Review of the 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation, Including Impact on Clinical Practice

Discussion with Brett Atwater, MD; Courtney Channels, NP; Pamela Brandt, DO; and Eric Sklar, MD

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EP LAB DIGEST. 2024;24(3):1,10-12.

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In this episode of The EP Edit podcast, we are sharing a discussion on the new guidelines for the diagnosis and management of atrial fibrillation (AF). Featured in this discussion are Brett Atwater, MD; Courtney Channels, NP; Pamela Brandt, DO; and Eric Sklar, MD, from the Inova AF Center at Inova Health System in Fairfax, Virginia. 

Brett Atwater, MD: Hi, my name is Brett Atwater and I am the director of electrophysiology (EP) at the Inova Schar Heart and Vascular Institute in Fairfax, Virginia. I am also the D’Aniello Chair of AF at Inova Health System. I am pleased to be with you all today.

Courtney Channels, NP: Hi, my name is Courtney Channels and I serve as the nurse practitioner (NP) for the Inova AF Center.

Pamela Brandt, DO: Hi, my name is Pamela Brandt and I am the director for Nonsurgical Weight Loss and Obesity Treatment for Inova.

Eric Sklar, MD: Hi, my name is Eric Sklar and I am the medical director of the Inova Sleep Disorders Program.

Atwater: Thanks everybody for joining us today. I am going to start the discussion with an overview of the new AF guidelines that were released in December 2023, and then if you have comments or thoughts as we go along, feel free to jump in. The guidelines begin with an updated review of the prevalence, incidence, morbidity, and mortality of AF, and they highlight the data that the prevalence in the United States is increasing dramatically from about 5.2 million Americans in 2010 to an estimated 12.1 million Americans with AF by 2030, with a near tripling of the incidence of new AF cases over that same timeline. It is clear that our current care model and infrastructure in the United States is not adequate to take care of all this burden of AF disease that we are seeing. Courtney, could you highlight some of the strategies that we have taken at Inova with the AF center model to improve our efficiencies and care processes?

Channels: There are 2 main things that we have done through the AF center model to help improve efficiency. First is improving access to care. Through our AF center, we have designated referral spots for patients with AF. Patients with AF are also able to see Dr Sklar from sleep medicine and Dr Brandt from weight management. Through this process, we have been able to develop a pathway with the emergency room (ED) in which we were able to give them guidelines on how to stabilize patients in the ED, safely discharge them, and enable close follow-up with the AF center. We have seen that this has helped minimize the delay that patients have in getting to EP and our specialists. Previously, patients would oftentimes go to the ED, then go to their primary care physician, make their way to cardiology, and eventually get to EP. So, this has definitely streamlined that process and increased their ability to quickly see an EP clinician. The other thing that we have done is made the consult visit much more efficient, which we have achieved in several ways. One of which is we developed educational videos that were made by our providers and we have encouraged patients to watch those videos prior to their consult visit. This has allowed the electrophysiologist to spend the main portion of their visit really talking to the patient about their treatment plan and less having to go through the initial basics of what AF is, stroke risk, and all those other details. In addition, we have developed an ability to assess the patient’s risk factors prior to their consult visit. Therefore, prior to the office visit, we send them survey questions that screen for risk factors so before we even meet the patient, we know if someone is at high risk for sleep apnea or if their body mass index (BMI) is elevated and that we would likely need to send them to our specialists. So, that is helpful in that we do not have to spend that initial consult visit only starting to assess for those risk factors.

Atwater: Thank you for that overview. The next major portion of the AF guidelines goes into the importance of risk factor modification (RFM), both for the primary prevention and secondary prevention of AF. They give a class 1B recommendation for targeting obesity, physical inactivity, unhealthy alcohol consumption, smoking, diabetes, and hypertension. For patients with a history of AF for secondary prevention of AF recurrence who are overweight or obese with a BMI over 27, they recommend weight loss with an ideal target of at least 10% BMI weight loss to reduce AF symptoms, burden, recurrence, and progression to persistent AF. Pam, can you summarize some of the newly available options for weight control and compare those to diet and exercise? How do you go through that discussion of what the best available option is for patients who need weight loss as part of their AF management?

Brandt: Yes, thank you. What struck me when I was looking at the guidelines and some of the literature behind it, is what most patients understand coming into this discussion about obesity as a disease or their weight in general. They have all been told and we have all talked about how increases in BMI are related to certain outcomes, in this case, an increased risk of AF recurrence, higher arrhythmia burden and symptoms, among others. So, I feel like people really get that direct connection. The higher my BMI is, the more likely I am to have these things. But what I think is interesting about where we are with the literature for AF now is we see that weight loss has a real impact on those factors. I think that is what is really promising to patients when we talk about why they should be motivated to do behavioral change and to work on weight loss. Because we can tell people all day long that they should lose weight, but what is that actually going to mean for them in terms of their health and how they feel? So, I think that is exciting. It is a threshold of 10% body weight loss, which I think to most people feels like a manageable amount. We know that there is a lot of other outcomes that also improve with 10% weight loss, usually glycemic control and blood pressure. So, I think several of the different risk factors to modify that are presented in the guidelines go along with that weight loss. And to your point, we traditionally have not had a lot of tools to help with weight loss. A lot of our time has been spent talking about lifestyle modification such as diet and exercise, which are certainly important things to approach with people, but the tools that we have to help people with in terms of medications are also improving. Therefore, I always try to talk to patients about these things in terms of being tools, because there is not anything that we can do to help people increase their metabolism or make them burn calories. There is no easy button with this, but the tools are getting better. Traditionally, most patients who attempt diet and exercise are actually not that successful with weight loss. So, if you look at the data for many years with lifestyle interventions alone, only about 5%-10% of people who attempt are able to lose that 10% body weight. That is not very good, and that is in spite of people putting a great deal of effort either into dietary changes and exercise and all those things that they feel are within their control. So, that tends to be really frustrating. There are traditional oral appetite suppressants. There are 2 brand-name medications that are FDA approved for weight loss: Qsymia (Vivus) and Contrave (Currax Pharmaceuticals). While it differs for patients and their response to medications, the proportion of patients who are able to achieve that 10% weight loss is in the 20%-50% range. So, it is definitely more successful than diet and exercise by itself, but we would still like to hope that we can get a majority of the people that we are working with to that 10% mark. With the newer medications such as semaglutide (glucagon-like peptide-1 [GLP-1] receptor agonists) and tirzepatide, the proportion of patients who are going to be successful with 10% weight loss or more significantly increases. With those medications, over 60% of the people who are on those medications succeed at losing at least 10% of their weight. With semaglutide, the average weight loss is about 15% across all the trials. Tirzepatide, which recently received FDA approval for weight loss but has been on the market as Mounjaro (Lilly) for diabetes, has an average weight loss of about 19%. So, we are seeing the outcomes improve as we get better with these medications. I am a medical doctor, not a surgeon, but I think we must be realistic about what tools are out there and what people may need. For bariatric surgery, the proportion of people that lose 10% is virtually 100%. Most people who have bariatric surgery are going to achieve a 10% weight loss if not much, much more. So, there may be a proportion of patients in this population where that might be the appropriate intervention for them. That is the difference between the various interventions that we can use to help with weight loss. 

In terms of how we evaluate people, when I see people at the AF clinic or in our other clinics, often they are patients who we do not want to use medications in because it will increase their heart rate or blood pressure. So, we try to avoid medications such as stimulants. Even with Contrave, we can see blood pressure elevations as well. Therefore, we must be cautious and monitor for that if we are going to use them. To contrast with that, for GLP-1 agonist medications such as semaglutide, we have the cardiovascular outcome data now, so we know there are studies showing that patients who take those medications, both with and without diabetes, have a reduction in cardiovascular mortality. If you look at the data on people with semaglutide, it goes from about 9% incidence of primary outcomes, so major adverse cardiovascular events or mortality, vs 6% with medication. It is a significant risk reduction with these medicines. Not only are they potentially not going to be harmful in terms of cardiovascular disease, they may actually have some other benefits in and of itself from the medicine, not just from the weight loss effect. So, I think that is exciting.

Atwater: Thank you very much for that. The next major topic in the guidelines is a review of the importance of sleep apnea treatment for patients with AF, particularly for their outcomes. They give a guideline recommendation to screen for sleep apnea in patients with AF, a class 2B recommendation. There is still a lot of uncertainty about whether treatment of sleep apnea and sleep-disordered breathing helps to maintain sinus rhythm among patients who already have a diagnosis of AF. Eric, can you go through that with us? What is the role for sleep management and sleep medicine in the treatment of AF? What are your thoughts on the most recent guidelines?

Sklar: To start out, there are a lot of comorbidities with patients who have obesity and other heart conditions with sleep apnea, so it does get a little complicated in terms of trying to determine the connection to AF. Screening people with a STOP-Bang score is what we usually use, which is basically 8 risk factors. If a patient has 3 or more of those risk factors, it correlates highly with a significant amount of sleep apnea. An easy screening like that is a good way to start and then have those patients get further evaluation with a specialist or a sleep study. We use that tool, and we also use the Epworth Sleepiness Scale score, which determines how sleepy a patient may be, if they need a sleep study, and what kind of study is needed. In the AF population, there is also a lot of other cardiac comorbidities, and generally, patients who have a lot of cardiac comorbidities are more appropriate for in-lab studies. However, with the advent of home sleep studies over the last 10-15 years, it has been much more economical and efficient to screen patients who have several risk factors and determine if they have any sleep apnea that might be significant. In terms of treating them, I think there is a lot of overlap in terms of symptomatology too. Patients with cardiac disease, AF, and obesity may be tired. So, treating sleep apnea can address part of that too. I often see patients who think they feel the way they feel because they are overweight or because of a cardiac condition. In reality, it might be from sleep apnea, but they never thought about it before. Maybe they are not a big snorer, but that does not really rule out sleep apnea. So, a lot of patients can have different combinations of risk factors; they may not be the stereotypical sleep apnea patient, but treating the sleep apnea does help them not only feel better but can lower cardiac comorbidities. It is a 2b recommendation in the new guidelines. 

With the STOP-Bang score, it is very easy to screen patients. It is almost not worth it to not do it. You can definitely pick up patients who are not the typical sleep apnea patients. In some cases, I think the patients that Dr Brandt is seeing are the ones who are maybe morbidly obese or big snorers—they are the obvious targets for a sleep study. But what I have noticed in the AF clinic is that we get a lot of people who are maybe not like that. They are older, they are men, who are more likely to have sleep apnea than women, and they have a big neck size or high blood pressure. Those are all part of the STOP-Bang score. So, there are different combinations of risk factors that may not fit the stereotypical sleep apnea patient, and if you do not look, you will not find it. In screening with something like a STOP-Bang score, I will always measure neck size on patients. That is very easy to do. Then, determining whether they need a sleep study is the next step. It is difficult to look at someone and say, “no, you do not have sleep apnea” or “yes, you do.” Sure, there are cases where there is a very high suspicion and there are some where you might not be sure. However, with the advent of home sleep studies, it has been much more economical and efficient to screen people, and we have been able to improve patients’ quality of life by treating their sleep apnea.

Atwater: Thank you very much for that overview. The next major part of the guidelines is a review of data management with all the wearable devices and consumer electronics that are capable of making diagnoses of AF. They also make a new recommendation for rhythm monitoring tools and methods. Specifically, they recommend that automated algorithms be confirmed by visual interpretation of the electrogram with a class 1B recommendation, that an implantable monitoring device is reasonable to identify AF in patients with a prior stroke or systemic thromboembolic event with a class 2A recommendation, and that it is reasonable to use consumer-accessible electrocardiogram (ECG) devices that provide high-quality tracings for AF burden monitoring in some patients. As physicians and advanced practice providers, we are now being confronted with a tremendous amount of ECG data from all these devices. Courtney, can you tell us your thoughts on data management and interpreting all this now that there is a new guideline saying we need to visually interpret all these ECGs to confirm that the automated algorithms are accurate? How do we handle that in the care setting?

Channels: Yes, happy to. It is certainly an exciting time to be in EP with this developing technology with wearables. Currently, we are fortunate to have the ability through MyChart for patients to upload rhythm strips to us. So, we are able to clinically interpret those rhythm strips and incorporate what we see into their treatment plan. Previously, a patient might have called us to say they thought they were out of rhythm, and then we would start the process of getting them into the clinic to get an ECG and go from there. It is much more efficient now that they are able to send us that rhythm strip. So yes, with volume increasing, I think this is an area that we are going to need to focus on in the future to adequately staff that extra volume. We need to find a way to incorporate that so that we are getting credit for that interpretation. It is important to find a way to bill for that as well.

Atwater: Yes, I think that is going to be key. For us to understand how to appropriately staff the necessary people to interpret all that data, we must figure out a way to get those people paid to do that work. So, understanding how to reimburse for interpretation of consumer electronic device-derived ECGs will be the next big step. The next major change that they focus on in the new guidelines is an increase on the use of rhythm control for AF in patients with heart failure. Specifically, in patients with reduced left ventricular function and persistent or a high burden of AF, they now give a class 1B recommendation for a trial of rhythm control, even in patients who seemingly are minimally symptomatic or asymptomatic but have symptomatic heart failure. I think this recommendation follows some important data that has come out between the last set of guidelines and this set of guidelines from studies such as CASTLE-AF, CASTLE-HTx, and others that consistently have shown improved heart failure outcomes, including reduced mortality, in patients undergoing catheter ablation or rhythm control of AF. Courtney, what are you recommending? If you are on an inpatient consult service and there is a patient admitted with symptomatic class III or IV heart failure and who also happens to have AF, are you recommending a trial of rhythm control? Cardioversion? Do they go straight for an ablation? How is that being managed now?

Channels: There are definitely several factors that go into it, but as far as long-term management, I think we are definitely seeing from previous data that it supports having an AF ablation, and that an AF ablation is much more effective and has less long-term complications than antiarrhythmics. It is also important to take the patient into account and the clinical and emotional impact that it has on them. When we think clinically, we know the association with increased risk of stroke, myocardial infarction, death, and heart failure in addition to multiple doctor visits, ED visits, and hospitalization. That is a high utilization of health care dollars. In addition is the anxiety that patients face of not knowing when their next episode is going to happen or if it is going to be one that is severe enough that they are going to have to go to the hospital. Previously we would try antiarrhythmics and hope that it would work. In a small portion of patients it might be successful, but an ablation as first-line therapy is better for them long term.

Atwater: Yes, I think that is definitely true in the heart failure population. But in the new guidelines, they even extend that to the general population of patients with symptomatic AF. Ablation now gets a class 1A indication for selected younger patients and a class 2A recommendation for all-comers, basically unselected patients of any age or any burden of comorbidity as the primary rhythm control option as opposed to antiarrhythmic drugs. I think this is probably going to result in a higher percentage of AF patients seeking ablation as their treatment of choice for rhythm control of AF and potentially a higher utilization of the procedure. This then increases the total number of patients coming through an AF center or traditional care pipeline, and more people seeking care for AF means more opportunities for RFM as well.

So, my last question is how do we see the future of AF management? Is it going to be a multidisciplinary model like what we have deployed here at Inova? Is it going to require that we do more telehealth? Can patients handle having all these appointments with all these different providers? Can they do rhythm control with an ablation, and at the same time, be losing weight with Pam’s help and getting a sleep study from Eric’s team in order to try and get their sleep apnea diagnosed and treated? Is this too much to be asking to do in a rush where all the data shows that the sooner we get a hold of all these things, the better the patient outcome? How do we improve our efficiencies to manage this long term? Let’s start with Courtney.

Channels: One thing that will be helpful, including here at Inova, is improving the efficiency and utilization of NPs on the clinical team. I believe 40% of the workforce at Inova is made up of NPs. In our current structure and clinic, we are often seeing patients post procedure, so on the back end of things. I think there is potential for us to be incorporated into that consult visit and see patients on the front end, similarly to how we do inpatient a lot of times where we will go and see the patient in the hospital before the doctor is available for a procedure and come up with a plan. Then, once we see the patient with the physician, we execute that plan. That can certainly translate into our clinic visits where we are having that initial discussion with the patient. I believe that would help improve our efficiencies.

Atwater: Pam, how about you? What do you think about opportunities to improve efficiencies for RFM?

Brandt: It is always difficult to figure out how to get people access for this. To your point about the burden of all the visits, we have to be mindful of that, including transportation issues. Thankfully, telemedicine access has been really helpful, that is something we are definitely still utilizing in our practice, with some of our patients ambulating. So, being able to do follow-ups, especially using telemedicine, is going to be key. I think it is hard when people have a lot of different pieces that they are trying to address at one time. People often have something like AF and a diagnosis of fatty liver disease or type 2 diabetes, so I have a captive audience to address all these other comorbid conditions where maybe they were not so worried about their weight before because they did not feel like it was impacting them. To hear that weight loss could actually help them reduce their risk of having more ablations or be on medications long term is helpful, because many people do not want to be on medicine forever. I think that you get a lot of motivation from people when they have these things that really hit home for them and they feel compelled to make changes all around. So, that is something we should also take advantage of when people are ready.

Atwater: Eric, I know you use a lot of home sleep studies and other things to try to accelerate care and make things more convenient for your patients. Can you share your thoughts on this increased burden of disease and how you plan to address it from the sleep perspective?

Sklar: I agree with what has been said. When the patient is motivated to address the risk factors and be educated that potential sleep apnea and certainly obesity are things that may play a role in their AF or other conditions, whatever it might be, that is when it is a good time to get testing, even though it is a lot in a short period of time. In our sleep clinic, we have not done this with the AF part of our clinic yet, but we do a lot of telemedicine and it allows us not only to get patients in quicker because they do not have to schedule a time to come into the office, but it also allows us to see patients who live farther away. Then, with home sleep studies, those can be done with a relatively quick turnaround. There are different ways to do it. We have a few different pathways to get patients home sleep studies.

So, the telemedicine component of things helps quite a bit. To Courtney’s point, what we do in our sleep clinic is there are 2 NPs who I work with, and they will follow up with patients after the sleep study to go over next steps, whether they need continuous positive airway pressure, weight loss, or positional therapies. That allows patients quicker follow-up after a sleep study. In the AF clinic, opening up time and fast-tracking those patients has worked out pretty well. As the population grows, dedicated days for having other specialists in the AF clinic will help as well.

Atwater: Well, this has been a great discussion. Thank you all for joining me today.

Sklar: Thank you!

Brandt: Thanks for having me!

Channels: Thank you! 

The transcripts have been edited for clarity and length.