References

1. Joglar J, 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. J Am Coll Cardiol. Jan 2024;83(1):109-279.

2. January CT, et al. 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation. J Am Coll Cardiol. Dec 2 2014;64(21):e1-76.

3. Kirchhof P, et al. Early rhythm-control therapy in patients with atrial fibrillation. N Engl J Med. Oct 1 2020;383(14):1305-1316.

4. Kim D, et al. Treatment timing and the effects of rhythm control strategy in patients with atrial fibrillation: nationwide cohort study. BMJ. May 11 2021:373:n991.

5. Dickow J, et al. Generalizability of the EAST-AFNET 4 Trial: assessing outcomes of early rhythm-control therapy in patients with atrial fibrillation. J Am Heart Assoc. Jun 7 2022;11(11):e024214.

6. Chew DS, et al. Diagnosis-to-ablation time predicts recurrent atrial fibrillation and rehospitalization following catheter ablation. Heart Rhythm O2. Nov 19 2021;3(1):23-31.

7. Wharton JM, et al. Comparative safety and effectiveness of sotalol versus dronedarone after catheter ablation for atrial fibrillation. J Am Heart Assoc. Feb 11 2022;11(3):e020506.

The first priority when managing atrial fibrillation (AFib) is taking steps to reduce a patient’s risk for stroke, which is 2.4 times higher than average.¹ Because irregular heart contractions in AFib fail to completely squeeze blood out of the atria into the ventricles, blood may pool and form clots, raising the risk of thromboembolism. The 2023 American College of Cardiology/American Heart Association (ACC/AHA) Guideline for the Diagnosis and Management of Atrial Fibrillation offers fresh insights based on recent research aimed at preventing strokes in AFib patients, which includes more expansive use of risk calculators, consideration of surgery for select patients, and an increased emphasis on lifestyle and risk factor modification.²

A more nuanced view of risk calculation

Anticoagulation is a key component of stroke prevention in AFib, though studies suggest that about half of patients don’t receive this potentially lifesaving therapy. Moreover, many patients are reluctant to use these therapies due to concerns about side effects such as bleeding; a 2022 study in the Journal of Managed Care & Specialty Pharmacy found that nearly one in five do not fill their prescriptions for anticoagulants.³

Having more data about a patient’s stroke risk based on his or her individual comorbidities and other factors can be helpful in conversations about anticoagulation, says clinical cardiac electrophysiologist and AFib researcher Mina Chung, MD, of the Cleveland Clinic, a coauthor of the new ACC/AHA guidelines.

Since its introduction as a refinement of the original CHADS₂ score, the CHA₂DS₂-VASc score has been the go-to tool for calculating the risk of stroke in patients with AFib. The ACC/AHA guidelines recommend anticoagulation for AFib patients with a CHA₂DS₂-VASc score of ≥2 for men and ≥3 in women, which places them at high risk for stroke or thromboembolism (an estimated annual thromboembolic risk of ≥2% per year). However, the new guidelines encourage clinicians to be flexible in their use of clinical risk scores and suggest “expanding beyond CHA₂DS₂-VASc for prediction of stroke and systemic embolism,” especially for patients who have lower CHA₂DS₂-VASc scores.

The reason for this change from the previous guidelines is that reliance solely on CHA₂DS₂-VASc could miss some patients who could benefit from anticoagulation, explains Dr. Chung. “The CHA₂DS₂-VASc score has been engrained in us,” she says. “But there are risk factors that aren’t accounted for by CHA₂DS₂-VASc, and there are other risk scores that you may want to use.”

Additional stroke risk factors to consider

A table in the guidelines summarizes key risk factors for stroke not included in CHA₂DS₂-VASc, which include:

• Higher AFib burden/long duration
• Persistent/permanent AFib versus paroxysmal
• Obesity (BMI ≥30 kg/m²)
• Hypertrophic cardiomyopathy
• Poorly controlled hypertension
• eGFR (<45 mL/h)
• Proteinuria (>150 mg/24 hours or equivalent)
• Enlarged left atrial volume (≥73 mL) or diameter (≥4.7 cm)

The CHA₂DS₂-VASc still has an important role in identifying patients at high risk for stroke, says Dr. Chung. Using an alternate risk calculator (such as ATRIA or GARFIELD, both available online) makes the most sense in patients whose CHA₂DS₂-VASc score places them at intermediate or low risk for stroke. “In that case, some of the other risk scoring systems may add additional value because they take into account other factors such as renal failure and those that may affect your risk assessment,” she says. “That can be very helpful in shared-decision making with patients.”

Surgery for select patients

Another change in the recently updated ACC/AHA AFib guidelines regarding stroke prevention concerns the use of percutaneous left atrial appendage occlusion (pLAAO) for AFib patients with long-term contraindications to anticoagulation. In pLAAO, a device (the most studied is the Watchman) is implanted that prevents blood clots from exiting the left atrial appendage. The ACC/AHA’s 2019 focused update gave pLAAO for stroke prevention in patients who cannot tolerate blood thinners a 2b (weak) recommendation, which has been upgraded to a 2a (moderate) in the new guidelines.

Why the upgrade? “We have more confidence and more data suggesting that the risk of complications from these devices has come down,” says the lead author of the guidelines, Jose Joglar, MD, Director of the Clinical Cardiac Electrophysiology Program at UT Southwestern Medical Center in Dallas. Dr. Joglar notes that growing experience in the clinical community and modifications by makers of the devices have made them a safer choice for properly selected patients.

An enhanced focus on lifestyle and risk factors

Early and aggressive rhythm control with catheter ablation and/or antiarrhythmic medications reduces the risk for stroke, as well as other cardiovascular conditions (such as heart failure and acute coronary syndrome) and mortality. However, modification of patient lifestyle and risk factors can contribute to rhythm control, too, according to recent research. The new ACC/AHA recommendations offer more prescriptive, detailed advice about lifestyle modification, notes Dr. Chung. “The data from randomized controlled trials really put a lot of teeth into our recommendations,” she says. Notably, weight control, physical activity, and reduction or elimination of alcohol consumption have been shown to help maintain sinus rhythm in recently published trials. Highlights of these findings include:

Weight loss: The ACC/AHA guidelines state that losing 10% of body weight is a target for patients with overweight/obesity (BMI ≥27 kg/m²). The 2015 LEGACY study in Australia found that patients who achieved that goal had a six-fold increased likelihood of remaining arrhythmia free compared with others who lost less or no weight.⁴ GLP-1 receptor agonists may boost weight loss for patients who are able to obtain prescriptions, notes Dr. Joglar. “I have patients with AFib who have lost a lot of weight on these medications and now they haven’t had recurrences,” he says, though he’s quick to add that studies are needed to confirm this benefit. (Most data on prevention of AFib recurrences in patients with obesity come from studies on the effects of bariatric surgery and comprehensive lifestyle programs.)

Physical activity: The guidelines recommend a target of 210 minutes per week of moderate-to-vigorous exercise. A 2023 randomized controlled trial published in JACC: Clinical Electrophysiology found that AFib patients who gradually increased their physical activity toward that goal were twice as likely to be arrhythmia-free at 12 months vs. a control group.⁵ However, Dr. Joglar is realistic about expectations. “I tell patients, ‘I don’t expect you to run marathons,’ ” he says. “A little walking every day is better than nothing.”

Alcohol moderation: The guidelines also recommend that AFib patients abstain from alcohol or limit consumption to no more than 3 drinks per week. Several studies published since 2014 support that recommendation, including a 2020 trial in the New England Journal of Medicine indicating that patients who were regular drinkers, but abstained or dramatically reduced their alcohol intake, experienced a significant reduction in arrhythmia over 6 months.⁶

—by Tim Gower

References

1. Odutayo A, et al. Atrial fibrillation and risks of cardiovascular disease, renal disease, and death: systematic review and meta-analysis. BMJ. 2016;354:i4482

2. Joglar J, 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. J Am Coll Cardiol. Jan 2024;83(1):109-279.

3. Guo JS, et al. Underprescribing vs underfilling to oral anticoagulation: An analysis of linked medical record and claims data for a nationwide sample of patients with atrial fibrillation. J Manag Care Spec. Dec 2022;28(12).

4. Pathak RK, et al. Long-term effect of goal-directed weight management in an atrial fibrillation cohort: a long-term follow-up study (LEGACY). J Am Coll Cardiol. May 2015;65(20):2159–2169.

5. Elliott AD, et al. An exercise and physical activity program in patients with atrial fibrillation: the ACTIVE-AF randomized controlled trial. JACC Clin Electrophysiol. Apr 2023;9(4):455-465.

6. Voskoboinik A, et al. Alcohol abstinence in drinkers with atrial fibrillation. N Engl J Med. Jan 2 2020;382(1):20-28.

It’s likely you’ve found patients to be most engaged soon after being diagnosed with atrial fibrillation (AFib): They’re eager to seek treatment for distressing symptoms and likely motivated to adopt healthy habits. As time goes on, however, a patient’s mindset can change: For individuals whose AFib is well-controlled, motivation to stay on top of their heart health may waver, notes John Mandrola, MD, of Baptist Health Louisville/Baptist Cardiology Associates in Kentucky. “It’s difficult to get people to change their lifestyle if they feel well,” he acknowledges. On the other hand, patients may get discouraged when they’ve done everything right but continue to experience AFib symptoms. They may feel anxious and stressed, which can mimic symptoms of arrhythmia or even trigger an episode—a vicious cycle that can complicate care and impact their quality of life.

Either way, empowering your patients to take control of their condition is the best solution. “It can be human nature to lose commitment,” notes John Day, MD, physician executive of cardiovascular services for MountainStar HCA Healthcare System in Salt Lake City. “The key is to have open and direct conversation with the patient and the caregiver. Good patient education often allows ongoing commitment despite setbacks—or lack of symptoms.” The following strategies can help you boost patient motivation and encourage self-management.

To promote lifestyle modification:

Stress the benefits for overall heart health

Be sure to explain that lifestyle modification will complement the patient’s AFib treatment—not replace the need for medication, particularly anticoagulation to lower stroke risk. That said, patients should be educated on the benefits of adopting healthy habits. Case in point: Several studies show that losing weight and improving fitness level can benefit patients at any point during the course of AFib.^1-4 And following a plan that includes exercise, heart-healthy nutrition and stress relief can improve overall cardiovascular health and help control common comorbidities, including hypertension, coronary artery disease and type 2 diabetes. AFib then becomes another addition to the list of reasons why a patient would benefit from lifestyle changes.

Explain the rationale for weight loss

Research shows that obesity can contribute to cardiac remodeling, resulting in diastolic dysfunction as well as increased left atrial size, which in turn increases the risk of developing AFib.⁵ The good news for patients: For individuals with a body mass index ≥27 kg/m², research shows that losing 10% of their body weight significantly reduces AFib burden and promotes maintenance of sinus rhythm. In another study, improving cardiorespiratory fitness, regardless of pounds lost, significantly decreased symptom severity in AFib patients with overweight/obesity.^1,2,4

Help them “program” their environment for success

“No one can resist temptations all day long. You need to program your environment such that most temptations can be eliminated,” recommends Dr. Day. First, clear the cupboards of junk food. “If there is no junk food in the house then it is pretty hard to eat unhealthy foods,” he says. “Most people won’t go through the hassle of driving to the grocery store just to get a quick fix of sugar or processed foods.”

And to make for an exercise-friendly home: Encourage patients to put exercise equipment near the TV so they’ll be inclined to walk/pedal/row instead of sitting while enjoying their favorite shows. As Dr. Day tells his patients: “This turns the living room into a real living room rather than a dying room,” since prolonged sitting is associated with an increased risk of cardiovascular disease and insulin resistance.

Encourage accountability

“Everyone needs someone or something to keep them honest and committed to their purpose,” Dr. Day points out. “If you have to report back to a trainer, a journal or an app that you just ate two donuts, then you probably won’t eat the donuts. People need to be accountable.” Likewise, fitness apps (e.g., MyFitnessPal.com), pedometers and even a notebook can help patients track habits, measure goals and instill a sense of accomplishment.

To help patients conquer anxiety and stress:

Explain the AFib-anxiety connection

“Anxiety and arrhythmias often go hand in hand. Either the anxiety triggers the arrhythmias, or the arrhythmias trigger anxiety,” Dr. Day explains. One study found that 15% of patients with AFib are “significant over- or under-estimators” of how often they experience symptoms—with anxiety and depression being common among over-estimators. The effect is so pronounced that the significant over-estimators thought they were in “near continuous” AFib, when their frequency was actually <10%.⁶

Empower them with a monitoring strategy

“Once people can differentiate anxiety from arrhythmia, they can get the treatment they need to find relief and this is no longer a problem,” notes Dr. Day. He teaches patients to monitor their own pulse so they can judge whether their heart is racing due to AFib (fast and highly irregular), or perhaps a panic attack (also fast, but regular). If patients have trouble grasping the distinction, he recommends they buy a blood pressure machine that tells them if their pulse is regular.

In addition, you can ease a patient’s mind by having them wear a 24-hour or 30-day Holter monitor to obtain an ECG recording. There are also smartphone apps (e.g., AliveCor.com) that allow patients to take an ECG reading on the spot. Another tip: “Patients could look at the flashing light of a pulse oximeter to determine their rhythm,” notes Dr. Day.

Encourage a regimen of stress relief

When it comes to reducing the physical and emotional toll of AFib, one method stands out: yoga. A study in the Journal of the American College of Cardiology reported that doing 60 minutes of yoga twice a week helped improve arrhythmia burden, heart rate, blood pressure, anxiety and depression scores, as well as several domains of quality of life, among patients with paroxysmal AFib.⁷ In addition, taking time daily to breathe deeply and practice mindfulness can help patients not only ease anxiety but also improve heart health: Research shows that meditation is associated with a significant reduction in the risk of all-cause mortality, myocardial infarction and stroke in patients with documented cardiovascular disease.⁸

Check in with them often.

Patients do best when they are included in the decision-making process and have a sense of control over their condition, notes Dr. Mandrola. Engaging patients on this level helps them be equal partners in their care. Part of that includes discussing what’s going on in their everyday life that could impact their ability to exercise, eat right and follow their treatment regimen. “What’s sometimes missing is that doctors don’t ask, How do you sleep? How is your stress at work?” says Dr. Mandrola. “Doctors often don’t address lifestyle. It is a really important adjunct.”

—by Harris Fleming

References

1. Joglar J, 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. J Am Coll Cardiol. Jan 2024;83(1):109-279.

2. Pathak RK, et al. Impact of CARDIOrespiratory FITness on arrhythmia recurrence in obese individuals with atrial fibrillation: The CARDIO-FIT study. J Am Coll Cardiol. 2015;66:985-996.

3. Pathak RK, et al. Aggressive risk factor reduction study for atrial fibrillation and implications for the outcome of ablation: The ARREST-AF cohort study. J Am Coll Cardiol. 2014;64:2222-2231.

4. Pathak RK, et al. Long-term effect of goal-directed weight management in an atrial fibrillation cohort: A long-term follow-up study (LEGACY). J Am Coll Cardiol. 2015;65:2159-2169.

5. Alpert MA, et al. Impact of obesity and weight loss on cardiac performance and morphology in adults. Prog Cardiovasc Dis. 2014;56:391-400.

6. Garimella RS, et al. Accuracy of patient perception of their prevailing rhythm: a comparative analysis of monitor data and questionnaire responses in patients with atrial fibrillation. Heart Rhythm. 2015;12(4):658-665.

7. Lakkireddy D, et al. Effect of yoga on arrhythmia burden, anxiety, depression, and quality of life in paroxysmal atrial fibrillation: The YOGA My Heart Study. J Am Coll Cardiol. 2013;61(11):1177–1182.

8. Schneider RH, et al. Stress reduction in the secondary prevention of cardiovascular disease: randomized, controlled trial of transcendental meditation and health education in blacks. Circ Cardiovasc Qual Outcomes. 2012;5:750-758.

PATIENT: SARA, 75, WAS RECENTLY DIAGNOSED WITH PAROXYSMAL ATRIAL FIBRILLATION. SHE WAS ALREADY TAKING MEDICATION FOR HYPERTENSION AND CORONARY ARTERY DISEASE.

“Sara’s stroke risk was steadily increasing”

PHYSICIAN:
Hugh Calkins, MD,
Professor of Medicine and Director of the Arrhythmia Service, Electrophysiology Laboratory and Atrial Fibrillation Program at Johns Hopkins Medical Institutions

Presentation:
Sara’s medical history was notable for coronary artery disease, with a stent placed 3 years ago following a non-STEMI. She was taking losartan 25 mg a day. Last year, however, Sara was suffering from palpitations, a racing heart and fatigue. A 7-day ECG monitor was ordered, as well as an echocardiogram. The echo was normal, with an ejection fraction of 55% and a left atrial size of 4.2 cm. The heart monitor, however, revealed paroxysmal atrial fibrillation (AFib) with a 15% burden of AFib. Sara’s internist prescribed apixaban (5 mg twice a day) to lower her stroke risk. In addition, based on her heart monitor findings, her internist also prescribed metoprolol (50 mg once a day), yet her AFib symptoms continued. In need of a consult, her doctor referred her to me.

Treatment:
When I met with Sara, she had none of the traditional risk factors that would make AFib more likely. She was slender, with a normal BMI, and drank only one glass of wine a week. She also didn’t snore, which is indicative of sleep apnea, another risk factor for AFib. Her overall stroke risk, however, was high, based on her CHA₂DS₂-VASc score of 5. For that reason, I insisted that she continue the apixaban indefinitely. We also discussed heart rate versus rhythm control. Given her ongoing symptoms—fatigue and palpitations—her beta blocker, metoprolol, clearly wasn’t doing enough to provide proper rhythm control. Because Sara was reluctant to have an invasive procedure, we ruled out catheter ablation and focused on her options for antiarrhythmic drug therapy.

When Sara asked me what I’d recommend, I told her dronedarone was an excellent choice because of its proven efficacy. In addition, the agent is indicated to reduce the risk of hospitalization for AFib, an important goal for Sarah. Most importantly, dronedarone is safe in patients like Sara who have a history of CAD, unlike a class 1C antiarrhythmic like flecainide or propafenone, which are both contraindicated in CAD. Dofetilide would have been an option, but Sara didn’t want to be hospitalized for 3 days to monitor the initial response to the drug. Other medications that had the potential to be efficacious came with serious toxicity risks.

We finally agreed on dronedarone, 400 mg twice a day. The results were impressive: When I saw Sara a month later, she was feeling well enough to play with her grandkids and resume taking her senior aerobics class.

Considerations:
Sara’s case reminds us that the primary indication for a rhythm control strategy is symptoms despite rate control. And while Sara didn’t have any significant AFib risk factors, clinicians should always first address risk factor modification, as many older adults struggle with weight and, for some, with alcohol dependence, both of which can trigger and/or exacerbate AFib. In Sara’s case, I presented all of the treatment options. Given how reluctant she was to have an invasive procedure, together we agreed that dronedarone, with its excellent safety and efficacy profile, would set her on the best path to better health.

KOL on Demand

DISPELLING MISCONCEPTIONS  

Q: What are some common misconceptions about AFib?

A: One of the most frequent misconceptions among patients is that atrial fibrillation (AFib) will always be noticeable. Even with patients for whom the rhythm has sometimes been very unpleasant, it is possible to have AFib at other times and not know it, particularly after medical treatment is started. Misunderstanding this can lead to real trouble if the patient assumes that they don’t need to be anticoagulated once they feel better. How well one feels is a very poor guide to the amount of AFib one is actually having, and blood thinners should always be chosen assuming that occult (unnoticed) AFib is occurring.

I think another common misconception is that a catheter ablation procedure for AFib is curative forever. Because many other arrhythmias can successfully be completely suppressed with an ablation, some people assume that recurrent AFib after an ablation represents a procedural “failure.” But a successful ablation means one doesn’t feel AFib any more, not that one can never have AFib. Even people with a “successful” ablation can get AFib again years later. Proper anticoagulation should never be discontinued after an ablation, because AFib can still recur and not be noticed by the patient.

—Daniel Philbin, MD, Director of Clinical Cardiac Electrophysiology, Lifespan Cardiovascular Institute, East Providence, RI, and Assistant Professor of Medicine, The Warren Alpert Medical School of Brown University

EDUCATION ON STROKE RISK

Q: How do you educate patients on their risk of stroke?

A: Once patients feel relief from their AFib symptoms, they mistakenly believe they are out of danger—they don’t realize they face a lifetime of elevated stroke risk. What’s more, they tend to grossly underestimate the risk of stroke with AFib, while overestimating the risk of bleeding with anticoagulants. I counter this by informing patients that one-third of AFib-related strokes are fatal, and those that aren’t often lead to serious permanent disability. I also impress upon them that the risk of stroke with AFib far outweighs the risk of adverse effects with an anticoagulant. There’s also a significant misconception on the provider side: Physicians too often substitute aspirin for anticoagulants because they perceive it to be safer with respect to bleeding. However, while aspirin is a good cardiac drug, unfortunately it does nothing to reduce stroke risk from AFib and is not safer than our current anticoagulants.

—Christian T. Ruff, MD, MPH, Director, General Cardiology, Cardiovascular Division, Brigham and Women’s Hospital; Associate Professor, Harvard Medical School, Boston

RHYTHM CONTROL

Q: How do you approach rhythm control? When do you recommend catheter ablation?

A: I’ll usually start with an antiarrhythmic drug. Although there have been few advances in these agents, when they do work, they eliminate the need for an invasive procedure. If trials of one or two antiarrhythmic drugs are ineffective and the symptoms continue to interfere with quality of life, I recommend catheter ablation. Catheter ablation is more likely to work in a relatively younger, healthier patient early in the course of AFib. Older patients with longstanding AFib tend to be sicker overall, and their AFib has become more persistent or permanent. Also, longstanding AFib alters the heart’s lining and overall structure. These factors make a positive outcome with catheter ablation less likely.

—Christian T. Ruff, MD, MPH

AFIB VS. ANXIETY

Q: How do you counsel patients who are anxious about having AFib or mistake the symptoms for anxiety?

A: Some anxiety about a heart rhythm disorder is normal, but fortunately, AFib can be very well treated. Provided that their rate is well controlled in sinus rhythm, and they are on the proper anticoagulant, a patient with AFib can live a long and normal life. Once people come to terms with that, their tendency to mistake stress-related rapid heart rates with AFib is markedly reduced.

—Daniel Philbin, MD