Atrial Fibrilation Updates 2024 Guidelines.pptx
- 1. Staying in Rhythm: Atrial Fibrillation Management 1
- 2. Abbreviatio ns • AAD: antiarrhythmic drug • ACS: acute coronary syndrome • AF: atrial fibrillation • AT: atrial tachycardia • BB: beta blockers • bpm: beats/minute • CAD: coronary artery disease • CKD: chronic kidney disease • CrCl: creatinine clearance • CV: cardiovascular • DCC: direct current cardioversion • DOAC: direct oral anticoagulant • HF: heart failure • HFrEF: heart failure reduced ejection fraction • HTN: hypertension • HR: heart rate • LA: left atrium • LVEF: left ventricular ejection fraction • LVH: left ventricular hypertrophy • NDCCB: non-dihydropyridine calcium channel blockers • NSR: normal sinus rhythm • OSA: obstructive sleep apnea • RF: radiofrequency • RVR: rapid ventricular response • T2DM: type 2 diabetes • TIA: transient ischemic attack 2
- 3. Authors involved in this presentation have no relevant financial relationships to disclose and no actual or potential conflicts of interest. Jasmine Hill, PharmD Alex Brown, PharmD Disclosur es 3
- 4. The purpose of this presentation is to educate pharmacists about the 2023 guideline updates for treatment and management of atrial fibrillation. Purpose 4
- 5. Learning Objectives Apply Atrial fibrillation treatment strategies to patient cases Identify & Describe The latest atrial fibrillation guideline updates Evaluate The evidence supporting treatment and management updates 01 02 03 5
- 6. An update to the 2014 AHA/ACC/HRS AF guideline and the 2019 AHA/ACC/HRS Focused Update of the 2014 guideline 2023 ACC/AHA/ACCP/HRS AF Guideline: Update 6
- 7. Backgrou nd • AF is one of the most common cardiac arrhythmias • AF prevalence in the US was estimated to be 5.2 million in 2010, with an expectation to increase to 12.1 million by 2030 Symptoms Asymptomatic Chest pain Palpitations Fast HR Dyspnea Fatigue Dizziness Abnormal electrical activity within the atria of the heart, causing them to fibrillate. Nesheiwat Z et al. NLM, 2023. 7
- 8. Biomarkers/ Genetics Other Conditions CV Disease Lifestyle Risk Factors Hypertension HF CAD Valvular heart disease Increasing age Smoking Physical Activity Alcohol Obesity Prolonged PR Elevated BNP Elevated CRP Increased size of LA Diabetes CKD OSA Hyperthyroidism 8
- 9. Diagnosis 9
- 10. Categorization paroxysmal AF persistent AF longstanding AF permanent AF Tradition al (old) AF resolves within 7 days AF lasts for > 7 days continuously (requires intervention) AF lasts for > 12 months Lasts indefinitely - no further attempts at rhythm control after discussion between patient and provider. 10
- 11. Stage One: Stages of AF Stage Two: Stage Three (A- D): Stage Four: at risk for AF with modifiable and/or non-modifiable risk factors pre-AF: structural or electrical predisposition AF • 3A (paroxysmal): AF resolves within 7 days of onset • 3B (persistent): AF lasts for > 7 days continuously • 3C (longstanding): AF lasts for > 12 months • 3D (successful ablation): percutaneous or surgical intervention *symptom treatment and stroke risk management indicated permanent AF no further attempts at rhythm control after discussion between patient and provider 11 Update
- 12. 12
- 13. Stroke risk management: AF Management Strategy Optimiz e: HEAD to TOES: Symptom Management: assess and treat all modifiable risk factors • Heart failure • Exercise • Arterial hypertension • Diabetes rate and rhythm control • Tobacco • Obesity • Ethanol • Sleep 13
- 15. Criteria C H A2 D S2 - V A S c Score Maximum Score Score Congestive HF Hypertension (> 140/90) Age 75 years old ≥ Diabetes Stroke/TIA/thromboembolism Vascular disease Age between 65-74 years old Sex category - Female 2 2 1 1 1 1 1 1 9 Most validating system *used to assess stroke risk 15
- 16. Intermediate risk: 1 to <2% annual thromboembolic risk Total score: 1 (men) and 2 (women) High risk: 2% annual thromboembolic risk ≥ 16 CHA2DS2 - VASc Score Total score: 2 (men) and 3 ≥ ≥ (women)
- 17. Criteri a A T R I A Score Maximum Score Score Age 85 years old ≥ 3 1 2-8 1 1 5 6 1 9 Age 75 years old ≥ Age 65-74 years old Female Hypertension Diabetes Congestive HF ** 8 points if age < 65 years old, 4 points if age 65-74, 2 points if age 75-84 years old, and 3 points if 85 years old ≥ 1 17 Renal disease 1 Proteinuria Stroke/TIA ** 1 2-8
- 18. Total score: 0-5 Low risk: <1% annual thromboembolic risk Intermediate risk: 1 to <2% annual thromboembolic risk Total score: 6 Total score: 7- 15 High risk: 2% annual thromboembolic risk ≥ 18 ATRIA Score
- 19. GARFIELD-AF Score Web-based tool that reports the calculated risk in plots and percent values 19
- 20. Total score EXCLUDING sex category 2 ≥ or approximate thromboembolic risk 2% ≥ DOACs are recommended over warfarin for oral anticoagulation in patients with AF EXCEPTION: patients with AF with a history of moderate to severe rheumatic mitral stenosis, a mechanical heart valve, or CrCl < 15 mL/min Oral anticoagulant agents: warfarin apixaban rivaroxaban dabigatran edoxaban oral anticoagulant recommended oral anticoagulant is reasonable Total score EXCLUDING sex category = 1 or approximate thromboembolic risk 1% but < 2% ≥ Update 20
- 21. In patients who are candidates for anticoagulation and without an indication for antiplatelet therapy, aspirin ± clopidogrel as an alternative to anticoagulation is NOT recommended to reduce stroke risk (Harm) In patients with AF without risk factors, aspirin (monotherapy) for stroke prevention is of no benefit. Anticoagulation 21
- 22. Criteria H A S - B L E D Score Maximum Score Score HTN (SBP > 160 mm Hg) Abnormal renal * / hepatic function ** Stroke history Bleeding history/predisposition Labile (unstable/high) INR Elderly patients (age > 65 years) Drugs that increase bleeding risk OR excessive alcohol use 1 1 1 1 1 each 1 9 *used to assess bleeding risk *abnormal renal function: chronic dialysis, renal transplantation, or SCr 2.26 mg/dL ≥ **abnormal hepatic function: chronic hepatic disease, significant hepatic impairment (e.g. bilirubin > 2X ULN with AST/ALT/Alk Phos > 3X ULN 1 each Score 3: ≥ higher bleeding risk 22
- 23. Other Bleeding Risk Calculators ATRIA Score: • Anemia • Severe renal disease • Age 75 years old ≥ • Prior bleeding • Hypertension HEMORR2HAGES Score: • Hepatic/renal disease • Ethanol abuse • Malignancy • Older age ( 75 years ≥ old) • Reduced platelet count/function • Re-bleeding risk • HTN (uncontrolled) • Anemia • Genetic factors • Excessive fall risk • Stroke 23
- 24. Patient Case Mr. Flutter is a 72 yo M with a PMH of uncontrolled HTN, T2DM, CKD stage III, and AF. He has no history of falls or major bleeding, his HAS-BLED score is 2. Should Mr. Flutter start on anticoagulation therapy? If so, which therapy would you recommend? 24 A. No anticoagulation is needed B. Yes, apixaban C. Yes, warfarin
- 25. Patient Case Mr. Flutter is a 72 yo M with a PMH of uncontrolled HTN, T2DM, CKD stage III, and AF. He has no history of falls or major bleeding, his HAS-BLED score is 2. Should Mr. Flutter start on anticoagulation therapy? If so, which therapy would you recommend? A. No anticoagulation is needed B. Yes, apixaban C. Yes, warfarin 25
- 27. • Data from earlier clinical trials suggest no significant difference in mortality between the two strategies • Shared decision-making with the patient is recommended to discuss rhythm versus rate control strategies Rate Rhyth m 27
- 28. Wyse DG et al. AFFIRM Trial. N Engl J Med, 2002 Clinical Evidence Randomized, parallel trial Randomized to either rate or rhythm control treatment strategies Primary outcome: all-cause mortality at 5 years Inclusion Criteria: • Age 65 with AF (likely to be ≥ recurrent) • AF likely to cause illness or death for participant • Long-term treatment of AF warranted • Other risk factors for stroke or death Exclusion Criteria: • Contraindication to anticoagulation therapy • Ineligible to undergo trials of 2 ≥ medications in either treatment strategy AFFIRM Trial 28
- 29. Wyse DG et al. AFFIRM Trial. N Engl J Med, 2002 Clinical Evidence Rate Control • Target HR: <80 bpm at rest and <110 bpm during activity Acceptable drugs to use: • Class II: beta-blockers • Class IV: calcium-channel blockers (verapamil and diltiazem) • Class V: digoxin Rhythm Control • AAD chosen by treating physician • Class Ia: quinidine, procainamide, disopyramide • Class Ic: flecainide, propafenone, moricizine • Class III: amiodarone, sotalol, dofetilide AFFIRM Trial 4,060 patients with nonvalvular atrial fibrillation Rate control (n=2,027) Rhythm control (n=2,033) 29
- 30. Wyse DG et al. AFFIRM Trial. N Engl J Med, 2002 AFFIRM Trial Primary Outcome Rhythm Control Rate Control All-cause mortality 32.7% 32% HR, p-value HR 1.15; p-value = 0.08 Adverse Effects Event Rhythm Rate P-value Torsades de pointes 0.8% 0.2% 0.007 Pulseless electrical activity, bradycardia, or other rhythm 0.6% <0.01% 0.01 Hospitalization 80.1% 73% <0.001 30
- 31. AFFIRM Trial Wyse DG et al. AFFIRM Trial. N Engl J Med, 2002 Results • More deaths occurred in the rhythm control group compared to the rate- control group, but the difference was not statistically significant • There is no survival benefit difference between rate and rhythm control • Patients receiving rhythm control were significantly more likely to be hospitalized and have adverse drug effects than those in the rate-control group 31
- 32. Rate Control Regulates ventricular rate 32
- 33. HR goal: < 100-110 bpm and < 80 bpm in select patients Medications: • BB or NDCCB recommended as standard of care for both acute and long-term control • Digoxin is not first line but may be considered in HFrEF patients • IV amiodarone can be used in acute rate control Rate Control 33
- 34. Rate Control Class Drug Mechanism Acute/Long Term Clinical Pearls BB metoprolol tartrate, metoprolol succinate, atenolol, bisoprolol, carvedilol, esmolol, propranolol Slows conduction through the AV node by blocking beta-1 receptors Used for acute and long-term rate control Avoid in decompensated HF NDCCB diltiazem, verapamil Slows conduction through the AV node by blocking Ca entry into the heart cells Used for acute and long-term rate control Avoid in HFrEF Other digoxin Slows conduction through the AV node by increasing vagal tone and inhibiting the Na/K ATPase pump Used for acute control (may also be reasonable for long term control) Can be considered in patients with HF because of the positive inotrope effects amiodarone Blocks the K, Na, and Ca channels + beta-adrenergic receptors to prolong repolarization and slow conduction maintaining NSR Acute control IV form is generally used for rate control May be considered in patients who are critically ill and/or in decompensated HF 34
- 35. Digoxin is considered standard of care for acute rate control in atrial fibrillation. Knowledge Check: T/F? 35
- 36. Digoxin is considered standard of care for acute rate control in atrial fibrillation. Knowledge Check: FALS E 36
- 37. Rhythm Control To achieve and maintain normal sinus rhythm - can improve symptoms of AF and reduce the likelihood of AF progression 37
- 38. • Patient preference • Younger age • Short AF history (within 1 year) • Higher symptom burden Factors that Favor Rhythm Control • Difficulty in achieving rate control • Smaller LA • More L ventricular or atrioventricular dysfunction 38
- 39. Warfari n INR goal: 2.0-3.0 apixaban, rivaroxaban, dabigatran, edoxaban DOACs Rhythm Control restoring NSR through cardioversion = improved cardiac contraction • Electrical cardioversion: quick, highly effective • Pharmacological cardioversion: medication-based, slower, less effective (some scenarios) • For patients with AF that has lasted 48 hours, it is important to reduce the risk of stroke ≥ before cardioversion: 1. anticoagulation for 3 weeks ≥ OR 2. imaging to exclude an intra-cardiac thrombus Guideline recommendations for anticoagulation: Patients undergoing cardioversion, anticoagulation must be continued for 4 weeks ≥ 39
- 40. Treatment of choice for patients with hemodynamically unstable AF • Preferred for: ⚬ rapid rhythm restoration in stable patients ⚬ symptom relief in persistent or symptomatic AF ⚬ when pharmacological cardioversion is contraindicated or ineffective • Electrical cardioversion achieves acute restoration of NSR, the durability of NSR may be influenced by ongoing acute conditions, duration of the history of AF and/or specific episode, and co-morbidities. Electrical Cardioversion 40
- 41. Clinical Evidence DCC Protocol: short-acting sedation + synchronized monophasic shock Observational Study Population-based retrospective study of patients with stable AF presenting to ED Objective: retrospectively compare the success rates and short-term complications of three treatment approaches. Chemical Wait & Watch Rate control without any cardioversion propafenone, procainamide, or amiodarone Dankner R et al. ED Cardioversion Study. Cardiology, 2009. 41
- 42. Clinical Evidence Dankner R et al. ED Cardioversion Study. Cardiology, 2009. Primary Objective DCC Chemical Wait & watch P-value Cardioversion rate 78.2% 59.2% 37.9% <0.001 Discharge from ED home 52.9% 47.9% 32.1% <0.001 ED hospital admission 39.3% 42.4% 59.5% -- Odds Ratio Treatment Reference OR 95% CI; p-value Electrical (DCC) Wait & watch 6.00 3.38-10.66; p<0.001 Chemical 2.43 1.36-4.33; p=0.003 Chemical Wait & watch 2.47 1.45-4.20 42
- 43. Clinical Evidence Dankner R et al. ED Cardioversion Study. Cardiology, 2009. Results • DCC was ~2.5 times more successful in converting patients to NSR compared to chemical cardioversion. • In terms of converting to NSR, DCC was the most successful treatment modality to convert to NSR. • Also, was associated with the lowest rate of hospitalization with no complications involved in treatment. 43
- 44. Electrical cardioversion is emphasized since it is more rapid and efficacious for restoring sinus rhythm from AF. 2023 Guideline Update: Update 44
- 45. Medications to Achieve NSR: • IV ibutilide or IV amiodarone • IV procainamide - if other IV agents are contraindicated • IV amiodarone - only agent that can be used if LVEF 40% ≤ • PO flecainide/PO propafenone - if utilizing the pill-in-the-pocket strategy • 2023 guidelines no longer recommend dofetilide and PO amiodarone • Once NSR is achieved, AAD may be started as maintenance therapy in patients who cannot or prefer not to undergo catheter ablation Medications to Maintain NSR: dofetilide dronedarone flecainide propafenone low-dose amiodarone sotalol Pharmacological Cardioversion 45
- 46. Rhythm Control 46 Drug Class / Mechanism Clinical Pearls Achieve NSR amiodarone (IV) Class III potassium-channel blockers: block K+ efflux Only recommended agent if LVEF <40% ibutilide (IV) Risk of QTc prolongation procainamide (IV) Class Ia sodium-channel blockers: blocks Na+ influx (intermediate) Can be considered If ibutilide and amiodarone are not reasonable options Risk of QTc prolongation flecainide (PO) Class Ic sodium-channel blockers: blocks Na+ influx (slow) “pill-in-the-pocket” strategy A BB or NDCCB should be administered 30 minutes prior propafenone (PO)
- 47. Rhythm Control 47 Drug Class / Mechanism Clinical Pearls Maintain NSR amiodarone (PO) Class III potassium-channel blockers: block K+ efflux • First-line for patients with prior MI or HF with LVEF <40% • NOT first line option due to side effect profile • Low-dose (100-200 mg/day) dofetilide (PO) Class III potassium-channel blockers: block K+ efflux • First-line for patients with prior MI or HF with LVEF <40% • MUST be initiated inpatient and admitted for at least 3 days – renal function, K, Mg and EKG should be monitored dronedarone (PO) ALL 4 classes: blocks multiple ion channels in the heart (Na, K, and Ca) • CI in patients with NYHA class III or IV HF or recent decompensated HF flecainide (PO) Class Ic sodium-channel blockers: blocks Na+ influx (slow) • Should NOT be used in patients with HF due to the risk of worsening HF and increased mortality propafenone (PO) sotalol (PO) Class III potassium-channel blockers: block K+ efflux • NOT first-line option • MUST be initiated inpatient and admitted for at
- 48. Clinical Evidence • Randomized, blinded-outcome-assessment trial • Patients were randomized to receive either early rhythm control or usual care • First primary outcome: composite of death from CV causes, stroke, HF hospitalization, or ACS hospitalization Inclusion Criteria: • AF diagnosed 12 months ≤ before enrollment • Age 75 with prior TIA/stroke ≥ • OR 2 of the following: age ≥ ≥ 65, female sex, HF, HTN, DM, CKD stage 3 or 4, LVH Exclusion Criteria: • Life expectancy < 1 year • Prior AF procedure (ablation or surgery) • Prosthetic mitral valve or severe mitral stenosis • Hepatic, thyroid, or renal dysfunction EAST-AFNET 4 Trial Kirchhof P et al. EAST-AFNET 4 Trial. N Engl J Med, 2020. 48
- 49. Kirchhof P et al. EAST-AFNET 4 Trial. N Engl J Med, 2020. EAST-AFNET 4 Trial Primary Outcome Early Rhythm Control Usual Care Composite 249 patients 316 patients HR, p-value HR 0.79; p-value = 0.005 49
- 50. Kirchhof P et al. EAST-AFNET 4 Trial. N Engl J Med, 2020. EAST-AFNET 4 Trial Results • Trial was stopped early for efficacy after a median of 5.1 years of follow-up per patient • Initiating rhythm control in all patients with early AF and concomitant CV conditions was associated with a lower risk of death from CV causes, stroke, or hospitalization for HF or ACS when compared to usual care. 50
- 51. Early rhythm control (within 1 year of AF diagnosis) can reduce hospitalizations, stroke, and mortality. Guideline Update: Update 51
- 52. Patient Case Mr. Flutter is a 72 yo M with a PMH of HTN, T2DM, and CKD stage III with AF diagnosed in 2022. Today in clinic he is reporting occasional palpitations but no significant fatigue or dizziness. His echo shows a LVEF of 60% and his resting HR is 114 bpm. Which initial management strategy is most appropriate at this time? A. Rate control B. Rhythm control - with DCC or AAD 52
- 53. Patient Case Mr. Flutter is a 72 yo M with a PMH of HTN, T2DM, and CKD stage III with AF diagnosed in 2022. Today in clinic he is reporting occasional palpitations but no significant fatigue or dizziness. His echo shows a LVEF of 60% and his resting HR is 114 bpm. Which initial management strategy is most appropriate at this time? A. Rate control B. Rhythm control - with DCC or AAD 53
- 54. Catheter Ablation Useful in patients with symptomatic AF where AAD have been ineffective, contraindicated, not tolerated, or not preferred to improve symptoms 54
- 55. Catheter Ablation • Procedure performed by inserting a catheter through a blood vessel in the heart • RF energy destroys a small area of heart tissue that is causing rapid and irregular heartbeats • Abnormal electrical impulses are now blocked restores regular heart rhythm 55
- 56. Warfari n uninterrupted anticoagulation uninterrupted or minimally interrupted DO AC Catheter Ablation Recommended for: • symptom improvement in patients that pharmacological rhythm control has been ineffective, intolerable, or not preferred • first-line therapy for certain patients with symptomatic paroxysmal AF For those undergoing catheter ablation: Anticoagulation should continue for at least 3 months 56
- 57. Kuck K-H et al. ATTEST Trial. Europace, 2021. Clinical Evidence • Randomized, prospective study in patients with paroxysmal AF • Objective: to determine whether ablation treatment delays progression to persistent AF compared with AADs • Primary endpoint: occurrence of persistent AF/AT Inclusion Criteria: • Adults 60 ≥ • Paroxysmal AF for 2 years ≥ • ≥ 2 episodes over the 6 months preceding enrollment • failed 1-2 AADs Exclusion Criteria: • Reversible AF • Previous diagnosis of persistent/permanent AF/AT • Cardioversion >48h after onset of AF/AT • Recent cardiovascular events ATTEST Trial 57
- 58. Kuck K-H et al. ATTEST Trial. Europace, 2021. Catheter Ablation ATTEST Trial Primary Outcome Radiofrequency ablation AAD Occurrence of AF/AT after 3 years 2 (2.4%) 15 (17.5%) p-value = 0.0009 58
- 59. Kuck K-H et al. ATTEST Trial. Europace, 2021. Catheter Ablation ATTEST Trial Results RF catheter ablation is superior to guideline-directed AAD therapy alone in delaying the progression to persistent AF. 59
- 60. Catheter ablation receives a Class 1 indication as first-line therapy in selected patients. Guideline Update: Update 60
- 61. Patient Case Mr. Flutter was started and maintained on rate control (metoprolol 50 mg BID), but his HR is 120 bpm today, and he has started to experience palpitations and fatigue. His EKG shows persistent atrial fibrillation. What is the most appropriate management strategy for his AF? A. Continue rate control with metoprolol B. Transition to rhythm control to restore NSR C. Use both rate and rhythm control strategies D. Nothing is needed at this time 61
- 62. Patient Case A. Continue rate control with metoprolol B. Transition to rhythm control to restore NSR C. Use both rate and rhythm control strategies D. Nothing is needed at this time 62 Mr. Flutter was started and maintained on rate control (metoprolol 50 mg BID), but his HR is 120 bpm today, and he has started to experience palpitations and fatigue. His EKG shows persistent atrial fibrillation. What is the most appropriate management strategy for his AF?
- 64. A greater emphasis is placed on lifestyle and risk factor management Guideline Update: Update 64
- 65. Lifestyle and Risk Factor Management Weight loss Physical activity Moderate alcohol use Smoking cessation Controlling T2DM and/or HTN 65 Update
- 66. Main Takeaways from 2023 guideline updates 3 2 1 AF classification is now categorized by stages instead of arrhythmia duration Early rhythm control. Goal: maintain NSR and minimize AF burden Catheter ablation receives a Class 1 indication as first- line therapy in selected patients 66
- 67. Referenc es 1.Nesheiwat Z, Goyal A, Jagtap M. Atrial fibrillation. National Library of Medicine. Published April 26, 2023. https://www.ncbi.nlm.nih.gov/books/NBK526072/ 2.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. 2023;149(1). doi:https://doi.org/10.1161/CIR.0000000000001193 3.Wyse DG, Waldo AL, DiMarco JP, et al. A comparison of rate control and rhythm control in patients with atrial fibrillation. New England Journal of Medicine. 2002;347(23):1825-1833. doi:https://doi.org/10.1056/NEJMoa021328 4.Dankner R, Shahar A, Novikov I, Agmon U, Ziv A, Hod H. Treatment of Stable Atrial Fibrillation in the Emergency Department: A Population-Based Comparison of Electrical Direct-Current versus Pharmacological Cardioversion or Conservative Management. Cardiology. 2009;112(4):270-278. doi:https://doi.org/10.1159/000151703 5.Kirchhof P, Camm AJ, Goette A, et al. Early Rhythm-Control Therapy in Patients with Atrial Fibrillation. New England Journal of Medicine. 2020;383(14). doi:https://doi.org/10.1056/nejmoa2019422 6.Kuck K-H, Lebedev DS, Mikhaylov EN, et al. Catheter ablation or medical therapy to delay progression of atrial fibrillation: the randomized controlled atrial fibrillation progression trial (ATTEST). EP: Europace. 2021;23:362–369. 67
- 68. Questions? 68
- 69. Staying in Rhythm: Atrial Fibrillation Management Jasmine Hill, PharmD PGY1 Resident Phoenix VA Health Care System 69