Seven Quick Thoughts on the New European AF Guidelines 

John Mandrola, MD


September 04, 2020

Here are seven aspects of the new European Society of Cardiology/European Association of Cardiothoracic Surgery guidelines on atrial fibrillation (AF) that caught my eye.

1. Visual Artistry

The writing group has perfected the visual presentation. One of the purposes of a guideline is teaching. The beautiful and clear illustrations in this paper will surely aid readers in comprehending the complexity of AF care.

2. The 4S Approach

After confirming the diagnosis of AF, which is more complex in the era of mobile electrocardiography (ECG) technology, the writers suggest a "4S" approach to management.

First assess Stroke risk; then Symptoms; then Severity of AF burden; and, of course, Substrate. This is best explained by considering two typical patients with AF.

One is an 80-year-old woman with left bundle-branch block, a left ventricular ejection fraction of 30%, rapid ventricular rates, and high-burden AF. She will be severely symptomatic and require aggressive intervention. On the other end of the spectrum is a 45-year-old man with a normal heart who has short-duration, self-terminating AF once every 3 months.

I laud the 4S approach because AF presents in vastly different ways. Though it sounds banal, AF management truly requires an individualized approach.

3. AF Screening

Profit-driven expansion of consumer wearables forced the writers to address screening. In general, I am skeptical that personal digital devices will be a net positive for society, but there is no denying that these devices are here to stay.

There were clear positives in the section on screening. The calls to fully inform patients about their diagnosis, provide referrals to experts, and require a physician over-read of the ECG-in-question are wise.

I would push back on the class 1 recommendation for opportunistic screening. While there is strong evidence that such screening picks up AF episodes, which in turn leads to increased use of oral anticoagulation, it is not clear that this will improve outcomes or be cost-effective.

Recall that the clinical trials that established the benefit of oral anticoagulation (the warfarin trials) enrolled patients from doctor's offices and hospitals. Screen-detected AF may be different. For instance, mobile devices and implanted devices pick up short-duration subclinical AF. It is not clear if people with this category of AF will benefit from anticoagulation; they may even be harmed by the drugs.

Other challenges with screening include misdiagnosis (due to imperfect specificity), off-target diagnoses (premature beats or asymptomatic bradycardia), and increased anxiety. Any recording of a cardiac rhythm is a medical test. Medical tests often start clinical cascades. Europe may differ from the United States, but cascades of care from testing are common, are not well-studied, and may bring more harm than benefit.

What is most needed for screening are randomized controlled trials that assess outcomes rather than the surrogates, such as AF episodes or how often anticoagulants are initiated. This has been done for cancer screening, and it ought to be done for rhythm screening as well.

4. ABC Pathway

The beauty of the CHA₂DS₂VASc score for risk assessment is its fast and frugal nature.

The ABC pathway of AF intervention is as fast and frugal as it gets. But is it too simple?

"A" is for anticoagulation to avoid stroke. The authors provide an extensive literature review for the many stroke prevention approaches. Much of this is not new.

A notable aspect of the 2020 guidelines is an added focus on the HAS-BLED score. Since bleeding risk changes over time, the authors believe repeated assessments of the integer score may lead clinicians to address modifiable bleeding risk factors and intensify follow-up for higher-risk patients. This makes sense, but there is significant overlap between the CHA₂DS₂VASc and HAS-BLED scores.

"B" is for better symptom control. Control of symptoms can come from either rate or rhythm control. The authors offer thousands of words and hundreds of references on the many options. Two specific recommendations stood out (see points 5 and 6 below).

"C" is for cardiovascular risk factors and concomitant diseases. During the virtual presentation, Professor Isabelle C. Van Gelder, from the University of Groningen, showed a slide with five words that elegantly summarizes AF care:

"AF almost never comes alone." I wish this was the subtitle of the entire guideline document. I say that phrase numerous times each week, to patients and colleagues alike.

The guideline writers correctly emphasized modification of the cardiometabolic risk factors because these adversely affect atrial structure and electrical function. 

One worry I have about the letter C designation is that it may oversimplify the complexity of risk factor modification.

Think about a typical overweight patient with AF: before ablation, a clinician must attend to weight loss, sleep-disordered breathing, alcohol counseling, blood pressure management, and perhaps glycemic control. That's a tall order—especially for an electrophysiologist.

5. Amiodarone Makes It to Class 1

The writers gave amiodarone a class 1 recommendation for long-term rhythm control in all patients with AF. They add the modifying phrase, "however, owing to its extracardiac toxicity, other AADs [antiarrhythmic drugs] should be considered first whenever possible."

A couple of thoughts on amiodarone. I do not often use this drug for AF. In the United States, unlike most of Europe, dofetilide is available for patients with significant structural heart disease.

Many will disagree, but I have long held that the evidence for extracardiac toxicity of amiodarone is quite weak. Nearly every case report of organ toxicity from amiodarone is confounded by comorbid conditions. Go look at it and tell me I am wrong.

That said, my concern with the class 1 recommendation is that amiodarone use may increase without the needed surveillance. If I were writing that text box, I would have added words about careful surveillance.

6. Catheter Ablation Recommendations

The standout for me in these guidelines was the class 1 recommendation for strict control of risk factors and avoidance of triggers to improve outcomes of ablation. My support for this transcends levels of evidence.

AF care is an opportunity to help patients improve their health through simple, safe, and effective means. A patient who loses weight, gains fitness, improves sleep, and reduces alcohol intake will become healthy—independent of the results of their ablation.

Another seemingly anodyne class 1 recommendation is to consider the procedural risks and the major risk factors for AF recurrence following the procedure and discuss them with the patient.

One might argue that a robust informed consent hardly needs space in a guideline document.  I don't know the situation with patient-doctor discussions in Europe, but in the United States, I've seen far too many patients get inadequate information before their procedure. AF ablation comes with significant risks and has modest success rates. Patients ought to be utterly clear on this.

7. Guidelines Lifespan

The guidelines cover 126 pages and have nearly 1500 references. Despite the clear writing, beautiful figures, and comprehensive evidence review, this document will have a very short lifespan.

Consider that on the same day it was presented at the European Society of Cardiology (ESC) Congress 2020, we also learned the results of two potentially practice-changing trials: RATE-AF and EAST-AFNET 4.

This isn't a criticism—just an observation. I wonder whether future guidelines will have to be more like digital platforms that can be updated in real time.

Let me know in the comments what sections I missed.

John Mandrola practices cardiac electrophysiology in Louisville, Kentucky, and is a writer and podcaster for Medscape. He espouses a conservative approach to medical practice. He participates in clinical research and writes often about the state of medical evidence. 

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