Diagnosis and Management of Atrial Fibrillation Guideline PDF 2023

Diagnosis and Management of Atrial Fibrillation Guideline 2023 ACC/AHA/ACCP/HRS SCE 1  Outlines 1. AF Background and Pathophysiology 2. Lifestyle and risk factor modifications for AF management 3. P...

Diagnosis and Management of Atrial Fibrillation Guideline 2023 ACC/AHA/ACCP/HRS SCE 1  Outlines 1. AF Background and Pathophysiology 2. Lifestyle and risk factor modifications for AF management 3. Prevention of thromboembolism 4. Rate control 5. Rhythm control Beyond the scope of this presentation 1. Genetics of AF 4. Management of Patients With AF and ICH 2. Silent AF and Stroke of Undetermined Cause 5. Role of Pacemakers and ICDs 3. Non-pharmacological Stroke Prevention 2 6. Af and specific patient groups and AF with HF  Updates two separate guidelines from 2014 and 2019 3  Class of Recommendation and Level of Evidence 4 Background and Pathophysiology  Definitions and Pathophysiology  Epidemiology  Risk factors  AF stages 5  Background and Pathophysiology A supraventricular tachyarrhythmia with uncoordinated atrial activation and ineffective atrial contraction It is the most common type of cardiac arrhythmia ECG characteristic: absence of distinct P waves AF is the result of impulses originating from additional sources within the heart (ectopic foci) rather than from the SA node or in response to reentrant activity This causes the atria to quiver, allowing blood to stay in the atria (stasis) and significantly increases the risk of developing a stroke. Chugh SS, et al. Worldwide epidemiology of atrial fibrillation: a Global Burden of Disease 2010 Study. Circulation. 2014 Wijesurendra RS, et al. Mechanisms of atrial fibrillation. Heart. 2019 6 Allessie MA, et al. Pathophysiology and prevention of atrial fibrillation. Circulation. 2001 Background and Pathophysiology Normal Conduction Atrial Fibrillation 7 Background and Pathophysiology  Epidemiology At least 5.6 million 50 million individuals with AF estimated individuals with in USA in 2015 AF worldwide in 2020  AF is associated with increased risks: 1.5-to 2-fold risk of death 1.5-fold risk of dementia 2.4-fold risk of stroke 1.5-fold risk of MI 2-fold risk of sudden cardiac death 1.6-fold risk of CKD 5-fold risk of HF 1.3-fold risk of PAD 8  Background and Pathophysiology  Risk Factors for Diagnosed Atrial Fibrillation Demographic, Anthropometric, Cardiovascular Disease Cardiovascular Risk Factors Advancing Age Obesity HF Valvular Heart Smoking Increasing Height CAD Disease Low Physical Activity Hypertension Cardiac Surgery Elevating Resting Diabetes Heart Rate Non-Cardiac Conditions CKD Sepsis OSA Thyroid disease CVD: Cardiovascular disease CAD: Coronary artery disease 9 CKD: Chronic kidney disease OSA: Obstructive sleep apnea;  Background and Pathophysiology  Risk Factors for Diagnosed Atrial Fibrillation Socioeconomic Determinants Genetic Markers of Health Family history/ heritability Education Level GWAS (presence of associated loci) Income Level Socioeconomic status Biological Markers ECG markers (prolonged PR, LVH) Biomarkers (elevated BNP, IL6/TNF-alpha, LP(a)) Imaging markers (increased left atrial size, increased LV wall thickness) GWAS, genome wide association studies LP(a): lipoprotein a 10 IL6: interleukin 6 LVH: left ventricular hypertrophy TNF: tumor necrosis factor   2014/2019 Background and Pathophysiology PAF E  Atrial Fibrillation Stages Evolution of Atrial Arrhythmia Progression - - C Sove valvular > - Warfarin January CT ،et al. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation 11 January CT, et al. 2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation   2023 Background and Pathophysiology Ri  Atrial Fibrillation Stages Evolution of Atrial Arrhythmia Progression 12 Management of AF HEAD 2 TOES 13  LIFESTYLE AND RISK FACTOR MODIFICATION (LRFM) FOR AF MANAGEMENT  Primary prevention  Secondary Prevention 14  LRFM FOR AF MANAGEMENT Primary Prevention - Patients at increased risk of AF should receive comprehensive guideline directed LRFM for AF, targeting:- Class 1 Obesity Smoking Diabetes Physical Alcohol Hypertension inactivity consumption 15 LRFM: Lifestyle and risk factor modification  LRFM FOR AF MANAGEMENT Secondary Prevention Overweight or Weight loss Reduce AF symptoms, burden, recurrence, and obese (BMI > 27 At least 10% progression to persistent AF kg/m2) patients Moderate to Reduce AF symptoms and burden, increase Target of 210 vigorous exercise maintenance of sinus rhythm, increase training min/week functional capacity, and improve QOL Class 1 AF and Optimal BP Reduce AF recurrence and AF related CV events hypertension control GDMT for Quit smoking tobacco to mitigate risks of adverse CV outcomes cessation 16 LRFM: Lifestyle and risk factor modification, QOL: quality of life , CV: Cardiovascular  LRFM FOR AF MANAGEMENT Secondary Prevention High prevalence of Although the role of treatment of sleep OSA in patients with Screening art disordered breathing to maintain SR is Class 2 AF uncertain Tenmesses Caffeine abstention to does not prevent AF episodes, It may reduce prevent AF episodes No benefit symptoms in patients who report caffeine Class 3 triggers. OSA: Obstructive sleep apnea 17 LRFM: Lifestyle and risk factor modification  throw Prevention of and Thromboembolism  Risk stratification to Prevent Thromboembolic Events in AF  Anticoagulant  Oral Anticoagulation for Device-Detected Atrial High-Rate Episodes (AHRE)  Active Bleeding and Reversal Drugs  Periprocedural management  Anticoagulation in Specific Populations 18 Prevention of Thromboembolism  Risk stratification to Prevent Thromboembolic Events in AF Stroke annual risk: CHA2DS2VASc score 19 Prevention of Thromboembolism scorn  Risk stratification to Prevent Thromboembolic Events in AF , * CHA2DS2VASc score - 2 Point - s 21 Prevention of Thromboembolism  Risk stratification to Prevent Thromboembolic Events in AF The CHA2DS2-VASc score is considered the most validated score Newer score as ATRIA and GARFIELD-AF Improve discrimination and control variables such as smoking status, renal disease, and dementia. L& - 22  Prevention of Thromboembolism  Antithrombotic Therapy Anticoagulant choice DOA ? * ·Starins enomic 1- mone [ ** cand Ie * CHA2DS2-VASc score of ≥2 in men and ≥3 in women 23 ** Equivalent to CHA2DS2-VASc score of 1 in men and 2 in women Prevention of Thromboembolism  Risk stratification to Prevent Thromboembolic Events in AF i] 24  Prevention of Thromboembolism Dose  Anticoagulant remal at Direct thrombin Factor Xa Inhibitor inhibitor Dabigatran Rivaroxaban Apixaban Edoxban Dosing 150 mg BID 20 mg OD 5 mg BID 60 mg OD Renal Adjusment1 CrCl 75 mg CrCl 15- 50 15 mg OD If any 2 of the following: age CrCl 15- 30 mg 15- 30 BID ml/min ≥80y, body weight ≤60 kg, 50 OD ml/min SCr ≥1.5 mg/dL ml/min 2.5 mg BID CrCl > 95 CI ml/min Liver Adjusment2 Child- Child-Pugh B Child-Pugh B Pugh B Avoid caution caution Drug Interactions Carbamazepine, phenytoin, rifampin Phenytoin to avoid2 Monitoring Renal , liver and CBC ( hemoglibine and hematocrite) 1- Dabigatran and Edoxban CI with dialysis 25 2- Other D-D interactions needs adjustment specially p-glycoprotein and strong CYP3A4 inhibitors (eg, systemic ketoconazole and ritonavir)  Prevention of Thromboembolism  DOAC monitoring and follow up P 26  Prevention of Thromboembolism O  Oral Anticoagulation for Device-Detected Atrial High-Rate Episodes (AHRE) Among Patients Without a Previous Diagnosis of AF Eco symshown no not Reasonable (2a) 24 hr 6 AHRE Burden Reasonable (2b) g O 5 min 3:No Benefit 1 2 3 4 5 6 CHA2DS2-VASc Score 27  Prevention of Thromboembolism RCT, Parallel group, Double blind, double dummy Population Subclinical AF (detected by pacemaker, defibrillator, or cardiac monitor), with at least one episode of AF 4012 that lasted between 6 minutes and 24 hours, and CHA2DS2-VASc score ≥3 Intervention Apixaban 5 mg twice daily (n = 2,015) Comparator Aspirin 81 mg daily (n = 1,997). Primary The primary efficacy outcome: composite of stroke and systemic embolism Outcome The primary safety outcome: major bleeding Efficacy 1ry outcomes(ITT): Apixaban vs aspirin Result 0.78% vs 1.24% per patient-year (HR, 0.63; 95% [CI], 0.45 to 0.88; P=0.007) Safety 1ry outcomes(OT): 1.71% vs 0.94% per patient-year (HR, 1.80; 95% [CI], 1.26 to 2.57; P=0.001) Follow-up was 3.5±1.8 years for the intention-to-treat analysis and 2.5±1.8 years for the on-treatment Time analysis. Apixaban resulted in a lower risk of stroke or systemic embolism than aspirin by 37%. But with higher risk Conclusion of major bleeding , however there was no increase found in fatal or intracranial bleeding detected. 28 Haley JS, et al. Apixaban for Stroke Prevention in Subclinical Atrial Fibrillation. N Engl J Med. 2024  Prevention of Thromboembolism  Active Bleeding and Reversal Drugs Reversal Drugs Anticoagulant Reversal Drug LOR Dabigatran Idarucizumab Class 1 4PCC1 Class 2a Apixaban Andexanet alfa Class 1 Rivaroxban Or Edoxaban3 4PCC1 Warfarin 4PCC and IV vitamin K Over FFP2 Class 1 1- 4-factor prothrombin complex concentrate 2- Fresh frozen plasma 29 3- Off label use  Prevention of Thromboembolism  Anticoagulation in Specific Populations I Chronic Coronary Disease AF i Anticoaguli Aspirit yL Complicating ACS or PCI > - -- as clopidogr Cas 30  Prevention of Thromboembolism Aspirin [1-43  Anticoagulation in Specific Populations P2Y12-closi DUACT WARFARIN 12 month Valvular Heart o Disease Peripheral s Artery Disease 31  Priphur - mono A in valulae Ac + warfar 222 monens s mitrial Rate Control valvular -> ACTDOA notmitriol 22 months  Goal and pharmacological agents ACS DownCASP + Clo  Acute rate control AC mono  Chronic rate control CCD -  Atrioventricular nodal ablation Ac erivaroxaban ord Y E ApiXbal Jabi satrale 32  Rate Control Goal Patients with AF without HF: Target resting heart rate - in BB ai commition te 44  Rate Control - Atrioventricular Nodal Ablation 45 Rhythm Control  Rate vs Rhythm Control  Goals of Rhythm Control Therapy in AF  Prevention of Thromboembolism in the Setting of Cardioversion  Electrical and Pharmacological Cardioversion 46  Rhythm Control  Favors Rate or Rhythm control = · E S egy, wonig gr HE 47  Rhythm Control  Goals of Rhythm Control Therapy in AF Rhythm control in patients with Recent AF Reduced LV function & AF and HF Symptomatic AF Diagnosis (< 1 year) Persistent AF Rhythm control can be A trial of rhythm control Rhythm control can be Rhythm control can be useful to reduce recommended to useful for improving useful to improve hospitalizations, stroke, evaluate if AF is symptoms and outcomes symptoms (2a) and mortality (2a) contributing to reduced such as mortality and LV function (1) hospitalizations for HF and ischemia (2a) 48  Rhythm Control  Goals of Rhythm Control Therapy in AF RCT, Parallel group, open, blinded outcome Population 2,789 with Early AF (AF diagnosed within 1 year) Intervention Rhythm control (n = 1,395) Comparator Usual care (n = 1,394) Primary 1- Composite of death from CV causes, stroke (either ischemic or hemorrhagic), or hospitalization with Outcome worsening of HF or ACS. 2- The number of nights spent in the hospital per year. First 1ry outcomes: 3.9 vs. 5.0/100 person-years (P-Y) ([HR] 0.79, 95% [CI] 0.66-0.94, p = 0.005) CV death: 1 vs. 1.3/100 P-Y (HR 0.72, 95% CI 0.52-0.98)||Stroke: 0.6 vs. 0.9/100 P-Y (HR 0.65, 95% CI 0.44-0.98) Result HF hospitalization and ACS hospitalization were not significant Second 1ry outcomes: Nights spent in the hospital: 5.8 vs. 5.1 days Time Median follow-up of 5.1 years per patient Early rhythm-control therapy was associated with a lower risk of adverse cardiovascular outcomes than usual Conclusion care among patients with early atrial fibrillation and cardiovascular conditions. ↑ 49 Kirchhof P, et al. Early Rhythm-Control Therapy in Patients with Atrial Fibrillation. N Engl J Med. 2020  Rhythm Control - ·  Prevention of Thromboembolism in the Setting of Cardioversion AF duration < 48 hours ine -) AF duration ≥ 48 hours &s · de temofi namically unstaple Left atrial appendage invoices chromias thrombus -- 50 Rhythm Control  Electrical Cardioversion Yes Hemodynamically No Stable? Immediate electrical -should be cardioversion performed (1) & Electrical cardioversion can be performed as initial rhythm-control Stab12 strategy or after unsuccessful - pharmacological cardioversion. (1) Will 51 Rhythm Control  Pharmacological Cardioversion A e are raa no *In the absence of preexcitation. † IV amiodarone requires several hours for efficacy 8-12 h † Ibutilide is generally effective in 30 to 90 min 52  Rhythm Control  Pharmacological Cardioversion Drug Class Major Adverse Effects Class III( k channel AV block, Bradycardia, Corneal microdeposits ,Elevation in transaminases, Amiodarone blocker) Hepatotoxicity, Hyperthyroidism, Hypothyroidism, Nausea, QT prolongation, Peripheral target loading dose 6-10 g - neuropathy, -Pulmonary Photosensitivity, - fibrosis, Skin pigmentation (blue-gray), TdP - Ibutilide Class III( k channel blocker) - Nonsustained VT, QT prolongation, TdP Procainamide Class Ia (Na channel & 2 Agranulocytosis, AV block, Exacerbation of HFrEF Hypotension- Neutropenia , QT blocker) & prolongation Rash Thrombocytopenia TdP Class Ic (Na channel Atrial flutter, AV block, Dizziness, Dyspnea, Exacerbation of HFrEF, Headache, Nausea, QT Flecainide blocker) prolongation, VT, Visual disturbances - - Class Ic (Na channel Atrial flutter, AV block, Dizziness, Dyspnea, Exacerbation of HFrEF, Nausea, Taste Propafenone blocker) disturbances , Visual disturbances - - 53  Rhythm Control Antiarrhythmic Drugs for Maintenance of Sinus Rhythm C 3 armful 54  Rhythm Control Inpatient Initiation of Antiarrhythmic Agents Drug Duration as Facility should be capable of Continuous ECG monitoring 1 Dofetilide2 (1) Admission for ≥3 days Periodic CrCl Cardiac resuscitation Continuous ECG monitoring Periodic creatinine clearance 2a Sotalol1 (2a) 3 days calculations Cardiac resuscitation Flecainide and 2a First dose in a facility Continuous EG monitoring Propafenone as PTTP (2a) 1- CrCl Assess for interstitial lung ECG Annual dermatologic and neurologic exam Sotalol ECG, K and Mg and CrCl Dofetilide ECG, K and Mg and CrCl ECG Dronedarone AST and ALT AST and ALT ECG Continuous ECG at least 4 hours Ibutilide K and Mg following infusion -- ECG ECG Procainamide BP BP during infusion -- ALT: alanine transaminase, AST: aspartate aminotransferase, BP: blood pressure, CrCl: creatinine clearance, CXR: chest x-ray, ECG: electrocardiogram, 56 TSH: thyroid stimulating hormone  Rhythm Control Catheter ablation 57  Rhythm Control r Anticoagulant and Catheter ablation Prior to ablation 193A After ablation 58  References 1. Chugh SS, Havmoeller R, Narayanan K, et al. Worldwide epidemiology of atrial fibrillation: a Global Burden of Disease 2010 Study.Circulation. 2014;129(8):837-847. doi:10.1161/CIRCULATIONAHA.113.005119 2. Wijesurendra RS, Casadei B. Mechanisms of atrial fibrillation. Heart. 2019;105(24):1860-1867. doi:10.1136/heartjnl-2018-314267 3. Allessie MA, Boyden PA, Camm AJ, et al. Pathophysiology and prevention of atrial fibrillation. Circulation. 2001;103(5):769-777. doi:10.1161/01.cir.103.5.769 4. Joglar JA, Chung MK, Armbruster AL, et al. 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines [published correction appears in Circulation. 2024 Jan 2;149(1):e167]. Circulation. 2024;149(1):e1-e156. doi:10.1161/CIR.0000000000001193 5. January CT, Wann LS, Alpert JS, et al. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines and the Heart Rhythm Society [published correction appears in Circulation. 2014 Dec 2;130(23):e270-1]. Circulation. 2014;130(23):2071-2104. doi:10.1161/CIR.0000000000000040 6. January CT, Wann LS, Calkins H, et al. 2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society [published correction appears in J Am Coll Cardiol. 2019 Jul 30;74(4):599]. J Am Coll Cardiol. 2019;74(1):104-132. doi:10.1016/j.jacc.2019.01.011 7. Healey JS, Lopes RD, Granger CB, et al. Apixaban for Stroke Prevention in Subclinical Atrial Fibrillation. N Engl J Med. Published online November 12, 2023. doi:10.1056/NEJMoa2310234 8. Ramesh T, Lee PYK, Mitta M, Allencherril J. Intravenous magnesium in the management of rapid atrial fibrillation: A systematic review and meta- analysis. J Cardiol. 2021;78(5):375-381. doi:10.1016/j.jjcc.2021.06.001 9. Kirchhof P, Camm AJ, Goette A, et al. Early Rhythm-Control Therapy in Patients with Atrial Fibrillation. N Engl J Med. 2020;383(14):1305-1316. doi:10.1056/NEJMoa2019422 59