Year in Review: Digital Health and A-fib Ablation Top 2019 Heart Rhythm News

A growing appreciation of the potential for wearable consumer devices to detect arrhythmias and continuing advancements in catheter ablation were among the major stories in electrophysiology and arrhythmia management over the past year, according to Andrea Russo, MD (Cooper University Hospital, Camden, NJ).

“It’s been a year of increased awareness of the importance of digital health and things like wearable devices for diagnosing arrhythmias,” she told TCTMD. Russo is president of the Heart Rhythm Society (HRS), which held its first Digital Health Summit as part of its annual scientific meeting in May.

In particular, the Apple Heart Study—presented at the American College of Cardiology Scientific Session in March and later published in the New England Journal of Medicine—has raised awareness about the availability of this type of monitoring, which engages patients in their own care and provides physicians access to data they haven’t been able to see before, Russo said.

Though dealing with the flood of data presents some challenges in terms of increased workload in doctors’ offices and reimbursement, which in turn may affect the long-term sustainability of using this information, she said that empowering patients is a positive overall. “Patients are really just taking more control of their own care, which is a good thing. They’re helping to acquire information to help us diagnose their new problem,” she said. “So I think it’s made a big impact.”

What remains to be seen is how wearable devices can be best deployed for screening patients for arrhythmias. Right now, these types of devices tend to be used by younger people who have low risks of A-fib, so further research is needed to determine the best population to focus on for A-fib screening, Russo said. “If we can diagnose it early, if they have multiple risk factors, maybe we can actually prevent stroke by initiating anticoagulation in some of these patients.”

Russo also said that the Apple Heart Study, for which she serves on the steering committee, was important in that it showed the feasibility of enrolling thousands of patients into a study over a relatively short time period using a virtual format that does not require face-to-face office visits.

Developments in Catheter Ablation

Russo cited two areas where catheter ablation advanced in 2019. In the realm of structural heart disease, there was increasing use of epicardial ablation, particularly for patients with nonischemic cardiomyopathy, she said. And in terms of treating A-fib, there have been enhancements in ablation technology. “We’re still not there in getting cure for most patients but we do have improved technology that helps us make more durable lesions over time,” Russo said.

This year also saw the long-awaited publication of the CABANA trial results; the study failed to show that catheter ablation improves hard outcomes in patients with A-fib compared with medical therapy alone but did show that ablation resulted in greater gains in quality of life.

There are no formal studies to assess how practice patterns have changed in the wake of CABANA, initially reported at the HRS Scientific Sessions in May 2018, but Russo said not much has changed for her personally. “It did not change my practice personally because I was ablating people who were symptomatic to begin with,” she said. “We clearly know we can improve quality of life in patients. We know we can reduce the occurrence of atrial fibrillation in patients [like those] enrolled in CABANA, so there’s a group that really benefits from ablation.”

So CABANA “reinforces what a lot of us were doing already, but I also think it tells people that it’s okay not to do an ablation—that if your patient doesn’t fall into certain categories of patients that would benefit, you don’t have to ablate everyone,” Russo said.

Pacing, Oral Anticoagulation for A-fib

Russo also touched on pacemakers/defibrillators and the use of oral anticoagulation for A-fib.

In 2019, there was increased usage of newer and better devices, including leadless pacemakers, which remove the weakest link in any kind of system (the leads), Russo said. “I think that has certainly had a big impact on what we’re doing [and will have] even a greater impact when we combine these leadless pacemakers with defibrillators that are subcutaneous. That’s not something we’re seeing yet but I think that we’ll continue to have more developments and more innovation in that particular area.”

As for anticoagulation, 2019 saw a focused update of the US A-fib guidelines to recommend a preference for non-vitamin K antagonist oral anticoagulants (NOACs) over warfarin in most patients, bringing that guidance in line with European recommendations. In addition, release of results from AUGUSTUS and ENTRUST-AF PCI provided more support for the concept that dual therapy with a NOAC and a P2Y12 inhibitor—as opposed to triple therapy with aspirin, warfarin, and a P2Y12 inhibitor—is the way to go in patients with A-fib who undergo PCI.

Registry data, particularly from the American Heart Association’s Get With The Guidelines-AFIB quality improvement initiative, shows that use of anticoagulation in the broader group of eligible patients with A-fib is underused, Russo pointed out. NOACs are easier for patients to take, don’t require routine blood work, and have fewer dietary restrictions than vitamin K antagonists. All these factors should make adherence less of an issue, she noted.

There are patients who aren’t good candidates for chronic anticoagulation, however, and in those groups, consideration should be given to left atrial appendage occlusion, Russo said. “We have lots of options,” she added. “We should really be able to prevent stroke by using anticoagulation in patients who are candidates. If they’re not, we should be considering some of these alternative methods to occlude the left atrial appendage to reduce the risk of stroke.”