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EP LAB DIGEST. 2024;24(7):16-17.

In this video discussion from Heart Rhythm 2024 with Bradley Knight, MD, and Jonathan Piccini, MD, MHS, key points from the 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation are discussed. 

Bradley Knight, MD: Hi, I am Brad Knight, Editor-in-Chief of EP Lab Digest and Director of Electrophysiology (EP) at Northwestern. I am delighted today to be talking with Jonathan Piccini from Duke about the recent atrial fibrillation (AF) guideline.¹ Jonathan, would you like to introduce yourself and your role in the guidelines? 

Jonathan Piccini, MD, MHS: Yes, my name is Jonathan Piccini, Director of EP at Duke, and I was fortunate enough to be a member of the writing group and participate in the 2023 guideline for the management of AF. 

Knight: Well, these guidelines have a huge impact on everything we do. Can you talk a little about what the highlights are as briefly as you can and the highlights of the newest guidelines for AF? 

Piccini: Yes, the last full guideline was published almost 10 years ago, so there is a lot that is new. There were updates along the way, but in terms of a full guideline, it has been quite a long time. There is a top 10 of take-home messages in the document, but I think the biggest point is really the recognition that AF is a progressive disorder. In the guideline, you see that in several different ways. There is an emphasis now on the stages of AF, including stage 1, which are the risk factors associated with AF, and stage 2, which is pre-AF in patients who have manifestations of the conditions that lead to AF. 

Knight: This seems consistent with other guidelines like heart failure. 

Piccini: Exactly. Then, stage 3 is manifest AF, and permanent AF is stage 4. But that is not the only emphasis on AF as a progressive disorder. The prevention and reduction of risk factors has been elevated to a main pillar in the management of the disorder, and there is a big emphasis on treatments that delay that progression or arrest it, including things like early rhythm control and catheter ablation—those types of interventions. I would say that is the major thematic emphasis of this version.

Knight: I think this notion of lifestyle modification really came about first in the European guidelines that were published a few years ago. It is consistent with the effort to identify AF as a public health problem. But along that notion, can you talk a little about the differences between different guidelines, such as the European guidelines and these guidelines? 

Piccini: Yes, a couple differences come to mind. One of the big ones is that in the current guideline, it says CHA₂DS₂-VASc can be used if that is your preferred risk stratification system, but there are a lot of systems out there, and the guideline moves away from saying specific scores towards annual risk of stroke. So, if it is more than 2%, that is a class 1 indication. If it is between 1% and 2%, it is a class II indication. That would be one difference. I think the second big difference is the fact that in these guidelines, catheter ablation for people with heart failure and reduced ejection fraction in AF have been elevated to a class I recommendation in appropriate patients for the prevention of adverse cardiovascular events. 

Knight: Yes, that is a move in a little different direction. So, I have been on committees where issues like this have to be decided upon with group decision-making. You have a lot of diverse electrophysiologists, cardiologists, and even cardiac surgeons, including Patrick McCarthy, as coauthors. Maybe you can give us some behind-the-scenes examples of some contentious issues where it was difficult to come up with a recommendation.

Piccini: Yes, with catheter ablation as a class I recommendation, one concern is does that mean every single person with heart failure or reduced ejection fraction in AF should be getting a catheter ablation procedure? I think any clinician recognizes that that is ridiculous. They have to be an appropriate candidate for the procedure and they have to be somewhat similar to the patients in the clinical trial. That was one area of concern. But the counterview to that is there is not 1 or 2, but there are multiple clinical trials that have demonstrated strong benefit with that therapy, and so that was the motivation for it to be a class I recommendation was the consistency across the trials.

Knight: This issue of how soon we should intervene and whether it should be ablation as first-line therapy is important, but I think the terminology sometimes gets misinterpreted or maybe misused. I think the notion that catheter ablation is reasonable as first-line therapy is intended to say it is first-line therapy for someone who is a candidate for rhythm control, but I start to see that sometimes catheter ablation is considered first-line therapy, meaning it is the first thing we do. So, what is your take on newly diagnosed AF? How should those patients be treated differently than patients with recurrent symptomatic AF? 

Piccini: I think we often forget about a lot of the guideline recommendations, but in someone with newly diagnosed AF, we need to do a careful review of all the things that can trigger and cause AF, and focus on those things. Make sure the patient does not have underlying structural heart disease that has not been diagnosed. I think the risk factor prevention has been elevated and given very specific targets like 210 minutes of exercise a week and a BMI less than 27 with so much weight loss prescribed. If they are a rhythm control candidate, considering first-line ablation is a class I recommendation in patients with paroxysmal AF who are candidates. 

Knight: Are any of these new obesity drugs mentioned or recommended in the guideline? 

Piccini: No. 

Knight: There is a lag, right? 

Piccini: Yes, there is a lag. So, the obesity medications and all the outcomes data really came out largely after the formational work from the guidelines had become available. We still do not have a lot of AF-specific data with those medicines. Also, when the guidelines were released in November, they had a lot of material about short-duration AF, so-called subclinical AF, and then the ARTESIA clinical trial was published literally days after the release. 

Knight: That brings up the notion that has been discussed for years. Is there a way to do things differently? For example, there are guidelines and new data that comes about, but there can be a 10-year lag between updating the guidelines before people then start referring to the European guidelines. Is there a better way to do this where you constantly refresh the guidelines and keep them up to date? 

Piccini: I think what we are going to see is the American Heart Association, American College of Cardiology, and Heart Rhythm Society want to move towards living documents, which means that as soon as the evidence is available, the guidelines are modified and updated to reflect the evidence. But a lot of time and effort goes into the guidelines to make sure that they are very evidence driven. So, I think that is going to be a journey that we are going to see the field go through over the next 3 to 5 years. 

Knight: I am aware of how much time and effort you and your colleagues put into doing these documents, so when you are completely published, I am sure you need a breather. The notion of constantly being in charge of keeping those up to date is a huge task. I think that is why it has not been adopted, because that has been talked about for years. Let me ask you about a specific example I thought was interesting. Perhaps I should have noticed in the previous documents, but it is still true in the current documents that there is not one antiarrhythmic drug we use for rhythm control of the 6 drugs we have available in the United States. There is flecainide, propafenone, sotalol, dofetilide, amiodarone, and dronedarone. Those drugs are used ubiquitously as there are patients who need them. Not everybody can get an ablation and not everybody is cured with an ablation, so these drugs are always used. There is a lot of data on that. However, not one has a class I recommendation on the guidelines. 

Piccini: A lot of the foundational clinical trials for those medications are now somewhat dated. Some are not even FDA approved, as you know. 

Knight: Amiodarone, for example.

Piccini: In the United States, we have dofetilide, but that is not available in many countries. Each medication, as you know, also has specific safety risks. I think when you take all of that into totality, it is not surprising that we have class 1 recommendations for catheter ablation, but we do not have class 1 recommendations for antiarrhythmic drug therapy, even though as you point out, many patients benefit from them, including some patients who have had an ablation.

Knight: Yes, it shows you a limitation of coming up with those classifications of recommendations. Maybe you could summarize some examples of how you think these have impacted your current practice, because if I can speak on my own behalf, it has kind of made me more comfortable pushing the envelope and recommending ablation sooner. I think the strongest case is to prevent persistent AF and interrupt the cycle of progression.

Piccini: One of the great things about getting to be on the committee is that you learn a lot. I really do think that these guidelines have changed how I practice. When I see people now who do not have AF, I ask myself, what modifiable risk factors are there? What things do I see that I might caution the patient about the risk of future AF? I think in our practice, we are already moving towards more ablation, but I think we all feel now well supported by the evidence. So, at Duke, I think we are doing more first-line ablation than we have in the past as a result of the guideline. 

Knight: Anything else you want to add about the document? 

Piccini: No, I think that is the lion's share of all the most important things. 

Knight: Thank you for your time! 

The transcripts have been edited for clarity and length.

Reference

1.     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. Circulation. 2024;149:e1-e156. doi:10.1161/CIR.0000000000001193