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2023 ACC/AHA/ACCP/HRS Guideline on AF Diagnosis & Management: Highlights & Implementation

Published: 23 Jan 2024

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Dr Jose Joglar (UT Southwestern, US) joins us virtually to discuss the 2023 guidelines for atrial fibrillation (AF) diagnosis and management.

These guidelines are an update to the 2014 document covering the full spectrum of managing patients with AF, from prevention to lifetime interventions, to rhythm and rate control, as well as special populations. A new classification of AF has been created, with an emphasis on the complexity of the disease. The updated guidelines also highlight the importance of a multidisciplinary approach to AF Management, from prevention to lifestyle modification, as well as rhythm management.

Questions:

  1. What is the background for the update? What is the scope of the guideline?
  2. What are the most impactful changes compared to previous guidelines?
  3. Can you summarize the key recommendations?
  4. What strategies can help clinicians incorporate the recommendations into practice?

Recorded remotely from Dallas, 2024.

Support: This is an independent interview conducted by Radcliffe Cardiology.

Transcript

"I'm Dr. Jose Joglar, professor of internal medicine at UT Southwestern Medical Centre in Dallas, Texas. I'm an elecrophysiologist and chair of the writing committee for the 2023 guidelines of Atrial Fibrillation.

What is the background for this update? What is the scope of the guidelines?

As you know, there was a 2014 guideline, so the management of patients with atrial fibrillations, and there has been an update since then. But in view of the advances in technology and so many new things that we can do for patients with atrial fibrillation, as well as so many new understanding on treatment, ways to treat and technologies and use science on prevention, et cetera, the Joint Committee on Guideline Development decided it was time to get a full guideline.

Does the scope is a full guideline that covers the entire spectrum of the management of patients with atrial fibrillation, from prevention to lifetime interventions to rhythm control, rate control and special populations, for example.

What are the most impactful changes compared to previous guidelines?

So there's a few important changes. One is that we created a new classification for atrial fibrillation and the purpose was to emphasise that atrial fibrillation is a complex disease. Atrial fibrillation is not just a rhythm abnormality, but it's just a manifestation of a complex substrate.

Thus, we emphasise the importance of a multidisciplinary approach to atrial fibrillation management from prevention, lifestyle and risk factor modification, lifestyle changes and of course, rhythm management as well.

When it comes to rhythm management, compared to the prior guidelines, there have been some updates that are quite important. For example, catheter ablation of atrial fibrillation in selected populations is now a class one recommendation. In the past, the prior guidelines advised to do catheter ablation, for example, after the patient had failed pharmacological therapy, and that is not required anymore, especially in patients who are deemed to be good candidates for the procedure.

We also upgraded the catheter ablation in patients with heart failure due to depressed left ventricular systolic function, also to a class one indication in view of recent data showing the benefit of this procedure in this specific population, we have upgraded the use of watchman devices to a class 2A recommendation in view of more recent data.

Also, over the years, like I mentioned before, there have been a lot of changes. One of those changes is the devices have become safer to implant. For example, we also changed a little bit in the way we advise on anticoagulation. Instead of using a specific score, we used magnitude of risk for the decision to anticoagulate or not. Those are some of the most important changes.

Can you summarise the key reccomendations?

The key recommendations we emphasise the importance of lifestyle interventions and risk factor modification. We elevated catheter ablation to class one recommendation in selected populations. Elevated catheter ablation to a class one recommendation in patients with heart failure. We also changed to magnitude of risk when we make recommendations on anticoagulation. We also open the discussion for using other scores when deemed necessary.

For example, the most used score is not enough to calculate risk in specific populations, such as those with renal disease, for example. We also have other things, for example, the management of atrial fibrillation in the setting of hospital illness, for example.


What strategies can help clinicians incorporate the recommendations into practice?

Well, when you talk about strategies, we have applications with a guideline tool. You can open the guideline in your mobile device, in your portable phone, for example, and open an access recommendation.

We wanted to make sure that this guideline provides all the essential recommendations for managing patients with atrial fibrillation across the board, across the entire spectrum. We not only include those essential recommendations we talk about, but we also include a lot of recommendations for more mundane things like, for example, when to stop or not anticoagulation, patients undergoing surgery, monitoring of anti-arrhythmic drugs, management of complications related to bleeding, and other things like that.

We're talking about strategies. We have an application. We're making the recommendations also to stand on their own so they can be easy to read at the point of care. So we're hoping that the public and the medical community uses this guidelines... Because we made it easy to use, With these applications.”

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Ramalitse Sakoane
3months
New AF Guidelines