European Society of Cardiology updates AF treatment Guidelines--Six major focus points

Dr John Mandrola

Disclosures

August 26, 2012

The treatment of atrial fibrillation is a fast-moving field. It's a good thing, because the prevalence of the disease continues to increase. In Europe, estimates are that AF burdens almost 2% of the general population. In the past two years, enough data have come available to warrant an update to the 2010 European treatment guidelines.

Here are summaries of six important focus points of this 2012 European update:

Use CHA2DS2-VASc rather than CHADS2 to predict stroke:

In contrast to the North American guidelines, which give preference to the simpler CHADS 2 score, Euro guidelines continue to emphasize the CHA2DS2-VASc score (congestive heart failure/left ventricular dysfunction, hypertension, age ≥75 [doubled], diabetes, stroke [doubled]–-vascular disease, age 65–74, and sex category) as the best means to predict stroke. CHA2DS2-VASc has two major benefits: It more accurately identifies true low-risk patients, which decreases the risk of over-treating. As important, it reclassifies many CHADS2-zero patients to a higher risk, which reduces the chances of undertreating. Guideline writer Dr Gregory Lip reminded us that stroke risk in a patient with CHADS2 score of zero ranges from as low as 0.8% to more than 5%. Speaking in a pro-con debate on post-AF ablation anticoagulation, he was clear about his feelings: "The CHADS2 score is useless. You might as well toss a coin."

Use less aspirin:

Despite robust evidence to the contrary, there exists a widely held view—in the real world of clinical practice—that aspirin is safer than anticoagulants. European guideline writers seek to change this thinking.

"The evidence in support of aspirin use is weak." The 2012 update focuses strongly on the superiority of oral anticoagulants, especially the new oral anticoagulants dabigatran, rivaroxaban, and when available, apixaban. Aspirin is recommended only in patients who refuse anticoagulation. The concern with aspirin is not only inefficacy, but also bleeding risk. This recent analysis in JAMA highlights the underestimated hazard of aspirin use in low-risk patients.

New anticoagulants are superior to warfarin:

"When oral anticoagulation is recommended, the newer anticoagulants are favored." On the matter of which of the new agents to use: "Insufficient evidence exists to favor one over the other."

It remains to be seen whether such strong endorsements will speed the surprisingly slow acceptance of new anticoagulants in real-world clinical practice. In the US, barriers to widespread usage of these drugs include their costs, fears over a lack of easily available antidotes, and enhanced coverage of adverse events, many of which have occurred with inappropriate use of these drugs. Think learning curve.

Vernakalant gets a nod of approval:

Vernakalant is a novel intravenous drug used to chemically cardiovert recent-onset atrial fibrillation. It works by selectively blocking ion channels in the atrium. It's available in Europe but not yet approved in the US. The evidence suggests vernakalant converts AF (of less than seven days' duration or less than three days after cardiac surgery) in more than 50% of cases, usually within eight to 14 minutes. The safety profile is satisfactory, with the most concerning side effects being transient hypotension and nonsustained VT. Notably, no episodes of torsades de pointes have been reported. It's not indicated in patients with low blood pressure, advanced heart failure (Class 3 or 4), long QT, or severe aortic stenosis. In this 254-patient trial randomized trial, vernakalant was superior to IV amiodarone for cardioversion of AF.

It's possible that vernakalant could become an easier-to-use ibutilide.

Catheter ablation keeps its strong recommendation:

Enthusiastic endorsements continue for left atrium ablation in patients with paroxysmal AF or those without structural heart disease, provided experienced operators perform the procedure. Departing from North American guidelines, AF ablation is recommended as first-line therapy in selected patients.

Dronedarone gets a demotion:

Recent safety concerns have moved European experts to recommend a much smaller role for dronedarone. Based on the highly negative PALLAS trial, the 2012 update recommends against using dronedarone in patients with permanent AF. Reversing previous notions, the most recent update says of dronedarone: "Its use should be relegated to a therapy of last resort for patients even with mild heart failure."

In general, the 2012 update to the European guidelines for the treatment of AF emphasizes earlier intervention, better risk stratification for stroke, and more aggressive support for newer stroke prevention therapies, primarily the newer anticoagulants.

JMM

Here is a link to the full document.

PS. I went to a lively debate on left atrial occlusion devices. I hope to post on this controversial topic in the future.

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