Tools of the Trade: Implementing New Guidelines for NVAF Management and Treatment in Primary Care

Introduction

Dr. Alpesh Amin (University of California): Welcome everybody to today's event.  Joining me today is Dr. Granger.  We are going to be talking about Tools of the Trade: Implementing New Guidelines for Nonvalvular Atrial Fibrillation Management and Treatment in Primary Care setting. 

Today's event is provided by Clinical Care Options and is supported by an educational grant from Bristol-Myers Squibb. 

My name is Alpesh Amin.  I am Associate Dean for Clinical Transformation at UC Irvine Health and also serve as Chief of the Division of Hospital Medicine and Palliative Medicine in the Department of Medicine at the University of California, Irvine.  Joined with me is my esteemed friend and colleague, Dr. Chris Granger, who is Professor of Medicine and Nursing at Duke University in North Carolina.  Welcome, Chris. 

Dr. Chris Ganger (Duke University): Thanks, Alpesh. 

Dr. Amin:  These are our faculty disclosures on this slide.  So today's learning objectives are:

• Interpreting clinical evidence that supports changes to nonvalvular AFib care represented by, in the 2023 ACC, AHA, ACCP and HRS guidelines;
• Also, we will be implementing the latest best practice for managing nonvalvular atrial fibrillation and providing high quality care, according to the most recent guidelines from these four prestigious organizations: the American College of Cardiology, the American Heart Association, the ACCP and the Heart Rhythm Society. 

So I wanted to start off by setting the stage around these new guidelines, and there have been some changes that have actually occurred in the 2023 AFib guidelines.  So as a background just for everybody's memory, major updates in the full context guidelines occurred in 2014.  And then there was a focus update from AHA-CC and HRS in 2019.  The guidelines reflect recent advances in AFib detection, management, especially for nonvalvular atrial fibrillation. 

Some of the key changes that occurred in the latest guidelines, the 2023 guidelines focused on these four areas that we are going to be highlighting in our conversation today.  New classification system, AFib is recognized as a disease continuum now as opposed to a very focused singular problem.  It has got a flexible risk scoring system and expanded the options of CHADSVASC for predicting stroke and systemic embolism. 

It also looked at DOAC dosing, with an emphasis on ensuring correct dosing for efficacy and safety.  And it looked at the important lifestyle and modified risk factors with a greater focus on lifestyle adjustments such as weight, alcohol and activity. 

Dr. Granger, what do you think about these key changes, especially around the risk scoring and the flexibility around risk scoring? 

Dr. Granger: Yes, Alpesh, as you point out, it has been a long time since we had updates.  I will also mention that the Europeans also have had an update in 2024.  And it is very well aligned with this.  And I think it is so appropriate that there is recognition of some flexibility around risk scores.  And I will talk a little bit more detail about that DOAC dosing.  We know that all too often these drugs are under dosed.  That is the bigger problem or not even used.  Those are the biggest challenges. 

And then for lifestyle and modifiable risk factors, it is so important.  This is where you as a primary care leader, it is so important, right, that we treat the comorbidities that may be equally important to treating the AFib itself because they are so closely linked. 

Dr. Amin: Chris, that is a really, really important point there, that last one, focusing on the underlying risk factors that contribute to atrial fibrillation and thinking about the patient as a holistic patient becomes a really important modifiable opportunity in terms of managing the continuum of atrial fibrillation. 

So for some additional details on advances in AFib management, we can see in the 2023 guidelines, there was a preferred use of DOACs over warfarin.  And this is really driven by the evidence that supports DOACs in terms of its improved safety and efficacy.  These are direct oral anticoagulants, as you all know.  And I would say that the evidence has gotten even stronger, not just based on clinical trial data, but also on real world data that supports the safety and efficacy of DOACs, and also the ease of use of DOACs over warfarin, both at the patient level as well as at the provider level. 

The second major advance is the risk stratification.  There has been an update and risk stratification for anticoagulation.  They refined the CHADSVASC score tailoring it to recommendations based on individual stroke and bleeding.  So we use the CHADSVASC score to predict whether what the risk of a patient is in terms of stroke, balancing it with the risk of bleeding and Dr. Granger will get into that a little bit more. 

And then this important last point, which is a patient-centered care, holistic care, prioritizing rate control for most patients that impacts quality of life and symptom management.  So these are really important key features that one should keep in the back of their mind. 

I also wanted to build out a little bit on the interdisciplinary approach, this holistic approach to nonvalvular AFib care and the role of primary care in its leadership.  We all talk about the team-based approach that integrates primary care with cardiology with hospital medicine specialists, pharmacy, other specialty areas and optimally managing nonvalvular atrial fibrillation. 

We have seen data that supports team-based approach, more heads around the table and each doing their part from a specialty perspective.  But besides these other specialties, I think there is others that are involved like social worker and case management and nursing, so keeping all of that in our mind.  And then also consistent communication, shared decision making with the patient and developing personalized care plans is really, really important as we continue to move forward. 

And then the expanding role of primary care becomes a central focus here as you are thinking about this coordinated communication, this coordinated plan with the patient.  Primary care is the first line for screening, for lifestyle guidance and routine monitoring.  It is also a patient-centered focused approach, empowers patients with education around nonvalvular atrial fibrillation management and quality of life. 

Chris, what is your thoughts about this spectrum of putting primary care in partnership with cardiology and managing atrial fibrillation? 

Dr. Granger: Yes, Alpesh, I think it is so important.  Because we know that most of this actually gets managed by primary care around the country.  And so I think for cardiologists to partner with primary care.  I will also highlight is, as you did the role of pharmacists, like somebody comes in with acute COVID, they are on Pax.  They want to treat with Paxlovid.  It has got a pretty strong interaction with DOACs, like in lots of other examples, you have got to be in contact with your pharmacist if you are going to provide good care for this population. 

So I think that is why I am so excited about this program, because of the partnership with you as a primary care leader, is so important to provide the best care for this population. 

I will also just reiterate what I said earlier, that one of the biggest opportunities is the population who is not on an anticoagulant at all.  And it is usually because of concern over bleeding.  And usually the risk of stroke is greater than the risk of bleeding.  And these patients should be treated with an anticoagulant, especially now with DOACs that have less than half the risk of intracranial hemorrhage compared to warfarin. 

So one thing we want to do is encourage you all listening to this, really almost every patient with AFib and risk factors for stroke should be on some stroke prevention treatment. 

Dr. Amin: Chris, you bring up a really important point.  Not all bleeding is the same, right?  Nobody likes bleeding.  But when the risk for intracranial hemorrhage, which is the bad bleeding, if you like, that you want to really avoid is 50% or less.  That is not the same thing as having a little bit of bleeding when you get a needle stick or a scratch or whatever.  So it becomes really important to really understand the balance between the risk for stroke and the risk for bleeding. 

I also wanted to point out that, and I have done this many times, asked audiences when I have given talks.  But would you rather actually have a stroke or would you actually rather have a bleed?  And in general, because of the significant comorbidities around stroke, people want to try to avoid that, which means that we need to be a bit more aggressive in our management strategies. 

Dr. Granger: Alpesh, if I could right now make two other key teaching points.  One is that for patients who fall because, as you know, the older population falls a fair amount actually.  Once you get to like late 70s, 80s.  And usually these patients are not hitting their heads and getting subdural.  And those patients clearly still benefit from anticoagulation unless they are really hitting their heads falling, in fact, is a sign of frailty and increased risk of stroke.  So treat those patients but with a DOAC, not with warfarin. 

And then secondly, one of the easiest ways you can improve safety of anticoagulation is not use aspirin.  Even for stable coronary disease, the DOAC alone provides protection against MI and is about half the risk of major bleeding.  So even stable coronary disease on a DOAC, do not use the aspirin or clopidogrel, DOAC alone. 

Dr. Amin: Perfect.  Those are really key important points.  And one last thing, Chris, is when you have a patient that may even be at risk of fall because they have imbalance issues or peripheral neuropathy or whatever, if they are in full cognition, their mental status is really good.  They know how to fall too, and it will protect the brain, protect the head and so forth. 

So again, we are trying to empower everybody here that the role of DOACs actually can be really helpful in the management of atrial fibrillation. 

So let us talk a little bit about some additional updates on the 2023 guidelines, which we are excited to point out here.  There has been a shift in focus beyond arrhythmia duration.  Atrial fibrillation is viewed as a continuum and it recognizes that atrial fibrillation progression with evolving risk factors and disease burden is talked about in the guidelines. 

The other aspects are stage specific management strategies.  So looking at targeted interventions at different stages.  And this becomes part of that concept of continuum of care.  What are the recommendations early when you detect atrial fibrillation?  What do you do at the preventative stage?  What do you do at the advanced management stage?  There should be a constant relook at how we are managing atrial fibrillation. 

And then, we pointed this out earlier, but this personalized approach, tailoring it to achieve the patient level outcomes and the quality of life across AFib continuum is also really important.  So these have been pointed out in the guidelines.  And I think they are all very important as we continue to talk through this. 

So just to add a little bit in terms of lifestyle and risk factor modification, some of the pillars around AFib management, which Chris will go into, emphasize lifestyle changes.  And we cannot highlight that the importance of that enough, because these lifestyle changes such as managing obesity, managing thyroid, managing alcohol can help prevent both the onset and progression of atrial fibrillation and adverse outcomes. 

Some of the key strategies, as you can see here, weight management, exercise and diet, regular physical activity and having a heart healthy diet is really important.  Also, controlling some of the risk factors around hypertension, diabetes, sleep apnea will help with AFib risk and the progression of disease.  And then really that individual patient focus on outcomes reducing the burden.  This starts with early lifestyle interventions and then is linked to improved quality of life and reduced AFib progression. 

So at this point, I am going to hand it over to Chris to get into more details around this.  So Chris. 

Dr. Granger: Good.  And I like this construct.  They have these three pillars to categorize what you should be thinking about for a patient who presents with atrial fibrillation.  I will start with the central one that, Alpesh, you have already emphasized is so important.  That is treating modifiable risk factors.  So important.  And they are listed down below in the foundation of this diagram. 

I will just point out also because people ask about this, like even modest amounts of alcohol, now, we know increase the burden of AFib.  It was actually a randomized trial published in New England Journal from Australia that if you are a modest drinker and you cut back substantially on the drinking or stop drinking, it reduces AFib by about 30%.  It is a big effect and it is an absolutely cause and effect.  Whereas caffeine, on the other hand, modest amounts of coffee do not seem to increase AFib for most people.  So tell people they need to cut back on drinking alcohol, but coffee is okay. 

So optimize these treatments of hypertension, sleep apnea, encourage exercise, obesity and whatnot. 

Next is symptom management.  So we want to manage symptoms.  And that is largely related to tachycardia and the irregular heart rhythm palpitations but also heart failure that can result from especially from poor rate control, and I will get back to that.  And especially with patients with decreased LV function in their ablation seems to be especially important opportunity to improve care. 

And finally, stroke risk and stroke is the most devastating complication, the most feared complication.  These strokes tend to be more fatal and more disabling than other types of strokes.  So optimizing stroke prevention is also something so important. 

Dr. Amin: Chris, can I just ask really quick?  When should a primary care physician think about rhythm control after going after rate control?  When is that key opportunity to move it to rhythm control? 

Dr. Granger: Yeah.  So great question.  More and more now, we are recognizing that the best rhythm control, the safest and most effective for most patients is ablation.  It has become safer, it has become better.  And I will mention in the guidelines it has been upgraded. 

And so I think, Alpesh, anybody who has got significant ongoing symptoms and is probably the most important category for where a cardiologist needs to see that patient to help decide, is this somebody where ablation, even early ablation, we used to say only consider ablation if you failed anti-arrhythmic therapy.  We now have trials showing even as a first approach, especially in a younger patient with no comorbidities or in somebody more advanced with heart failure and decompensated heart failure, those are categories where ablation, you really should be thinking about it very early for people who are having symptoms. 

So in terms of the risk scores, you mentioned this.  There is a de-emphasis on the CHADSVASC score.  In the current guidelines, it is more like if somebody has an annual risk of stroke of at least 2%, then they should be anticoagulated.  1% to 2%, you should consider it.  Still, the CHADSVASC score is the score that we use mostly.  But we no longer count female sex as part of it.  So it is actually the CHADSVASC score, in fact.  And then there is some additional factors that I will get back to. 

And then shared decision making, especially for patients, let us say, who have a CHADSVASC score of 1, let us say, a healthy man or woman who is 68 years old, no risk factors, like what do you do with that person?  And then you use shared decision making.  And you say you can reduce the risk of stroke, but the stroke risk is not high. 

Two things that I really like in terms of additional factors are proBNP, very powerful predictor of risk of stroke and left atrial size.  You definitely want to get an echocardiogram.  Make sure that they do not have valvular abnormalities, their LV function. 

And then the left atrial size tells you about if it is small, they are going to be less likely to have risk of stroke and progression of their AFib. 

And then the risk of anticoagulation.  HAS-BLED score is not very good.  The most important factors for people who are higher risk are people who have had previous bleeding.  If they have anemia, that is higher risk.  And if they are very elderly, that is higher risk.  And if they are on aspirin, back to what I said earlier.  So stopping the aspirin when you are using an anticoagulant is maybe the most simple, important opportunity that you have got. 

Okay.  How about a little more on the additional factors?  So those who have an annual stroke risk of less than 2%.  In other words, basically a CHADSVASC score of 1.  What do you do for them?  And I have already gone into this to some extent.  You look at other risk factors for stroke, which include left atrial size and proBNP, as some of the important ones. 

How about early rhythm control?  You mentioned this, Alpesh.  So there is, in the guidelines now, an increased focus on early intervention to maintain sinus rhythm.  And this is based on the fact that now ablation is more effective and safer and better supported by randomized clinical trials as a way to improve quality of life and reduce hospitalization.  That includes, for example, from the EAST-AFNET 4 trial. 

This is a trial that was done in Europe.  But it really reinforced that being in sinus rhythm really is better to improve outcomes, especially for patients who are having symptoms of AFib and have maybe the first episode of AFib or AFib with a reversible cause you would not put in that category.  But most people who have any significant symptoms from AFib think really seriously about rhythm control to keep them in sinus rhythm.  And that improves both hard clinical outcomes like hospitalization as well as quality of life, and maybe also reduces the progression of atrial fibrillation. 

So then the Class 1 indications for ablation are first-line therapy in selected patients.  Again, this tends to be people who are younger, who have normal left atrial size and therefore you can really effectively control their rhythm and give them better quality of life with an ablation.  And again, this is really supported by randomized trials.  And we don't really like these drugs, amiodarone or Class 1C agents.  They have real risk to them. 

And so we like to try to minimize the use of antiarrhythmic drugs.  Maybe in the very older population, something like amiodarone can be a really good choice. 

So how about patients, I have mentioned this, who have heart failure with reduced ejection fraction, especially if they are having tachycardia?  Then ablation here.  Also, we have pretty good data now that it improves clinical outcome.  It really helps with their heart failure.  If they have tachycardia-induced cardiomyopathy, their LV function might also really improve.  So that is a time when it is really important to refer to the cardiologist. 

Another major area is device detected AFib.  So this is patients who have already have an implanted cardiac device like a pacemaker or an ICD.  And then they are not having clinical symptoms of AFib.  But on their reports you see they are having, one to six hours of long episodes of atrial fibrillation.  How do you consider that? 

It is associated with increased risk of stroke.  And we know now from two randomized trials from last year that that stroke is preventable.  But the risk in the overall population is relatively low.  So what I would advise for a tailored approach, which is what is recommended is – and we know this from the ARTESIA trial, recently published data that if a patient has a CHADSVASC score of greater than 4 or prior stroke, they have this greater than 2% annual risk of stroke that was defined in the guidelines as reason to treat, and over a 50% reduction in stroke with treatment with in those two trials that was with either apixaban or edoxaban. 

The other thing is, if they have a little bit of AFib, it predicts patients who will develop longer AFib.  So when you see some device detected AFib, monitor those patients carefully because they may be developing more AFib. 

Finally, they did mention and there is increasing evidence that left atrial appendage occlusion devices have benefit.  We know this from the Lighthouse trial in patients who are undergoing cardiac surgery, that there was about a 30% reduction in risk of stroke for people with AFib who had left atrial appendage occlusion during surgery. 

And then there was another trial that was just presented and published that looked at patients who were having AFib ablation and had left atrial appendage occlusion, and there was some evidence of benefit there.  So it is now a Class 2A recommendation.  So what I would say here is anticoagulation is still the best way, the gold standard way to prevent ischemic stroke.  Use that as your foundation. 

But if it is somebody who cannot take anticoagulation because of recurrent GI bleeding, for example, or absolutely refuses to take anticoagulation, then left atrial appendage occlusion is a way to reduce the risk of stroke and is something that you should really consider, I would say not so much as an alternative as a backup plan, if the patient cannot be on an oral anticoagulant, which is a lot of patients.  And there, of course, you also need to refer to an experienced center. 

And then one last topic is that of transient AFib that was in the setting of an acute illness, like an acute medical illness, like classically pneumonia, pericarditis, or around the time of surgery, bypass surgery.  30% of people have some AFib after bypass surgery, for example.  But other types of surgery also. 

And here, recognizing that this is a predictor of patients who are higher risk for subsequent AFib.  So monitor these patients and keep track of whether they are developing AFib, be that with like a cardio live core device, if they are having any symptoms or an Apple Watch, those are potential ways.  They are not highly accurate.  And they are only with symptoms with the cardio device.  But still, those are potential tools or periodic monitoring with a Holter or a patch, could be considered also, because these patients are at risk for developing subsequent atrial fibrillation. 

So I hope then that that we've been able to highlight some of the really important updates from the new guidelines, both the North American guidelines as well as I have also mentioned the European guidelines.  They are very closely aligned.  Really focus on the treating comorbidities.  You will improve patients, both their AFib and their risk of stroke will go down by doing that. 

Focus on the symptoms and consider ablation as an earlier part of your pathway.  For patients who have ongoing symptoms of being in paroxysmal AFib.  And then for stroke prevention, make sure that you are treating patients with anticoagulants, DOACs preferred over warfarin.  Make sure they are on the appropriate dose which is modified by age and renal function, and in the case of apixaban, also body weight.  But make sure you are treating all your patients who have AFib and risk factors for stroke should be on some treatment to prevent the risk of stroke. 

And Alpesh, let me turn it over to you for comments from your perspective on these issues. 

Dr. Amin: Yes, Chris, I think you hit a lot of really good summary points there.  I would just add that the multidisciplinary approach and the communication amongst the team, it will support best practices in managing patients, thinking about a personalized approach, which we talked about for the patient to achieve the outcomes that, that we are hoping to achieve.  And then really taking a step back and understanding that the risk of bleeding with the DOACs has minimized to a great degree, and the risk of intracranial hemorrhage is very, very, very low for patients that are on DOACs. 

So there really needs to be a view that one should actually think about giving a DOAC unless there is a real strong reason not to, right, as opposed to being worried and scared about bleeding in most patients.  And we certainly need to think about it.  But in many cases, we need to move towards evidence that the risk of bleeding with DOACs is actually minimized considerably compared to other therapies. 

Dr. Granger: Alpesh, I think that is a great way to end it, because I agree, there is no issue more important than the fact that there is risk of bleeding, but we can minimize it and we need to be preventing stroke as our number one priority around that issue.  And I think it has been such a pleasure for me to do this program with you because I think symbolically, the partnership of primary care and cardiology is the foundation, along with others, as you pointed out, including pharmacists.  But it is the foundation.  We have to work together to provide the best care for this population. 

And we hope this program has been helpful to you to provide tools that you can use to improve the care of your patients with atrial fibrillation.  And you can get more by going online from Clinical Care Options for coverage of the implications of these new guidelines for the management of atrial fibrillation.  There is a ClinicalThought Expert commentary, a downloadable patient resource, and an interactive decision support tool on anticoagulation for management of atrial fibrillation. 

Thanks so much for being with us today. 

Dr. Amin: Thank you, Chris.  It has been a great pleasure.  And thank you everybody.

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