2019 AHA/ACC/HRS Focused Update for Management of Atrial Fibrillation

How This Guide Helps Your Atrial Fibrillation Care

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Atrial fibrillation is a heart rhythm disorder characterized by a rapid and irregular heartbeat. It is the most commonly diagnosed heart rhythm abnormality. While it usually causes minimal symptoms, atrial fibrillation is a health risk. It is associated with increased stroke risk, accounting for about 1 in 7 strokes.

In 2019, the American College of Cardiology, the American Heart Association Task Force on Clinical Practice Guidelines, and the Heart Rhythm Society (AHA/ACC/HRS) published a focused update of atrial fibrillation guidelines aimed at addressing the quality of life concerns associated with the condition and reducing the risk of stroke.

The renewed recommendations speak to the use of blood thinners, interventional procedures, and lifestyle strategies for the management of atrial fibrillation. Additionally, the statement advocates for diagnostic considerations that may improve the chances of identifying atrial fibrillation.

Atrial fibrillation is a heart rhythm disorder
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The Centers for Disease Control and Prevention (CDC) estimates that between 2.7 and 6.1 million people in America have atrial fibrillation.

Lifestyle

The updated guidelines provide direction for people who have atrial fibrillation and want to take personal action to reduce the possible adverse health effects of this condition.

For those who are overweight or obese with a body mass index (BMI) higher than 27, a structured weight management program is recommended. When combined with management of atrial fibrillation, weight loss has been found to improve long term outcomes.

Furthermore, decreasing alcohol and tobacco use and identifying and treating sleep apnea, high blood pressure, hyperlipidemia, and glucose intolerance improve health outcomes with atrial fibrillation as well.

Blood Thinners

The irregular heart rhythm of atrial fibrillation can cause blood clots to form in the heart. These blood clots may lead to a stroke if they travel to the brain, where they can interrupt blood flow.

Blood thinners are a mainstay of atrial fibrillation treatment. These medications don’t affect the heart rhythm, but they prevent blood clots from forming, which substantially reduces the risk of having a stroke.

According to the AHA/ACC/HRS update, the decision about starting an anticoagulant, which is a type of blood thinner, for managing atrial fibrillation should not depend on whether the rhythm abnormality is persistent or intermittent.

Both intermittent ("paroxysmal) and persistent ("chronic") atrial fibrillation substantially increase the risk of stroke in certain patients.

Non-Vitamin K Oral Anticoagulants (NOACs)

Edoxaban has been added to apixaban, dabigatran, and rivaroxaban as a non-vitamin K oral anticoagulant (NOAC) that can be beneficial for stroke prevention. These are relatively new anticoagulants that work by inhibiting thrombin, an enzyme involved in blood clot formation.

When someone with atrial fibrillation has had a coronary artery stent, one blood thinner may not be adequate, and an anti-platelet agent such as Plavix (clopidogrel), Effient, or Brillinta may be added to a NOAC.

Kidney and liver function should be tested before NOACs are started, and these tests should be repeated on a yearly basis when taking NOACs.

The statement says that NOACs are considered a better choice for managing atrial fibrillation than Coumadin (warfarin)—which is an anticoagulant that works by preventing the action of vitamin K (a vitamin that helps form blood clots in the body).

A key difference between warfarin and NOACs is that the anticoagulation effect of NOACs is predictable and does not need to be monitored every few days, while warfarin effects must be monitored frequently with blood tests. Additionally, warfarin interacts with many medicines, and even some foods.

However, there are situations in which warfarin might be considered a better option for anticoagulation than NOACs. These include:

  • Having had an artificial heart valve surgically placed in the heart
  • Having moderate to severe mitral stenosis
  • Advanced kidney disease, with a creatinine clearance greater than 15 milliliters per minute (ml/min)
  • CHA2DS2 score of two or higher for men or three or higher for women. This score is calculated with a point for congestive heart failure, hypertension, age (over 65 = 1 point, over 75 = 2 points), diabetes, previous stroke/transient ischemic attack (2 points)

Reversing Blood Thinners

While blood thinners are an important part of stroke prevention for people who have atrial fibrillation, these medications may increase the risk of bleeding. When someone who is taking a blood thinner is scheduled to have a surgical procedure, blood thinners may be stopped temporarily. Never stop a blood thinner without first consulting with the prescribing physician.

In certain situations, such as life-threatening bleeding or emergency surgical procedures, the effects of blood thinners may need to be quickly reversed, and the reversal agents used will vary based on the blood thinner in effect.

Reversing the blood thinner can help prevent excessive bleeding, and the blood thinner can be restarted after surgery.

Procedures

Several interventional procedures can help prevent symptoms and adverse effects of atrial fibrillation. The updated guidelines suggest consideration of procedures, including catheter ablation or atrial appendage occlusion.

While you might not have symptoms, some people with atrial fibrillation can experience intermittent dizziness, lightheadedness, a lack of energy, or fatigue. The condition can also contribute to the risk of heart failure and more severe heart rhythm or conduction problems.

Atrial Fibrillation Catheter Ablation

Atrial fibrillation catheter ablation is a procedure in which areas of the heart responsible for the generation of the abnormal electrical signals resulting in afib are isolated and neutralized. This is an invasive but nonsurgical procedure performed by cardiovascular subspecialists known as electrophysiologists.

Atrial Appendage Occlusion

Atrial appendage occlusion is an invasive, nonsurgical procedure that seals off a small section of the heart. This section, the atrial appendage, is a site where blood may pool and thus promote clot formation—and subsequent stroke.

Diagnosis

When a person has a stroke without an identifiable cause, it is often described as a cryptogenic stroke. It is difficult to prevent another stroke when the cause is not known, but research suggests that atrial fibrillation—especially intermittent or paroxysmal atrial fibrillation—can be a cause of cryptogenic stroke.

The updated atrial fibrillation guidelines aim to address the problem of undiagnosed atrial fibrillation with expanded indications for testing. An implantable heart monitor should be considered to rule out atrial fibrillation for people who have a cryptogenic stroke if standard heart monitoring doesn’t help in identifying a heart rhythm abnormality.

A Word From Verywell 

If you have been living with atrial fibrillation, your condition may have been stable for many years. Rest assured that the management of atrial fibrillation is usually effective, and the outcomes are good. However, progress continues to develop in terms of atrial fibrillation management, and your doctor might make some changes to your treatment based on updated guidelines.

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