New ESC A-fib Guidelines Call for Integrated Care for All Patients

ROME. Italy—For the first time, the European Society of Cardiology has collaborated with the European Association for Cardio-Thoracic Surgery to issue guidelines for managing patients with A-fib, and that partnership shines through with a new focus on integrated, team-based care.

The team should be composed of nurses, cardiologists, stroke neurologists, cardiac surgeons, and electrophysiologists, Paulus Kirchhof, MD (University of Birmingham, England), chair of the task force that wrote the guidelines, told TCTMD. The whole team would not be required for every patient, with a more formal heart team approach reserved for the trickiest patients, such as those who have a stroke or intracranial hemorrhage while taking anticoagulation or patients who repeatedly fail attempts at rhythm control, he said.

Also critical to the integrated approach is a more central role for patients in the treatment process, he said. Much like hypertension or dyslipidemia, treating A-fib does not necessarily yield immediate benefits, “so empowering the patient to understand what you’re actually doing is another thing that we emphasize in the guidelines,” Kirchhof said.

The guidance, which was last updated in 2012, was published online August 27, 2016, ahead of print in the European Heart Journal and the European Journal of Cardio-Thoracic Surgery, coinciding with the opening of the European Society of Cardiology Congress 2016 here. It was endorsed by the European Stroke Organisation.

Keeping Patients on Oral Anticoagulation

Citing a 30% to 50% rate of discontinued oral anticoagulation in the first year after initiation, Kirchhof said another focus of the new guidelines is on keeping patients treated. There are detailed recommendations on how to handle bleeding on treatment and when and how to reinitiate anticoagulation after an ischemic stroke or intracranial hemorrhage.

The overall indications for anticoagulation, however, have not changed much from the previous guidance. One minor adjustment is downgrading the recommendation for using anticoagulation in patients with only one CHA₂DS₂-VASc risk factor, who have been shown to have a very low rate of stroke without treatment, from class I (“is recommended) to class IIa (“should be considered”).

The preferential use of non-vitamin K antagonists in eligible patients initiating oral anticoagulation remains a class I recommendation, but there is a stronger emphasis in the new guidelines based on accumulating data showing a halving of the rate of intracranial hemorrhage and a reduction in all-cause mortality with the newer agents relative to warfarin, Kirchhof said.

Other Recommendations

In terms of rate control, there have not been major modifications, said Kirchhof, who noted that one of the identified evidence gaps is the lack of data informing the choice of rate control strategy and the rate target.

The guidance on rhythm control has been revised to reflect recent evidence that A-fib burden is not dramatically different between patients with paroxysmal or persistent disease. Thus, the differentiation between the two A-fib types is less important when it comes to choosing a rhythm control approach.

Also reflected in the new guidelines is increasing evidence supporting the safety and efficacy of catheter ablation as an alternative to antiarrhythmic drugs, Kirchhof said.

Source:

• Kirchhof P, Benussi S, Kotecha D, et al. 2016 ESC guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J. 2016;Epub ahead of print.

Disclosures:

• Kirchhof reports multiple relationships with industry.

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