LONDON — The European Society of Cardiology has released new guidelines for managing atrial fibrillation, changing how this complex condition is treated.
The first and most important step in treating atrial fibrillation (AF) is identifying and managing other health conditions and risk factors that a patient may have. These underlying issues are key to effectively managing AF, said Dr. Isabelle Van Gelder, a cardiology professor at the University Medical Center in Groningen, Netherlands, during the European Society of Cardiology (ESC) Congress.
Dr. Van Gelder emphasized that treating these additional health issues is just as crucial as addressing the irregular heart rhythm itself. In fact, these underlying conditions often trigger or worsen atrial fibrillation, making their management central to successful AF treatment.
Class I Recommendation
Based on strong evidence, the guidelines now include a Class I recommendation to manage several health conditions like high blood pressure, heart failure, obesity, diabetes, alcohol use, and exercise in patients with AF. Sodium-glucose cotransporter-2 (SGLT2) inhibitors are also recommended for all AF patients.
Dr. Van Gelder warned that without aggressive treatment of these underlying conditions, patients face higher risks of treatment failure, poor outcomes, and wasted healthcare resources.
Sleep apnea management is also highlighted, although the supporting evidence is slightly weaker, earning it a Class IIb recommendation.
The focus on managing additional health conditions isn't entirely new. The 2023 joint guidelines from groups like the American Heart Association and American College of Cardiology also emphasized this. However, the new ESC guidelines go further by making comorbidity management the first priority in patient care pathways for AF.
These pathways, which provide detailed steps for treating newly diagnosed, paroxysmal, and persistent AF, always begin with assessing other health conditions, followed by preventing strokes, mainly through anticoagulation.
Direct oral anticoagulants are recommended for most patients, except those with mechanical heart valves or mitral stenosis. Patients with a CHA2DS2-VASc score of 2 or more should definitely receive these, and those with a score of 1 should consider it.
The ESC guidelines are summarized in the acronym AF-CARE, where "C" stands for comorbidities.
In the "A" step of the framework, managing bleeding risk factors is a top priority. Dr. Van Gelder advised against stopping anticoagulants solely because of CHA2DS2-VASc risk factors and stressed that all decisions should be personalized and discussed with the patient.
The guidelines also cover symptom management and rhythm control, with specific recommendations based on the type of AF. The importance of regularly reassessing patients for new risk factors related to comorbidities, stroke, bleeding, and AF is also highlighted.
The shift in focus from just managing AF to also tackling underlying health issues is expected to improve long-term control of AF. This approach relies on multidisciplinary care, chosen in partnership with the patient, to reduce or eliminate the triggers of AF and its complications.
Guidelines Apply to Everyone
A new and important recommendation is to treat all AF patients, regardless of age, gender, race, or risk level, using the patient-centered AF-CARE approach, according to Dr. Van Gelder.
These changes reflect a growing understanding that AF is often caused by underlying health issues, which cannot be treated separately from the heart rhythm problem itself, explained Dr. José A. Joglar, a professor at the University of Texas Southwestern Medical Center in Dallas and chair of the 2023 AF guidelines committee.
"AF is increasingly recognized as a complex disease that requires a comprehensive, multidisciplinary approach, not just as an abnormal heart rhythm," Dr. Joglar said.
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