The American College of Cardiology (ACC) guidelines in the 2023 update translated the available scientific evidence into recommendations for clinicians to improve cardiovascular health in patients with AF (2).Particular emphasis has been given to the rhythm control strategy rather than attempting a frequency control strategy, in line with what has already been expressed by the 2020 European guidelines (3).
Atrial fibrillation: the stages of a progressive disease
In the ACC/AHA 2023 guidelines, the modification and prevention of risk factors are two aspects emphasized more than in previous guidelines. Similar to other pathologies, such as heart failure, AFib is now recognized as a progressive disease, the classification of which is reflected in several stages along a continuum, within which the strategies for the four different phases are defined:
- stage I — denotes a risk of AF due to certain risk factors;
- stage II — is considered pre-AF based on structural or electrical findings that predispose a patient to AF;
- stage III — includes paroxysmal, persistent, long-lasting AF, AF with successful ablation and able to evolve into the next stage;
- stage IV — that of a permanent AF.
The key themes of the 2023 guidelines
Stages of AFib — The previous classification of AFib, was based only on the duration of the arrhythmia and tended to emphasize therapeutic interventions.The new 2023 classification, using stages, recognizes AFib as a continuum disease that requires a variety of strategies and interventions, from prevention, lifestyle and modification of risk factors, screening and therapy.
Modification and prevention of risk factors — Lifestyle and modification of risk factors are recognized as a pillar of AF management to prevent AF onset, progression, and adverse outcomes. The 2023 guideline emphasizing the management of risk factors throughout the disease continuum offers more prescriptive recommendations, including management of obesity, weight loss, physical activity, smoking cessation, alcohol moderation, hypertension, and other comorbidities.
Flexibility in using clinical risk scores — Beyond the CHA2DS2-VASc, for the prediction of stroke and systemic embolism, recommendations for anticoagulation are now made on an annual basis of thromboembolic event risk using a validated clinical risk score, such as CHA2DS2-VASc.However, patients with an intermediate annual risk score, where there is uncertainty about the benefit of anticoagulation, may benefit from taking other risk variables into account to aid decision-making, or the use of other clinical risk scores to improve prediction and facilitate shared decision-making.
Consideration of stroke risk modifiers — Patients with intermediate to low annual risk AF (<2%) of ischaemic strokes may benefit if factors that modify the risk of stroke are taken into account. In this regard, AF characteristics are relevant, such as AF load, which is defined as the duration of an episode or as a percentage of AFib duration during the monitoring period, rather than non-modifiable risk factors (sex) and other modifiable dynamics or factors (e.g.blood pressure control) that can inform the doctor/patient discussion to make shared decisions.
Early Rhythm Control — A new body of consistent evidence supports the importance of early and ongoing management of patients with AF who should focus on maintaining sinus rhythm while minimizing sinus burden.
Transcatheter AF ablation is recognized as a first-line therapy in selected patients with a class 1 indication, updating the recommendation for superiority emerged from recent RCTs compared to drug therapy for rhythm control. This group of patients includes younger patients, with fewer comorbidities and presenting with symptomatic paroxysmal AF. Transcatheter ablation is useful because it helps not only improve symptoms but, according to some studies, helps reduce the progression from paroxysmal AF to persistent AFib.
Transcatheter AF ablation in eligible heart failure patients with reduced ejection fraction receives a class 1 indication, as recent RCTs have demonstrated the superiority of transcatheter ablation in these patients compared to drug therapy for rhythm control.
For AF detected by implantable or wearable devices; the recommendations have been updated in light of recent studies, providing more prescriptive recommendations, which have taken into account the interaction between the duration of the AF episode and the patient’s underlying risk of thromboembolism.
Left auricular closure devices have received a higher level 2a recommendation than previous indications, pending additional data on their safety and efficacy.
In patients in whom AF is identified during a non-cardiac medical illness, surgery, or precipitating events, dedicated recommendations are provided, with particular attention placed on the risk of recurrent AF in these individuals after AF discovery.
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Source — https://www.univadis.it/viewarticle/fibrillazione-atriale-aspetti-rilevanti-linee-guida-2023-2024a10002yr