New AF Ablation Consensus Doc Previewed at Boston AF Symposium

Reed Miller

January 17, 2012

January 17, 2012 (Boston, Massachusetts) — The forthcoming international consensus statement on atrial fibrillation (AF) includes a new set of standardized definitions, indications classed by evidence-level, and more information about anticoagulant therapy, among other improvements to the first AF ablation consensus released in 2007 [1].

In a presentation here today at the Boston Atrial Fibrillation Symposium 2012, consensus task force cochair Dr Hugh Calkins (Johns Hopkins University, Baltimore, MD) said: "This consensus document is an up-to-date, highly referenced review that 45 of your colleagues spent a lot of time working on," he told symposium participants. "We hope this document will improve patient care by providing a foundation--for those who are entering or involved in this field--of optimal approaches."

The single most important innovation is that the new version will include a level-of-evidence designation for each indication, like those used in professional guidelines, Calkins told heartwire after his presentation.

Commenting on Calkins' presentation, Dr John Camm (St George's Hospital, London, UK) said he expects that the level-of-evidence designations will probably guide the policies of many third-party healthcare payers. Indications given a class IIB rating will not be covered by some payers, class I indications will be adopted, and class IIa indications "will remain somewhat controversial in many parts of the world," he said.

"So we always have to be aware of that knock-on effect, but generally, I think this substantial consensus document will be very helpful to the healthcare economy," Camm said. In many parts of the UK, ablation of anything "worse than paroxysmal AF" is not covered by the National Health Service, while ablation of paroxysmal AF is covered, he explained. But "there are several initiatives going forward to address that, and a consensus document of this kind is very helpful [for that effort, because] we shouldn't simply be classifying AF based on whether its paroxysmal or persistent, but we should be looking at other characteristics of the patient that define success or failure, such as the extent of atrial remodeling [and] underlying cardiovascular disease."

New Drugs, New Recommendations

According to Calkins, the second-most important changes are updates to the specific recommendations regarding anticoagulant therapy, including information on newer anticoagulants, direct factor Xa inhibitors, and GP IIb/IIIa inhibitors, as well as an emphasis on the importance of using the CHA2DS2-VASc scoring system for determining which patients should be anticoagulated. The consensus document will also direct physicians that "it's fine to perform these procedures [in patients] on [warfarin]," he said. The new document states that ablation in patients who are systemically anticoagulated with warfarin does not alter the need to use heparin.

Importantly, the updated consensus document will also include a new glossary with 53 definitions and "a new bibliography for the field to move it forward." Many of these definitions were requested by the Food and Drug Administration to help guide clinical research, Calkins said.

Some of the changes include new definitions of "brief episodes of paroxysmal and persistent AF," where the patient is cardioverted very quickly. In the new document, AF lasting less than 48 hours before being successfully cardioverted or terminated with drug therapy is defined as paroxysmal instead of persistent AF.

In the 2007 document, performing transesophageal echocardiography (TEE) prior to ablation was recommended in all patients. In the new document, TEE with AF for at least 48 hours is recommended if the patient hasn't been on adequate anticoagulation for the previous three weeks. For patients in AF for less than 48 hours, the new document states TEE "may be considered", but is not mandatory. Many centers are now being more selective about TEE.

The consensus document also includes recommendations for future research about AF ablation, Calkins said.

The document was developed by experts from the Heart Rhythm Society, European Heart Rhythm Association, and European Cardiac Arrhythmia Society, in collaboration with the American College of Cardiology, American Heart Association, and Society of Thoracic Surgeons. The group began working on the statement in early 2010.

Calkins said he expects the new document to be released online in March and available in print a few weeks later.