Atrial Fibrillation Guidelines 2023

Diagnosis and Management of Atrial Fibrillation Guideline (2023 ACC/AHA/ACCP/HRS)

• Guideline updates separate guidelines from 2014 and 2019
• Covers diagnosis and management of atrial fibrillation (AF)
• Outlines: AF background and pathophysiology, lifestyle and risk factor modifications for AF management, prevention of thromboembolism, rate control, and rhythm control

Beyond the Scope of this Presentation

• Genetics of AF
• Silent AF and stroke of undetermined cause
• Non-pharmacological stroke prevention
• Management of patients with AF and ICH
• Role of pacemakers and ICDs
• AF and specific patient groups and AF with HF

Background and Pathophysiology

• AF is a supraventricular tachyarrhythmia with uncoordinated atrial activation and ineffective atrial contraction
• It's the most common type of cardiac arrhythmia
• ECG characteristic: absence of distinct P waves
• Impulses originate from additional sources (ectopic foci) within the heart, instead of the SA node, or result from reentrant activity
• This causes atrial quivering (stasis), significantly increasing stroke risk

Epidemiology

• 50 million estimated individuals worldwide with AF in 2020
• At least 5.6 million individuals in the USA with AF in 2015
• AF is associated with increased risks of death, stroke, sudden cardiac death, heart failure, dementia, myocardial infarction, chronic kidney disease, and peripheral artery disease

Risk Factors for Diagnosed Atrial Fibrillation

• Demographic, Anthropometric, and Cardiovascular Risk Factors: Advancing age, obesity, smoking, low physical activity, hypertension, elevated resting heart rate, diabetes, chronic kidney disease, obstructive sleep apnea, coronary artery disease, cardiac surgery, valvular heart disease
• Non-Cardiac Conditions: Sepsis, thyroid disease
• Genetic Markers: Family history, heritability, presence of associated loci (GWAS)
• Socioeconomic Determinants of Health: Education level, income level, socioeconomic status
• Biologic Markers: Prolonged PR interval, left ventricular hypertrophy (LVH), elevated brain natriuretic peptide (BNP), raised inflammatory markers (IL6/TNF-alpha), increased left atrial size, raised lipoprotein (a), increased left ventricular wall thickness.

Atrial Fibrillation Stages Evolution of Atrial Arrhythmia Progression

• Paroxysmal AF: Terminates spontaneously within 7 days of onset, episodes may recur
• Persistent AF: Sustained for more than 7 days
• Long-standing persistent AF: AF lasting more than 12 months
• Permanent AF: Patient and clinician agree to stop further attempts to restore normal sinus rhythm; acceptance of AF reflects a therapeutic attitude.
• Nonvalvular AF: Absence of rheumatic mitral stenosis, a mechanical or bioprosthetic heart valve, or mitral valve repair

Lifestyle and Risk Factor Modification (LRFM) for AF Management

• Primary Prevention: Patients at increased risk of AF should receive comprehensive guideline-directed LRFM, targeting--Obesity, Smoking, Diabetes, Physical inactivity, Alcohol consumption, Hypertension
• Secondary Prevention: Overweight or obese patients should aim for at least a 10% weight loss, target of 210 min/week of moderate to vigorous exercise training, optimal blood pressure control including use of guideline-directed medical therapy for tobacco cessation

Prevention of Thromboembolism

• Risk Stratification: Annual risk of thromboembolic events to be evaluated using a validated clinical risk score, such as CHA2DS2-VASc
• Anticoagulation: Oral anticoagulation recommended if the annual risk of stroke is ≥2%/year; or if the annual risk is 1 to 2%/year in those with AF who are not candidates for rhythm control
• Specific Populations: Anticoagulation in patients with chronic coronary artery disease, AF complicated by acute coronary syndrome or percutaneous coronary intervention (PCI). Anticoagulation should consider the specific risk factors in specific populations like valve disease, peripheral vascular disease

Rate Control

• Goal: Target resting heart rate <100–110 bpm in patients without heart failure (HF)
• Pharmacological agents: Beta blockers; Non-DHPs; Digoxin (used with caution); Amiodarone
• Acute rate control: Direct current cardioversion, Magnesium, Beta blockers, verapamil and diltiazem; Digoxin,Amiodarone
• Chronic rate control: Nodal ablation, beta blockers, Digoxin, Nodal conduction system drugs like Diltiazem or Verapamil

Rhythm Control

• Goals: Rate vs. rhythm control, rhythm control therapy in AF, Prevention of thromboembolism in the setting of cardioversion, electrical and pharmacological cardioversion
• Favors rate control vs. rhythm control: Patient factors (preferences, age, history of AF, symptom burden), physical examination factors (easily controlled heart rate, LA size, LV dysfunction, AV regurgitation)
• Rhythm control therapies: Electrical and pharmacological cardioversions, catheter ablation, choice of antiarrhythmic agents for maintenance of sinus rhythm
• Factors to consider for atrial fibrillation and choosing between rate and rhythm control strategies: Patient’s overall health, comorbidities, symptom burden, preferences.
• Inpatient initiation of antiarrhythmic agents: Considerations include drug duration, admission time, facility capabilities, need for continuous ECG monitoring, periodic creatinine clearance calculations, and cardiac resuscitation

Anticoagulation in Specific Populations

• Chronic coronary disease
• Complicating acute coronary syndrome or percutaneous coronary intervention (PCI)