The latest update of the atrial fibrillation (A-fib) guidelines from the American Heart Association, American College of Cardiology and Heart Rhythm Society incorporated data regarding the novel anticoagulants (NOACs), updated the preferred risk assessment tool to the CHA2DS2-VASc score, and updated the data and recommendation level for A-fib ablation.

KEY RECOMMENDATIONS FROM THE UPDATED GUIDELINES

• The risk of stroke and bleeding should be considered in all patients.
• The CHA2DS2-VASc score is recommended for the assessment of stroke risk.
• Decisions regarding anticoagulation should be based on risk score, irrespective of whether the patient has paroxysmal, persistent or permanent A-fib.
• NOACs (dabigatran, rivaroxaban, apixaban) were given a level I recommendation as an alternate to warfarin.
• A-fib ablation is recommended therapy for patients who have failed at least one class I or III antiarrhythmic drug, and is considered reasonable as first-line therapy in selected patients.

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Prevention of thromboembolic events, such as stroke, continues to be an area of focus. The decision to anticoagulate patients should take into consideration bleeding risk as well as stroke risk. The CHA2DS2-VASc score is now the preferred assessment, rather than the CHADS2 score. Risk scores such as the HAS-BLED score are used to estimate bleeding risk. The decision to anticoagulate should be made independent of the type of A-fib (paroxysmal, persistent or permanent). Choices for anticoagulant therapy include warfarin and now also the NOACs, except in patients with certain prosthetic heart valves or valvular A-fib. If warfarin is chosen, then monitoring is recommended at least weekly during initiation and monthly once INR levels are stable.

While rate control continues to be important, the role of ablation for A-fib was expanded in the guideline update. Ablation for A-fib was upgraded to a level I indication for symptomatic patients with paroxysmal A-fib who have failed a class I or II antiarrhythmic drug. In addition, ablation as initial therapy for patients with symptomatic paroxysmal A-fib was given a class IIa indication. Finally, ablation for patients with symptomatic persistent A-fib who are refractory or intolerant to a class I or III antiarrhythmic agent was given a level IIa recommendation.

Kent E. Morris, M.D., electrophysiologist, Norton Heart & Vascular Institute Heart Rhythm Center, said providers should consider referring A-fib patients to an electrophysiologist if they’re symptomatic. “Those are the people we can probably help most,” he said. “We don’t need to see every patient with A-fib, but certainly patients who are symptomatic.”

Classic A-fib symptoms include heart palpitations or a racing heart. Other symptoms can occur that are less obviously due to A-fib. They include fatigue, lack of energy and shortness of breath, which patients tend to attribute to a number of different factors.

Dr. Morris said an electrophysiology evaluation also can be helpful if questions arise about any aspect of treatment. For example, an electrophysiologist can help determine if an anticoagulant or antiarrhythmic medication is appropriate and which one would be best. An electrophysiologist also can access whether a patient is a good candidate for invasive management, such as ablation or left atrial appendage occlusion.

Any patient who has symptoms serious enough to go to the emergency department is a good candidate to be seen by an electrophysiologist, Dr. Morris said. Existing patients who are symptomatic also should probably see an electrophysiologist, he added.

The complete guidelines can be found here. Make a referral here, select cardiology, and reason for referral, note “electrophysiology.”