Atrial Fibrillation new 2023 ACC 2.pptx

AF new guidelines

1. Atrial Fibrillation ACC guidelines 2023 Dr Rajesh Ponnada Cardiology Resident Apollo Hospital, Visakhapatnam

2. Atrial Fibrillation Electrophysiological abnormalities (Impulse generation) Structural abnormalities Ectopic action potentials Reentrant activity Atrial Ectopy Sufficient Subtrate Reentry to persist PV

3. Heterogeneity in IK1 Abnormal Ca2+ handling Downregulation of connexin Genetic, Old Age, Inflammation, SDB ( Atrial cardiomyopathy) Prothrombotic LA Electrical remodeling, Heterogenous atrial conduction velocity and repolarization NLRP3 knockdown prevented AF

4. Persistence of AF

5. The ANS as AF trigger Modi fi able AF risk factors promote ANS dysfunction

6. I ncidence and prevalence Increasing Multi factorial Increased Detection

7. Age-Standardized Global Prevalence Rates of AF and Atrial Flutter per 100,000, Both Sexes, 2020

8. Risk Factors for Diagnosed AF

9. CVDs causing AF

10. Consider Increased Surveillance Treat modifiable risk Factors Monitor AF burden clinically throughout Risk of stroke Assessment, Pathophysiological changes, Treatment of symptoms S.O.S

11. S.O.S

12. Definitions Term Definitions AF A SVT with uncoordinated atrial activation and ineffective atrial contraction Clinical AF Subclinical AF Atrial high-rate episodes AF burden First detected AF Paroxysmal AF Persistent AF Long-standing persistent AF Permanent AF

13. Risk Strati fi cation and Population Screening CHARGE-AF (Co- horts for Heart and Aging Research in Genomic Epidemiology model for atrial fi brillation Total points 0-8. For the C2HEST score, the C statistic was 0.749, with 95% CI of 0.729 – 0.769. 10 The incident rate of AF increased signi fi cantly with higher C2HEST scores.

14. N ewly diagnosed or suspected AF A ssess other electrical abnormalities Basic laboratory tests, CKD, LFTs and hyperthyroidism. electrolyte abnormalities, clinically relevant disorders , Bleeding/Stroke risk T ransthoracic E chocardiogram Chamber size, Valve Functions, RV pressure, LVEF, Impacts decision on Antiarrhythmic medication, Rhythm control therapies Strain Imaging,( for infiltrative disorders Amyloidosis) LA size and function, stronger predictor of recurrence after ablation A mbulatory electrocardiographic monitoring, may be pursued based on the results of these initial evaluations

15. The initial clinical evaluation of the patient with newly diagnosed or suspected AF

16. Monitoring options for AF standard 12-lead ECG, continuously recording loop-recording electro- cardiographic monitors implantable loop recorders handheld ECGs, and smartwatches (Photoplethysmography) RCTs have demonstrated that implantable cardiac monitors exhibit the highest sensitivity in detecting AF compared with external ambulatory monitors, likely related to the longer duration of monitoring

17. LIFESTYLE AND RISK FACTOR MODIFICATION (LRFM) FOR AF MANAGEMENT O besity and physical inactivity each independently increase the risk of newly diagnosed AF But avoid pursuing years of regular, high-volume ( > 3 h/day) high-intensity endurance training , J curve Phenomenon B ariatric surgery in Class III obese individuals (BMI > 40 kg/m 2 ) with AF was associated with improved sinus rhythm maintenance after catheter ablation and reversal of AF

18. In patients with AF and diabetes undergoing catheter ablation, optimal glycemic control preablation may lessen the risk of AF recurrence postablation. 3

19. Comprehensive Care RACE 3 (Rate Control versus Electrical cardioversion for persistent atrial fi brillation) trial (SAFETY [Standard versus Atrial Fibrillation speci fi c management study])

20. PREVENTION OF THROMBOEMBOLISM Risk Stratification Schemes patient’s absolute risk of stroke is central to recommendations about anticoagulation Category Rate Low < 1% per year Intermediate 1 to 2 % per year High >2 % per year Scores are problematic to use in clinical decision-making because they incorporate several clinical factors that increase the risks of both stroke and bleeding HEMORR2HAGES HAS-BLED

21. CHA2DS2-VASc score Original CHADS2 suboptimal performance in selected populations, Renal diseases Newer risk scores may modestly improve risk discrimination (c-index) compared with CHA2DS2-VASc and may offer potential advantages in specific populations ATRIA (Anticoagulation and Risk Factors in Atrial Fibrillation ), GARFIELD-AF 3 (Global Anticoagulant Registry in the Field-Atrial Fibrillation) risk scores

22. A higher risk of bleeding without predicting higher risk of stroke Factors previous bleeding, anemia, and certain medications Population-based studies suggest that the bene fi ts of stroke prevention with oral anticoagulation generally outweigh the risks of bleeding, even in patients determined to be at high risk for bleeding Decision-making about oral anticoagulation should be based on consideration of both benefits and harms, not by using bleeding risk scores in isolation,

23. CHA2DS2-VASc of 1 (CHA2DS2-VASc of 2 in women) Additional Risk Factors discussion with patients 1-point-concept of risk estimation in the subgroup of patients with a CHA2DS2-VASc score AF burden , can be considered when interpreting a stroke risk score Degree of Hypertension Control ARISTOTLE ( Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation) trial, a single elevated BP measurement during the study was associated with a 50% increased risk of stroke patient-speci fi c risk factors, such as certain biomarkers ( eg , proBNP ), LA or left atrial appendage (LAA) function and anatomy, or ECG features, among others

24. Additional Risk Factors That Increase Risk of Stroke Not Included in CHA2DS2-VASc Risk Factor Definitions for CHA2DS2-VASc Score as in the Original Article 2

25. Risk-Based Selection of Oral Anticoagulation: Balancing Risks and Benefits Risk of stroke should inform the decision Regardless of the pattern of AF Periodically Reassessed

26. High risk for stroke or systemic embolism is about 2% per year DOAC trials Re-LY [Randomized Evaluation of Long-Term Anticoagulation Therapy ROCKET AF [ Rivaroxaban Once Daily Oral Direct Factor Xa Inhibition ARISTOTLE Vitamin K Antagonism for Prevention of Stroke and Embolism Trial in Atrial Fibrillation] ENGAGE AF-TIMI 48 [Effective Anticoagulation with Factor Xa Next Generation in Atrial Fibrillation – Thrombolysis in Myocardial Infarction 48 intermediate risk (1%-2%/y) can also benefit from anticoagulation, and the RE-LY1 and ARISTOTLE3 trials

27. IMproved ICH and mortality risk of DOACs compared with warfarin in meta-analyses of the DOAC trials, 5-7 it is appropriate to designate a lower stroke risk threshold if a DOAC is utilized Markov state transition decision model 16 concluded that anticoagulation was preferred for a stroke rate of 1.7%. AVERROES trial ( Apixaban Versus ASA to Prevent Stroke In AF Patients Who Have Failed or Are Unsuitable for Vitamin K Antagonist Treatment) Aspirin was studied compared to apixaban Trial was stopped early due to the bene fi t of apixaban over Aspirin to prevent stroke or systemic embolism, while major bleeding was similar between the 2 arms.

28. ACTIVEW (Atrial fibrillation Clopidogrel Trial with Irbesartan for prevention of Vascular Events) combination of clopidogrel and aspirin was compared to VKAs trial was stopped prematurely due to T he superiority of anticoagulation with VKAs to prevent stroke, non–central nervous system systemic embolus, MI, or vascular death

29. Approximately 25% to 30% of ischemic strokes remain cryptogenic after standard stroke evaluation detection of occult AF after stroke may have signi ! cant therapeutic implica - tions Implantable recorder was superior in detecting AF at 6 months (8.9% versus 1.4%), 12 months (12.4% versus 2.0%), and 3 years (30% versus 3% ) conventional ECG follow ups CRYSTAL-AF (Cryptogenic Stroke and Underlying AF) trial

30. FIND-AF (Future Innovations in Novel Detection of Atrial Fibrillation), which compared repeated sets of 10-day Holter monitoring (at baseline, 3-month, and 6-month timepoints) to con- ventional 24-Holter in patients $ 60 years of age with recent stroke, higher rates of detection were associated with repeated monitoring PER DIEM ( Post-Embolic Rhythm Detection with mplantable vs External Monitoring) RCT also showed a signi ! cantly greater proportion of patients with AF detected at 1 year with prolonged monitoring.

31. ASSERT (Atrial Fibrillation Reduction Atrial Pacing Trial), adjudicated AHREs > 24 hours was associated with an increased risk of subsequent stroke or systemic embolism

32. Nonpharmacological Stroke Prevention RCTs have demonstrated pLAAO to be noninferior to warfarin and DOACs for stroke and systemic embolism with a reduced risk of major bleeding. EWOLUTION (Evaluating Real-Life Clinical Outcomes in Atrial Fibrillation Patients Receiving the WATCHMAN Left Atrial Appendage Closure Technology) prospective registry showed a high rate of Watchman device procedural success (98.5%) with a low ischemic stroke risk

33. Recommendations for Active Bleeding on Anticoagulant Therapy and Reversal Drugs

34. Bleeding Events (Percentage Per Year) in DOAC Pivotal Clinical Trials

35. AF Complicating ACS or Percutaneous Coronary Intervention (PCI) Chronic Coronary Disease (CCD)

36. Peripheral Artery Disease (PAD) Recommendations for CKD/Kidney Failure

37. Recommendations for CKD/Kidney Failure

38. Recommendations for AF in VHD

39. Recommendations for Anticoagulation of Typical AFL

40. RATE CONTROL RACE II study (Rate Control Ef ! cacy in Permanent Atrial Fibrillation A difference was not seen regarding either the primary composite outcome of death from cardiovascular causes, hospitalization for HF, stroke, systemic embolism, bleeding, and life-threatening arrhythmic events A Comparison Between Lenient Versus Strict Rate

41. Atrioventricular Nodal Ablation (AVNA)

42. RHYTHM CONTROL

43. Electrical and Pharmacological Cardioversion Electrical cardioversion is more effective than pharmacological cardioversion alone Thromboembolic risks and considerations for anti- coagulation apply to both pharmacological cardioversion and electrical cardioversion

44. Recommendations for Electrical Cardioversion

45. Recommendations for Pharmacological Cardioversion

46. Drugs for Pharmacological Conversion of AF to Sinus Rhythm

47. Treatment Algorithm for Drug Therapy for Maintenance of Sinus Rhythm

48. Management of Patients With HF and AF

49. Management of Early Onset AF, Including Genetic Testing Recommendations for Anticoagulation Considerations in Patients With Class III Obesity

50. Recommendations for WPW and Preexcitation Syndromes

51. Prevention and Treatment of AF After Cardiac Surgery

52. Treatment of AF After Cardiac Surgery

53. Unexplained AF before 30 years of age electrophysiological study In patents with an onset of AF before 45 years of age Referral for genetic counseling, Cardiomyopathy ,

54. Acute Medical Illness or Surgery ( AF in Critical Care) 1 % to 46% in medical illness with 6% to 22% in severe sepsis 3 % to 16% after noncardiac surgery

55. Recommendations for Pregnancy

56. Thank you…..