2023-12-22 08:50:11
Washington, United States — The American recommendations on the diagnosis and management of atrial fibrillation have been updated. The classification of cardiac arrhythmia is redefined by distinguishing for the first time four stages, including two pre-arrhythmic stages, which highlight the major role of risk factors and primary prevention.
Another new feature: the place of catheter ablation as first-line treatment in cases of rhythm control is clearly reinforced. To help practitioners choose ablation as first intention in controlling sinus rhythm according to the patient profile, experts have made available a specific tool accessible online specifying for each case the level of recommendation for ablation.
Published in the Journal of the American College of Cardiology et Circulation[1,2], these recommendations were issued by the American College of Cardiology (ACC), the American Heart Association (AHA), the American College of Chest Physicians (ACCP), and the Heart Rhythm Society (HRS). They follow this version of 2019 and the European recommendations of the European Society of Cardiology (ESC) of 2020.
In this document, the authors present a new classification of AF which no longer only takes into account the duration of the arrhythmia, but also includes risk factors. The four stages defined are as follows:
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stage 1 (Risk of AF): presence of risk factors (age, high blood pressure, excess weight, sleep apnea, type 2 diabetes, etc.);
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stage 2, (Pre-AF): identification of clinical findings suggestive of anatomical (dilatation of the atria, etc.) or electrical abnormalities which predispose to AF;
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stage 3, (FA): diagnosis of paroxysmal type AF, with intermittent episodes of arrhythmia (stage 3A), persistent when the episodes last more than a week (stage 3B), long-lasting persistent when the duration exceeds one year despite a strategy of rhythm control (stage 3C) or controlled following ablation (stage 3D);
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stage 4 (permanent AF): arrhythmias last more than a year and are resistant to any therapeutic intervention to control rhythm.
According to the authors, this classification leads us to perceive AF in its continuity, “which involves resorting to various strategies at each stage using prevention, modification of lifestyle and risk factors, screening and treatment” .
These recommendations thus underline “the need to modify lifestyle and risk factors, in addition to medical treatment”.
Involve primary care more
In previous recommendations, AF was defined from stage 3. “The creation of these stages 1 and 2 preliminary to AF is a way of emphasizing the importance of risk factors in the management of fibrillation atrial which is not limited to anticoagulants and anti-arrhythmics”, commented to Medscape French edition Professor Laurent Fauchier (Tours University Hospital), who participated in the drafting of the latest European recommendations concerning AF.
The creation of these stages 1 and 2 preliminary to AF is a way of emphasizing the importance of risk factors in the management of atrial fibrillation Pr Laurent Fauchier
“This is a way of affirming that the treatment of AF begins well upstream, by intervening on the risk factors”, in particular high blood pressure, overweight and sleep apnea, underlines the cardiologist. These new recommendations thus show a desire to involve primary care more and not just cardiology and rhythmology.
“The care is global and multidisciplinary. It involves cardiologists, rhythmologists, but also general practitioners, pharmacists, nurses, professionals involved in therapeutic education, physiotherapists, dietitians, etc. With the aim of detecting risk factors and provide information to reduce the risk of AF. »
“The recommendations emphasize the management of risk factors throughout the disease and therefore propose more mandatory guidelines on weight loss, physical activity, smoking cessation, alcohol consumption, hypertension and other comorbidities,” say the experts.
Progress of AGG closure
Concerning anticoagulant treatment to prevent the risk of vascular accident, no major changes in these new recommendations which maintain the indications for anticoagulation on the basis of the CHA2DS2VASc score. Note, however, a progression of percutaneous closure of the left atrial appendage (LAA). The device can now be more widely considered in the event of a contraindication to anticoagulation (Class IIa).
In the United States, this technique being used more frequently, “observational data were able to confirm the relative safety of the device and its implementation”, which led the experts to increase the level of recommendations for this preventive approach, a clarified Professor Fauchier. “The level of evidence on the effectiveness of the device in preventing stroke, however, still remains limited.”
As a reminder, in France, LAA occlusion is indicated in patients with AF at high risk of stroke (CHA2DS2-VASc ≥ 4) and a formal and definitive contraindication to oral anticoagulants. With these fairly restrictive indications, “we treat 1,000 to 2,000 patients per year, compared to nearly 50,000 in the United States.”
In European recommendations, percutaneous closure of the LAA is less widely considered (Class IIb). “Apart from certain patients in therapeutic impasse with medications, it is uncertain whether the next European recommendations will exactly follow the American version for this invasive and rather expensive procedure, which has an average level of proof for its effectiveness,” estimates Professor Fauchier. .
Benefits of early rhythm control
Regarding heart rate control, recommendations are in favor of early and continued intervention. In patients recently diagnosed with AF (less than 1 year), with or without symptoms, rhythm control “may be helpful in reducing hospitalizations, strokes and mortality,” as well as disease progression (Class IIa).
The benefit of an early rhythm control strategy with antiarrhythmic drugs and/or catheter ablation to reduce cardiovascular complications was demonstrated in the randomized EAST-AFNET 4 study, which compared this approach to a strategy of less proactive control of the heart rate rhythm, in cases of AF diagnosed less than a year ago [3].
In this study, the primary endpoint was a composite of cardiovascular death, stroke, acute coronary syndrome or hospitalization for heart failure. After a median follow-up of 5 years, it occurred in 3.9% of patients per year with early rhythm control, compared to 5% per year with rate control, i.e. a reduction in the relative risk of 21% in favor of early rhythm control.
“This trial has changed the game by showing the benefit of maintaining sinus rhythm as much as possible. This benefit was for a long time difficult to demonstrate, probably due to the side effects of antiarrhythmic drugs which might worsen heart failure or have ventricular pro-arrhythmic effects,” commented Professor Fauchier.
“Rather than slowing the ventricle with rate control, the trend is toward more rate control through antiarrhythmic drugs or ablation. The EAST-AFNET 4 trial finally provided proof that by being careful, contemporary strategies for maintaining sinus rhythm can improve the prognosis of patients with recent AF. »
Prefer ablation over antiarrhythmics
Other trials have also shown the superiority of catheter ablation with isolation of the pulmonary veins (mainly by radiofrequency or cryotherapy) compared to antiarrhythmic drugs, thus contributing to strengthening the progression of this approach. “They suggest that when rhythm control has been decided, ablation is the most effective method,” specifies the cardiologist.
When rhythm control has been decided, ablation is the most effective method
The new American recommendations therefore give pride of place to ablation now recommended as first line “in selected” symptomatic patients (Class I). The experts specify that this concerns “particularly young patients with few comorbidities”. In these patients, “the success rate of ablation is high” and can justify the use of this technique, adds Professor Fauchier.
In the 2020 European recommendations, ablation had a Class 1 recommendation in cases of persistent symptoms when antiarrhythmics are ineffective. On the other hand, first-line ablation was only considered in certain symptomatic patients in cases of paroxysmal (Class 2b) and persistent (Class 2a) AF. This time, American experts go further by recommending treatment immediately in certain patients with symptomatic paroxysmal AF.
Another novelty regarding ablation: it is recommended as first line in patients with heart failure and an impaired left ventricular ejection fraction (LVEF < 35%) (Class I). “If ablation reduces symptoms and relapses in younger patients, the benefit in terms of survival is greater in these fragile patients with heart failure, despite a higher recurrence rate,” underlines the cardiologist.
The progression of AF in patients with heart failure follows the results of the CABANA and CASTLE-AF randomized trials. A meta-analysis including these trials has in fact shown at three years an improvement in symptoms and LVEF, while mortality, hospitalizations and strokes are reduced by almost 50% in these patients with impaired LVEF following ablation of the LVEF. FA, in comparison with drug treatment [4].
Antiarrhythmic drugs not accessible in France
The online tool made available by American experts aims to help opt for first-line ablation according to the patient’s profile (duration of AF, presence of symptoms, atrium dilated or not, heart failure, etc.). According to Professor Fauchier, “this decision support tool has the merit of addressing all the criteria that must, in theory, be taken into account”.
Finally, no notable change regarding the prescription of antiarrhythmic drugs, except that the majority of them are now in France, either unavailable (dofetilide, dronedarone), or regularly affected by supply difficulties (flecainide). , or subject to restrictions on use (sotalol). Only amiodarone is easily accessible, making it the default antiarrhythmic, despite its numerous and frequent side effects.
“Given that it is becoming more difficult to prescribe long-term antiarrhythmics, we are inevitably opting more often for ablation given the benefit demonstrated in recent years,” emphasizes Professor Fauchier. . A situation which, however, is not without problems for community cardiologists, who are calling for the lifting of restrictions on antiarrhythmic drugs and an end to supply difficulties.
Given that it is becoming more difficult to prescribe long-term antiarrhythmics, we are inevitably opting more often for ablation given the benefits demonstrated in recent years.
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