med. 2023;388(2):105-116. doi:10.1056/NEJMoa2212540; Connolly SJ, Healey JS, Belley-Cote EP, et al. Oral anticoagulation use and left atrial appendage occlusion in LAAOS III. Circulation. 2023;148(17):1298-1304. doi:10.1161/CIRCULATIONAHA.122.060315; Goldberger JJ, Mitrani RD, Baez-Garcia C, et al. LB-456089-1 Pre-ablation weight loss as a predictor of atrial fibrillation ablation outcome in the liraglutide effect on atrial fibrillation (LEAF) study. Heart Rhythm. 2023;20(7):1079. https://doi.org/10.1016/j.hrthm.2023.04.029.; Marrouche NF, Brachmann J, Andresen D, et al. Catheter ablation for atrial fibrillation with heart failure. N Engl J Med. 2018;378(5):417-427. doi:10.1056/NEJMoa1707855; Nesheiwat Z, Goyal A, Jagtap M. Atrial fibrillation. StatPearls Publishing. 2023 Apr 26. Available from: https://www.ncbi.nlm.nih.gov/books/NBK526072/; Pathak RK, Middeldorp ME, Meredith M, et al. Long-term effect of goal-directed weight management in an atrial fibrillation cohort: A long-term follow-up study (LEGACY). J Am Coll Cardiol. 2015;65(20):2159-2169. doi:10.1016/j.jacc.2015.03.002; Peigh G, Wasserlauf J, Vogel K, et al. Impact of pre-ablation weight loss on the success of catheter ablation for atrial fibrillation. J Cardiovasc Electrophysiol. 2021 Aug;32(8):2097-2104. doi: 10.1111/jce.15141. Epub 2021 Jul 5. PMID: 34191371; PMCID: PMC9305992.; Rotta Detto Loria J, Desch S, Pöss J, et al. Percutaneous left atrial appendage occlusion-current evidence and future directions. J Clin Med. 2023;12(23):7292. Published 2023 Nov 24. doi:10.3390/jcm12237292; Yamane T. Catheter ablation of atrial fibrillation: Current status and near future. J Cardiol. 2022;80(1):22-27. doi:10.1016/j.jjcc.2022.02.005.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Kaplan was recorded at the 46th Annual Cardiology Update, held May 30 to June 1, 2024, in Charleston, SC, and presented by the Medical University of South Carolina. For information about upcoming CME activities from this presenter, please visit https://medicine.musc.edu/education/cme. Audio Digest thanks the speakers and presenters for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0.50 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0.50 CE contact hours.

Lecture ID:

IM714602

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.