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Atrial Fibrillation Cardiologist Perspective
Cardiologist Perspectives: Key Takeaways From the 2023 Atrial Fibrillation Guideline Updates

Released: July 08, 2024

Expiration: July 07, 2025

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Key Takeaways
  • Optimizing control of modifiable risk factors for stroke in patients with atrial fibrillation, such as hypertension and obesity, and implementing positive lifestyle changes are potentially overlooked components of managing atrial fibrillation.
  • Anticoagulation therapy is the cornerstone of therapy for reducing stroke risk, and healthcare professionals should take care to evaluate each patient’s specific circumstances when recommending treatment.

The multidisciplinary 2023 atrial fibrillation (AF) guideline update from the American College of Cardiology, American Heart Association, American College of Clinical Pharmacy, and Heart Rhythm Society was a highly important and comprehensive update for the management of patients with AF. Here, I will highlight the areas that I think are of particular importance and summarize the take-home messages of each point.

Three General Pillars of Care
The new guidelines place a renewed emphasis on 3 general pillars of care for AF. 

  • Assessment of stroke risk factors and treatment with anticoagulants, if appropriate
  • Optimizing control of general risk factors for AF, including managing comorbidities such as hypertension and obesity, as well as implementing lifestyle changes, such as reducing alcohol intake
  • Symptom management to control heart rate and/or heart rhythm using strategies tailored to each patient’s needs

Estimating and Managing Stroke Risk
In particular, the updated guidelines reconsider how to estimate and manage stroke risk in the context of AF. For the first time, the guidelines call for expanding beyond the CHA2DS2-VASc score to approach stroke risk assessment more generally. Rather, any validated risk score may be used to estimate annualized stroke risk and determine recommendations for anticoagulation. The 3 validated risk models identified in the guidelines were CHA2DS2-VASc, ATRIA, and GARFIELD. If patients’ annual risk of stroke is high (>2%) according to one of those risk scores, then a Class 1 recommendation is provided to use oral anticoagulation. However, for patients with an intermediate annual risk of stroke (1%-2%), healthcare professionals should consider oral anticoagulation. Of importance, there are additional risk factors or qualifiers for patients in that 1% to 2% range that can be used to help make the decision, such as left atrial size. Another one that I feel is very important but that was not particularly emphasized in the guidelines is pro B-type natriuretic peptide (proBNP). Elevated proBNP is a very powerful biomarker for predicting risk of stroke, independent of other risk factors. For example, if a patient’s proBNP is highly elevated to 800-1000 pg/mL, that patient generally would require oral anticoagulation, even if their CHA2DS2-VASc score is 1.

The guidelines also provide recommendations on how to use anticoagulation appropriately. Of note, the guidelines discuss the importance of using the evidence-based doses of anticoagulation, rather than off-label doses, which are often inappropriately low and ineffective. This includes anecdotal dose adjustment to account for perceived or assessed risk of bleeding with therapy. The guidelines also recommend against using aspirin instead of anticoagulation and using aspirin with anticoagulation except in specific cases, such as for patients who are within 1 year of having a coronary stent.

A major issue is the fact that only approximately one half of patients who have AF and meet the treatment criteria for anticoagulants are actually using anticoagulation, mainly because of concerns with bleeding. To address this issue, the guidelines recommend not using the HAS-BLED score to decide whether to use anticoagulation, as these scores are directly and linearly related to CHA2DS2-VASc scores. In other words, risk factors for bleeding are also risk factors for stroke, so withholding anticoagulants based on HAS-BLED scores can result in preventable stroke. Factors that predict increased risk of bleeding that are independent of predicting increased risk of stroke should be used when weighing the risks and benefits of anticoagulation. For patients who have a true long-term contraindication to anticoagulation, there is a 2A recommendation to consider left atrial appendage occlusion.

For patients who do not qualify for a left atrial appendage occlusion but still have a high risk of bleeding and need anticoagulation, I believe the first step is to address the modifiable risk factors for bleeding, for example, avoiding aspirin with anticoagulation and not using nonsteroidal drugs, avoiding alcohol, and managing blood pressure. If patients are at increased risk of bleeding due to falls, referrals to geriatrics specialists, pharmacists, physical therapists, or occupational therapists may help to decrease that risk. If patients have a prior history of gastrointestinal bleeding, I would consider using a proton pump inhibitor or further evaluation to identify a treatable source. I also would suggest evaluation of individual patient characteristics, such as creatinine clearance, to determine the correct anticoagulant dose.

In all, the risk of stroke must be weighed against the risk of bleeding when using anticoagulants, and healthcare professionals must decide with their patients whether reducing risk of stroke is the higher priority.

Left Atrial Appendage Occlusions
Another update of note is that based on new data regarding the safety and efficacy of left atrial appendage occlusion (LAAO) devices, the class of recommendation for these devices was upgraded to 2a. For patients who have AF and are undergoing cardiac surgery, surgical LAAO has a Class 1 recommendation based on the LAAOS trials.

Rhythm Control
Furthermore, the new guidelines acknowledge and emphasize the importance of early rhythm control based on data from the EAST-AFNET 4 trial, which provided evidence that early rhythm control was associated with improved symptoms and outcomes for patients with AF.

Catheter Ablation
Separately, based on recent studies demonstrating that catheter ablation is superior to drug therapy for rhythm control in certain populations, catheter ablation now has a Class 1 indication as first-line therapy for appropriately selected individuals, namely, younger patients with fewer comorbidities with paroxysmal AF.

Recent studies also provided evidence for catheter ablation vs drug therapy for patients who have heart failure with reduced ejection fraction. In light of this data, catheter ablation also received a Class 1 indication for this population of patients, especially those who have rapid ventricular response and who have features that would make them likely to have beneficial results from catheter ablation of AF, for example, having left atrial size that is not markedly enlarged and some degree of paroxysmal AF.

Device-Detected AF
Lastly, the guideline recommendations on device-detected AF were updated. The new recommendations now account for the relationship between episode duration and individual underlying risk for thromboembolism. The updated guidelines recommend that patients who have device-detected AF (eg, with pacemakers or defibrillators) longer than 5 minutes consider starting oral anticoagulation, especially for patients with a higher annualized risk of stroke related to AF.

The new guidelines were published before the results of the ARTESIA trial—which compared apixaban vs aspirin for stroke prevention among patients with device-detected AF—were published. However, in support of the guideline recommendations, we now know from ARTESIA that patients who have device-detected, subclinical AF; a CHA2DS2-VASc score >5; and prior stroke clearly benefit from reducing risk of stroke with anticoagulation.

In addition to AF detection by these medical devices, some commercial wearable technology may now alert patients to the presence of potential arrhythmias. Patients may present to primary care providers or pharmacy counters as a result to ask whether this is a cause for concern. I think it is important to note that that these patients should be referred to cardiologists for additional workup. This can be challenging because of the dearth of evidence about how to evaluate and treat those patients, but it is important that they at least be evaluated for other risk factors for stroke. If other risk factors are present, these patients should have some type of longer-term monitoring to determine their actual rhythm and whether treatment is appropriate.

Your Thoughts?
How have the new guidelines for AF affected your practice? How likely are you to initiate oral anticoagulation for your patients with AF with a high annualized risk for stroke? Leave a comment to join the discussion!

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How often to you use scoring systems such as CHA2DS2-VASc, ATRIA, and GARFIELD to guide your treatment recommendations for patients with AF?

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