What Doctors Need to Know About NICE Atrial Fibrillation Guidance

Dr Rob Hicks

Disclosures

July 08, 2021

This transcript has been edited for clarity.

Hello and welcome to this Medscape UK video. I'm Dr Rob Hicks.

Today we're going to be discussing the updated atrial fibrillation diagnosis and management guideline from the National Institute for Health and Care Excellence (NICE). And I'm delighted to have with me Dr Neil Andrews, who is a consultant cardiologist and electrophysiologist at Portsmouth Hospitals University Trust, and also the topic advisor on the National Institute for Health and Care Excellence (NICE) atrial fibrillation guideline committee. Welcome. And thank you for joining me today.

Dr Andrews

Hi, thank you. Thank you for inviting me.

Dr Hicks

I'd like to begin by asking you, why do we need this guideline?

Dr Andrews

So the last guideline was in 2014. And since then, the DOACs have become much more widely used, but not comprehensively, so these newer anticoagulant agents have largely replaced warfarin, but there are areas of the UK which haven't gone that way. So there was a need to provide some uniformity, some guidance.

And there'd also been some developments in terms of the use of ablation of atrial fibrillation. And so deciding where that exactly stood, and how cost effective it was, was important. And there'd also been some work looking at the different tools that you can use to decide who should be anticoagulated, and what their bleeding risk was.

So, and there were some minor issues, and minor other points as well, that there’d been some work on. But they were the three main areas that needed revision.

Dr Hicks

What's the most challenging aspect of managing AF?

Dr Andrews

The most important thing about atrial fibrillation is the risk of it causing a stroke. And it's relatively easy to make, however, as we'll discover in our discussion today, but it's relatively easy to make the decision about when to anticoagulate, and also what agents to use, because there's lots of data. But the area that we're struggling with is trying to improve the morbidity that atrial fibrillation causes the rest of the population.

So anticoagulating those people who don't know they have atrial fibrillation, who doctors don’t know, and knowing how much atrial fibrillation is enough to give them that diagnosis and therefore, go through the scoring processes and decide whether they have anticoagulation.

So all those things are uncertain. And you know that also reflects in day to day clinical practice.

The patients who often come and see us with the most symptoms of atrial fibrillation may in fact have a very low risk of any adverse outcomes. And the ones who hardly know they've got atrial fibrillation are often the most difficult to manage because they're the ones who are probably more likely to have bad outcomes. And knowing how much effort to put into cardioverting them back to normal rhythm, and knowing whether that's going to improve their prognosis, remains uncertain.

So, really identifying asymptomatic patients, and knowing in the highest risk groups, whether getting them back into normal rhythm is going to make any difference.

Dr Hicks

What new recommendations does this guideline make?

Dr Andrews

The most important, probably the headline is that the NOAC agents, the newer oral anticoagulants, or the direct acting oral anticoagulants, are preferred over warfarin based on their effectiveness and their reduced risk of intracerebral haemorrhage, and that translates into a significant cost effectiveness advantage.

So I think that's the headline.

And then the next important aspect of it is that ablation for atrial fibrillation is confirmed as a valuable tool, and that should be routinely used in patients who have not been successfully treated with an anti-arrhythmic agent.

You could even argue that, failure to respond to a beta-blocker, but most would say that when we say antiarrhythmic agent, what we mean is something like flecainide, or amiodarone, a drug that most general practitioners would be probably uncomfortable prescribing.

So once we've seen them and we’ve failed, we should move on to ablation pretty promptly.

Dr Hicks

How should the risk of bleeding be assessed when considering anticoagulation for those with AF?

Dr Andrews

This is a new part of the guideline recommendations, which actually although not a headline, it's caused quite a bit of controversy.

We've decided that HAS-BLED, which is the traditional scoring system for measuring bleeding should be replaced by ORBIT.

ORBIT appears to perform better when we want to determine what somebody’s risk of bleeding is, particularly in patients not taking warfarin, so it works well with the direct oral anticoagulants. And it gives a better idea of what the real risk is in those at the highest risk of bleeding. And that's why it was preferred over HAS-BLED.

Dr Hicks

Who should, and who should not, have anticoagulation therapy for stroke prevention?

Dr Andrews

So we've stuck with the traditional scoring system, which is the CHADS2-VASc, which I'm sure most of your listeners are familiar with.

The subtlety is that we would say that everybody with a CHADS2-VASc of 2 or more - so anybody over the age of 65 who are hypertensive, or if you know the details of the CHADS2-VASc score, or you’re a female, or have heart failure, or particularly those who have had a stroke, should receive anticoagulants. In fact anybody who has had a stroke should receive anticoagulants.

And the second group where you should consider - but not necessarily anticoagulate, but certainly strongly consider it - are those groups of men whose CHADS2-VASc score is 1. So somebody over the age of 65 who's male, or somebody who's hypertensive, and male, but if you're, if you're female, and hypertensive, then you'd automatically be strongly considered for anticoagulation.

Dr Hicks

What's the role of left atrial ablation?

Dr Andrews

In terms of mechanism, the idea is to isolate the pulmonary veins from the rest of the left atrial chamber, because atrial fibrillation, not surprisingly, arises obviously in the atria, and it's particularly the pulmonary vein.

So the technique is designed to prevent those veins triggering the atrial fibrillation, which also provides some electrical stability to the structure.

But in terms of the role in managing patients, it's for patients with paroxysmal or persistent atrial fibrillation. It’s not for those with permanent fibrillation. So once you've decided that getting people back into normal rhythm is no longer an option, ablation is no longer an option for that.

And the group that responds probably the best are those whose atrial fibrillation has been going on for less than a couple of years. But where that line is, we’re unsure.

In that group, 60% to 70% of them can have a good response to ablation.

So I would emphasise, you know, as we discussed briefly at the beginning, it's not for all of those with atrial fibrillation. The first line treatment is beta-blockers and rate control. And subsequently, if they need rhythm control then a class 1 agent or a class 3 agent, so flecainide and propafenone, or amiodarone. And it's those who don't respond to those antiarrhythmic treatments who recommend ablation.

Dr Hicks

Well, that's all we have time for today. We hope you found our discussion interesting, and if you've any comments, then we'd love to hear from you.

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