Various Arrythmia Risk-Assessment Tools Streamlined in Multisociety Consensus

A wide variety of risk-assessment tools can be used in the setting of cardiac arrhythmias, and four heart rhythm societies from around the world decided it was time to provide guidance on how to choose the right ones for specific scenarios.

Looking across a broad range of disease states, practice patterns, and management strategies, the expert writing group sought to provide an overview of what’s available to clinicians. “There’s a lot of variability in tools used and so I think to try to treat patients in the best manner, risk-stratify in the best manner, [and] use techniques in a way that will help people, we wanted to put together this document,” T. Jared Bunch, MD (Intermountain Heart Institute, Salt Lake City, UT), Heart Rhythm Society (HRS) co-chair of the task force, told TCTMD.

Led by European Heart Rhythm Association (EHRA) chair Jens Cosedis Nielsen, DMSc, PhD (Aarhus University Hospital, Denmark), the group also included representatives of the Asia Pacific Heart Rhythm Society and the Latin American Heart Rhythm Society. Their guidance was co-published last week in EP Europace, the Journal of Arrhythmia, Heart Rhythm, and the Journal of Interventional Cardiac Electrophysiology.

“Objectives were to raise awareness of using the right risk-assessment tool for a given outcome in a given population, and to provide physicians with practical proposals that may lead to rational and evidence-based risk assessment and improvement of patient care in this regard,” the authors write.

“A large variety of methods are used for risk assessment and choosing the best methods and tools hereof in a given situation is not simple,” they continue. “Even though parameters and test results found [to be] associated with increased risk of one outcome (eg, death) may also be associated with higher risk of other adverse outcomes, specific risk-assessment strategies should be used only for the purposes for which they are validated.”

Many Tools to Choose From

The document starts out with an overview of the various means for risk assessment and their strengths and weaknesses, ranging from clinical tools like the CHA₂DS₂-VASc score to ECG, imaging, invasive electrophysiology studies, implantable loop recorders, biomarkers, tissue diagnostics, genetics, artificial intelligence, and consumer wearable devices. The rest of the guidance focuses on evaluating risk of A-fib and ventricular tachyarrhythmia and risks for adverse outcomes in patients with those and other specific cardiac conditions, like ventricular premature contractions, Wolff-Parkinson-White syndrome, and focal atrial tachycardia.

The authors used a system for grading their recommendations that was less formal compared with practice guidelines, giving a green heart for strategies that should be used, a yellow heart for approaches that may be used, and a red heart when something should not be done.

Several green hearts were given for ECG, including for recommendation to obtain a 12-lead ECG in all patients undergoing evaluation for known or suspected heart disease.

A yellow heart was given for the use of wearables or direct-to-consumer products: “Wearables may provide diagnostic data that contribute to disease detection and management when integrated into the clinical context and physician judgement.”

Bunch said the paradigm that includes ordering tests routinely in the hospital to evaluate patients with cardiac arrhythmias “is shifting greatly in westernized countries,” where approved diagnostic tools are sold direct to consumers wishing to learn more about specific disease states. “So these now become tools in that toolkit that are increasingly used, and I think we would have been [remiss] if we did not recognize that and also try to put down some approach of how to use it,” he explained.

These consumer devices, like the Apple Watch, may be able to detect A-fib 5 to 10 years earlier compared with how diagnosis was made in the past, he said, adding that many patients have adopted these types of technology and are sending ECG tracings into doctors’ offices daily. The medical community is still figuring out the best ways to incorporate that deluge of information, but, Bunch said, “I think wearables are definitely here to stay.”

The writing group also wanted to be forward-thinking when it came to a discussion of artificial intelligence and machine learning and what role these may play in the future, despite the current lack of high-level data, Bunch said. That gap is why no specific recommendations were made.

“Machine learning has shown accuracy in predicting mortality and risk stratification of patients with CAD,” the authors note in the paper. “Machine learning has also been shown to accurately discriminate between athletic hearts compared to hypertrophic cardiomyopathy hearts. Machine learning has great potential in this area of risk assessment because of the large amount of data contained in the large ECG and clinical data sets available to determine rules.”

Raising Awareness

Some topics sparked more discussion than others among members of the writing group, Bunch said.

One such area was for the assessment of stroke risk in patients with A-fib, which has traditionally been done using age and risk factors with a tool like the CHA₂DS₂-VASc score. But there is emerging evidence that systemic biomarkers like troponin and B-type natriuretic peptides can help in risk assessment, and there was extensive debate over whether there were enough data to support a recommendation to consider biomarkers to help guide anticoagulation strategies in patients with A-fib, Bunch said. Ultimately, the group decided that there wasn’t enough prospective evidence to support a formal recommendation along those lines.

Another somewhat controversial issue was how to manage patients after undergoing left atrial appendage (LAA) closure. The strongest recommendation, a green heart, was given to performing transesophageal echocardiography 6 weeks after the procedure and, if necessary, at 1 year to detect peridevice residual flow, incomplete appendage ligation, and device-related thrombus and identify patients with an elevated stroke risk. Bunch noted that there is still a need for adequately powered prospective comparisons of LAA closure and direct oral anticoagulants for long-term stroke prevention.

Bunch said that he hopes this consensus document will become a resource that physicians use when making evidence-based decisions regarding risk assessment. “We’re hoping this improves physicians’ use and awareness of the tools that are available across multiple disease states and multiple high-risk categories of patients. We hope that the tools that are available will be used appropriately in the patients that are of most need,” he said.

“I think this document as well will bring awareness of patients that are higher risk that may not have been assessed previously for outcomes beyond just stroke and heart failure, but cognitive decline, dementia, poor quality of life,” Bunch continued, adding that he thinks the document will help in individualizing approaches to patient management.