Chapters Transcript Video AHA/ACC/HRS: Atrial Fibrillation Guideline Update Review Dr. Kiehl and Dr. Patel provide recommendations to guide clinicians in the treatment of patients with atrial fibrillation. This is um gonna be a joint grand rounds uh by both myself and Dr Patel. Um and actually is a topic that was asked for actually. So when we made this schedule at the beginning of the year, this was not something that we had on the, had on the docket. But um, Ashford uh had seen these guidelines can come out and wanted us to kind of spent some time going through them because as everyone knows, a F is an extremely endemic um disease at this point. Um not just in the US, but internationally. And so how we, how we have to deal with kind of a burgeoning amount of a FB patients uh is really important, not just from a medical perspective, but almost kind of from a, you know, care delivery perspective. So, um we're gonna do our very best to go through this in a non boring fashion. I'm not trying to put up slides and say, ok, I'm just gonna read, you know, what's class one, what's class two A and what's class two B but rather kind of focus on the things that are new, the things that I think we get wrong a lot. Um, and, uh, and then, um, gonna hand it over to, to div at the end who's gonna kind of go through, um, what that means going forward. And then also, um, you know, how, how we're gonna have to struggle with, I think care delivery, um, care delivery issues. And I think, you know, at the end of the talk, you try and be optimistic about things. I think you, you might hear me be a little bit more pessimistic about things just because of uh you know, um supply chain issues for lack of a better reason in terms of how we're going to deliver care for these patients. All right. So let's get into the meat of it. Um I don't think it's advancing. Uh Oh, there we go. All right. So, uh disclosure, these are all mine actually. Um uh So I do get um compensation from an uh an ablation perspective uh from uh bio since Webster, I'm on their advisory board. Um uh And so I don't think anything here is specific to biosense Webster, but um I'm also on the Metronic Advisory Board, um which has the Aera catheter coming out was part of that clinical trial. Um I will touch a little bit or I think actually de will touch a little bit on that trial and what that looks like going forward. But um this should be pretty much free from bias. All right. So this is the uh the new Clinical Practice guideline. Um It's a joint statement from the American College of Cardiology, the American Heart Association and the Heart Rhythm Society. Um It was published uh late last year, I think, or maybe it came out early this year, but it um was the first update in the last five years, which you might say, well, five years is not a long time, but actually in a FB, that's a huge amount of time if you think about and all the people from the EP lab that are here, all the different catheters that we used uh five years ago. Um And so in, in a FB, actually, five years is, it feels like forever. Um So I've actually had the pleasure and curse of being on a guideline committee recently. And so, um again, I'm trying not to make this boring, but I, I think it's important to go through this because the people who are involved in the A FB guideline put a ton of work into this. Um I recently served on the um uh new committee. Uh It was Heart Rhythm Society and uh basically the um kind of non us uh heart rhythm societies to basically look at left bundle pacing and Coronary Sinus pacing indications. Um And it was about during COVID A 3 to 4 year labor of Love. Um That, that was super exciting intellectually, but frankly, I'm not sure I ever wanted to be involved in again. And so I have a lot of respect for the people who, who worked on this A FB guideline because, whereas, you know, left Bundle pacing is new and there wasn't a ton of data. Um If you look at this document, it's like 250 or 300 pages long in PDF, in the last like 80 pages are all references. So these people had to spend lots of non compensated time with their friends and families uh writing this document. So uh this, this talk is really um a tribute to them. All right. So when it, when you go through guidelines, the most important thing is to understand how do guidelines work. So, um usually there's kind of three indications, there's a class one indication, which basically means the benefit far outweighs the risk of the, of the procedure or the medication. And so that intervention should always be your standard of care. Class two A is basically the benefit is likely more than the risk. Um And so you should probably choose um treatment A over treatment B um class two B um which is considered a weak recommendation is that you'll see these statements of might or may be reasonable should be considered, you know, might be considered. Um But the, but the usually the level of evidence for those recommendations is a little bit less. Um This is where when you're on a guideline committee, that's where your artistic license is, is to say two B indications. So I'm gonna focus actually a fair amount on some of the two B indications. Doesn't mean that they're the ones that have randomized control trial data. But um they're the ones that over time you'll see, get stronger indications. And I'm actually gonna focus on one of the two B indications, which I think is gonna become a level three indication based on new, new data that came out after the guidelines. Class three actually is broken up into two different ones. So there's basically equipoise or trend towards harm and then there's a strong trend towards harm. And I'm gonna focus just on a couple that are strong trends towards harm, which um frankly, I don't think any of the people are on this uh on this call virtually, but uh are probably more pertinent for the emergency medicine department than anything else uh for this guideline. So, so that's the level of recommendation. But the level of evidence that helps drive the level of recommendation is kind of the quality of the study. So how large are they? Are they randomized randomized control trials? Are the registry studies? Are they well run retrospective or small pros prospective studies? Are they meta meta analysis? So the darker the blue, the stronger the evidence and the lighter the blue, the less the evidence. So level CEO we don't use a whole bunch, but it's basically expert opinions. That's, that's the artistic license of the guideline committee to basically say that, you know, we don't have enough data, but we think this is probably a good idea. Uh level CLD is, is um you know, there's good studies but maybe not anything super randomized or this me analysis of small subjects suggesting that there is a trend. So this again, the light blue is kind of the artistic license of the guideline committee. All right. So before we get into the actual guidelines, uh this isn't surprising to anyone but A FB is becoming more common. It doesn't matter who you are if you get older, um you'll see um over time, each age group A FB is becoming more common. Male, female. If A FB is becoming more common, whether you're white, African American Hispanic A FB is becoming more common and whether you're um you know, struggling to make ends meet or you're Mark Cuban A FB is more common. So, um the, the reason why this is so important is we're gonna have to figure out how to deal with all of these patients. And this is why if I if you look at C MS um expenditures, uh rhythm of management is now the largest growing expenditure in the United States, that's not across cardiology, that's just period. Um And so I think this is probably the most important slide from this entire talk is how do we conceptualize A F? So this is a central illustration from the new guideline document. I think they've done a nice job with it. So we're ST we're trying to not think of things as paroxysmal, persistent, long standing, persistent permanent anymore. We're supposed to think about a FB as a disease continuum. So why do people get a FB genetics, you know, weight lifestyle, um you know, um certain triggers. Um and then you know what happens when patients start to get a FB while their heart remodels, oftentimes the left atrium will get larger. You might get a little bit of left ventricular hyper hypertrophy hypertension that drives that um pulmonary hypertension, tricuspid regurgitation. So you can start to see kind of pre signs of a FB and then you develop a FB and you start off with these little short bursts and then they might last a little bit longer and then they last a little bit longer and then they don't go away and then you need a cardioversion and then it comes back after a cardioversion and then it lasts for months. So a, a person who's paray who has, you know, uh one hour is very different than somebody who is persistent, who has seven days in a row, who's very different than somebody who's still persistent who has four months at a time. Um who can only be taken out with cardioversion. And so how those patients do and how you would manage them, not just pharmacologically or procedurally, but with medications are very different. Um And this idea of permanent A FB, really, we want to be a small pie. So if we can get to these patients earlier, maybe even prevent them before they have a FB. That's really what we're trying to do. Some, some of the things that they want to change the lingo on the guidelines. We don't use the word chronic A fib anymore. Uh Again for the same, you know, topic of, we really wanna talk about where in the disease state you are. Um This is a big thing, I think more for patients um when we talk about blood thinners, but the terms valvular and nonvalvular fib are no longer to be used. So uh where that's pertinent is um you know, in terms of anticoagulation guidelines, um we talk about nonvalvular A FB and that's become extremely um confusing, I think to a lot of people as to what nonvalvular A FB is and what they're basically saying is that, you know, if you don't have, you know, severe mi stenosis and prosthetic mechanical valves, that's, you know, that, you know, valvular A FB, but it's not necessarily that the valve is causing the A FB. It's just those are particular populations where the anticoagulation guidelines may be different. And then lo A FB, this idea that you just have a FB isolated isn't really a thing anymore. It's, it was kind of a term that's fallen out a long time ago. So don't use these terms anymore. All right. So let's start before treatment. Let's talk about initial diagnostics and monitoring. So again, I just kind of clipped out the ones that I thought were were important. I think everyone knows the first one. So basically, if you have a patient that has new, a new A FB diagnosis, you should get lab work to look for uh reversible causes like hyperthyroidism. Um And an echocardiogram is needed because again, we're trying to see where are you in the disease process in terms of remodeling. Um Do you have severe left atrial dilation? Do you have mild left atrial dilation? Is your ejection fraction low? It helps us triage patients as to how quickly uh they need to be uh cared for. Um This I think is a really important one for a lot of patients. So the second one in patients with newly diagnosed A FB protocols, testing for ischemia uh should not be routinely performed. If you look in the community, most, I'm not gonna name names, but there's a lot of cardiologists who say, oh new A FB, I need a stress test or a cath that should not be done. Um It, there isn't a trend towards harm. This is that level three indication where there's no benefit. Um Now, if you are using it to make a decision about whether you wanna start Flein because Flein is contraindicated in patients with coronary disease, that's a different thing. But the idea that every patient who has a FB needs AC because a FB is an ischemic rhythm is, is not true. Um So it is not recommended. Um I think a very interesting thing that's in the new guidelines is what to do about wearable technology. So um and I was preparing another talk for another talk uh uh in, in a couple of weeks last night, it's focused primarily on diagnosis and monitoring. But this is the first time that there's actually data in the guidelines that's now being quoted uh supporting the use of um cardio mobile or live course. So a wearable technology and this is whether we like it or not, this is here to stay. Um And so that's a level two a indication. Actually, it's not A two B, it's not um you know, this was kind of beyond the point of artistic license. Um And there, there, like I said, there's the Apple Watch study for that. There's a nice study from actually one of my former colleagues about the use of cardia. So lifestyle modifications. Um I think again, the first one that is important that we can't just talk about the A FB, we have to talk about the conditions that are comorbid with a FB. So um obesity, you know, um exercise, alcohol consumption, uh smoking, diabetes, hypertension and management in a comprehensive way is important. I think Doctor Patel is gonna talk a little bit about that. Uh later in the talk, we talk about the A FB clinic. Another thing that I see often times is patients will come to come to me, referred from either a PC P or a um, uh general cardiologist. And they'll be saying, well, can I drink coffee again? Um There is no data that, that si significant caffeine usage causes a FB. I think there's, if you're drinking 12 diet Cokes a day, that's one thing. But having a cup of coffee, if that puts you into a FB, you need something done about your A FB. So there's no benefit for that. Um Sleep apnea is a very interesting thing. So again, it's important to comprehensively treat the patient sleep apnea is associated with A FB. But there has been no convincing data that the treatment of sleep apnea dramatically reduces the outcomes of A FB. So there's kind of been this i it's not as prevalent anymore, but I think when I was training in fellowship, there'd be this thing. Oh, this patient has sleep apnea, we're gonna treat their sleep apnea. If their sleep apnea goes away, then we'll, then we'll be fine if it doesn't go, if it doesn't go away after their sleep apnea, um is treated, uh then we'll offer them an ablation. Um There were some randomized, small randomized data and then larger non randomized data that hasn't really panned out there. All right. So, stroke reduction consideration. So when I see patients in the office and, and um they're coming for a FB I always, the first thing I say to them is we treat a FB for three reasons, stroke prevention, heart failure, prevention and symptoms. So this is the stroke prevention category of um of atrial fibrillation uh guidelines. So, um you should be using things like the chads two va score. Another one that's commonly used is the Atria score. Um I think it's important for everyone to know how bad both of those scores are. So the c statistic for the Atria score is 0.71 and the chad two vas score is 0.67. Um I think that chas C vasco is probably well known by most cardiologists, probably a lot of people in the room, most internal medicine doctors as like this um gold standard of, of, you know how we predict patients to have strokes. AC statistics of of 0.67 is actually really poor. Um When I was doing um uh cardiac arrest prognostication, which is kind of uh obviously a little bit controversial in terms of if people are gonna live or die earlier after they card, they have cardiac arrest. I was getting a lot of um push back from reviewers that the scoring system I created had a bad A UC and the A UC was like 0.85. So um so 0.67 for something we're, we're using chronically. Isn't that great but nevertheless, we're using a level of one recommendation because it is what we have. Um but there are other things that can kind of put you at increased risk of bleeding, increased risk of stroke. And so it's some things to think about. Um in table 11, as commented in the guideline are that the longer you have a FB, that may be a risk factor. Patients with persistent or permanent A FB may be at higher risk. Obesity isn't included. Hypertroph are different, poorly controlled hypertension is different than just having hypertension. Uh renal uh disease is certainly a risk factor and then severe left atrial dilation. And I'd also add in um if you've had multiple ablations before and you have developed myopathy related to the ablation that is probably also a risk factor. So just don't think only Chaz to vasco, obviously, that's important for things like watchmen and, and, and you know, um you know, insurance approval for things, but it's not the end all and be all of all things because the data just isn't that good. All right, stroke reduction management. So I think most people know this, but it's important to mention that when we look at Chad's two vs. Um and you're talking about men versus uh women because the, the s the um gender part of Chad's two VASK women is only an additive risk factor if you have two other risk factors. So they, they comment on this in the guidelines that you should get basically anticoagulation if your score is greater than two in men or greater than three in women. And that's what that comes from. So, having hypertension and being female is actually basically a chance to ask, corrected of one. Um Also see a lot of patients still on aspirin monotherapy. There is no data for aspirin monotherapy. It does not reduce the risk of stroke, it's not harm necessarily. But remember in the coronary artery disease world, we used primary prevention aspirin for a long time and that's kind of fallen out of favor in patients who don't have coronary artery disease because of G I bleeding. And so it's possible in the future, you might see a situation where this actually gets a harm recommendation for isolated atrial flutter. This is a really, really um I think interesting thing. So for patients who have typical atrial flutter and have undergone successful CT I ablation, which is typical flutter ablation without a history of a FB, they should receive close follow up and arrhythmia monitoring to text silent A FB. If they are not receiving ongoing anticoagulation, I think I'm gonna call this the Jeff Headley Point. Um He doesn't believe and I kind of agree with him that isolated atrial flutter exists that eventually you're going to find a FB. And so one of the things you could do here is consider an Apple watch or a cardio device or a loop recorder to try and make sure patients aren't having Salin A FB and if they have high chasity vast scores. Um So this is another one, I'm gonna spend a little bit of time on. And I think for the um for the people who see patients and order holter ambulatory monitors at home, that's internal medicine physicians, other EPS and cardiologists, I think just listened very closely to this part. So it's a level two a indication that if patients have device detected A FB, those are high rate events. And this is really talking mostly about pacemakers, but I'm gonna kind of expound upon it to monitors it well. Uh um And you have more than 24 hours of, of continuous A FB and a chance you've asked score of greater than two or three. If you're female, it's reasonable to start blood thinners. If you have uh an high ari weight of between five and 25 minutes and 24 hours, it's reasonable, but only at A two B indication for patients that have it less than five minutes, you should not start oral anticoagulation again, no benefit. So we see a lot of referrals in EP where again, not naming names, but we'll see like 16 beats of pat A FB and they've been started on a blood thinner. There is literally no data to support that. Um And there is actually data that I'm gonna review in a second that that may actually cause harm. So I would say be a little thoughtful about when you start blood thinners. Here's the new data. This was not in the guidelines. And I think the to be recommendation of 5 to 24 5 minutes to 24 hours is going to become a level three harm on the next set of guidelines. So the on the left is the Artesia trial and that was basically looking at the use of um I think it was a, it wasn't a dox band, it was a Pix Aan um for uh patients who had um six minutes to 24 hours of, yeah, it was Eliquis versus aspirin of um uh device detected a FB and they looked at stroke reduction and bleeding ri uh bleeding risk. And if you look at this, so this is cumulative incidence of stroke, there is a stroke benefit of Eliquis over aspirin. But if you look at the major bleeding, there's a major uh bleeding concern with, with uh Eliquis. And if you actually put the composite of both of those together, it was pretty much equivalent. Similarly, there was also the uh no a af net six trial that came out. These are both recent trials. This is January of 2024. This is September of 2023 Ad Doan versus placebo, major bleeding risk of AD Doan was uh far more uh this was statistically significant, far more higher than a placebo. And if you looked at a stroke risk, this did not meet statistical significance, this was a Doan versus placebo. Um and the rates were both exceedingly low. So again, I think this might become in the future guidelines, a level three, no benefit to potentially even harm. So again, if you have a fib that is de device detected, it is not quite the same, all right, stroke reduction management with left atrial appendage occlusion devices. So, um basically, we don't have any level one indications for Watchmen or Amulet or anything like that. But there's a level two in to a indication that if you have a contraindication to uh long term anti coagulation that a percutaneous left atrial appendage occlusion device like Watchmen is reasonable. There's a two B indication. Again, this is artistic license a little bit um that patients with A F and are moderate to high risk of stroke um with patient preference. Um There may be a reasonable benefit to, to pursue um pursue uh you know, something like Watchmen. Um When you're talking about uh surgeries, we have somebody who's going to surgery uh for a bypass or aortic valve surgery. And I think we already do a really good job of this. It uh is very reasonable to, to do uh left atrial appendix exclusion in addition to continued anticoagulation. Interestingly, they do comment that there's no clear data that if you have a successfully occluded appendage that you're safe to come off blood thinners um there's not real good randomized data for this. Now, I think a lot of us in practice will get AC T the CT looks good, particularly with modern left atrial appendage occlusion will take patients off uh anticoagulation. But the data I guess doesn't really support that. And the guidelines did not make a comment on, on um on doing so um periprocedural anticoagulation management. So this is, you know, patients who are undergoing um you know, noncardiac surgery, there's the bridge trial, basically, what I want you to get out of this is we overuse heparin bridging in the hospital just because patients have a history of a FB, that's regardless of whether they're going for a cath or whether they're going for, you know, colon resection. And um and so if you look at the per day risk of stroke off of a blood thinner while you're hospitalized for some, you know, elective procedure or some semi elective procedure, the risk of stroke is low enough that there's no real data to bridging um low molecular weight. He heparin should definitely not be administered. Uh This is a level three harm and in terms of when we get these um these uh pre op forms in the office and they'll say, ok, well, we wanna stop Eliquis for seven days for surgery or we wanna stop, you know, uh Xarelto for three days. This is actually from the guidelines, what the high bleeding risk procedures uh should be. So actually, there's really not anything that's more than four days other than warfarin, obviously to let the inr come down. So if you really feel strongly, you know that you need to be off seven days for Eliquis as a, as a surgeon, you kind of have to look at this and say, well, what is that coming from? There's no data to support that. All right. So now we're gonna move from stroke prevention, lifestyle management into the kind of the meat of the, of the slides. Um And then hopefully we'll get through kind of the boring uh graphs here shortly. But um, so in terms of rate control, um basically, the thing I want you to get out of this slide is in patients with a FB with rapid ventricular response and known moderate or severe LV dysfunction, that's really like 40% with or without compensated heart failure. So it doesn't mean if you're in an acute heart failure, exacerbation or not intravenous uh calcium channel blockers such as Diltz should not be administered. So we should not be using IV Diltz in the, er, in patients with heart failure. Mostly cardiologists know that I think it's the most commonly used drug in the, er, because it's easy. Um, but there is the risk of negative inotropic response in precipitating heart failure. The same is true. Again, if your ef is low with oral uh drugs of that, of that type and that's the rec the recommendation above there is comment about the use of AMIO for rate control in here. That's a two B indication. But there's an asterisk here that says, consider the risk of cardioversion and stroke when using amiodarone as a rate controlling agent. But sometimes it's all we've got. And then in terms of what is the goal for rate control? It's 100 to 100 and 10 beats per minute. Um In the absence of, you know, decompensated heart failure that might be better served by a lower heart rate. There's not really a lot new in the guidelines about anti arrhythmic drugs like dofetilide or um or Sotolol or amiodarone. So I didn't really put much in here. All right, this is, this is what you've all been waiting for. OK. So what about ablation? So, in patients with symptomatic, a FB, in whom anti arrhythmic drugs have been ineffective, contraindicated, not tolerated or this is the most important thing, not preferred and continued rhythm control is desired, desired, catheter ablation is useful to improve symptoms. What that is saying is you do not need to fail anti arrhythmic drugs to get an ablation. If a patient comes to your office and says I want an ablation first line. It is a level one or a um uh level one level of evidence, a recommendation that's as strong of a recommendation as can be given and the data is really strong for that. So it it further goes into persistent versus paroxysmal. So, um, in selected patients, it says generally younger with few comorbidities with symptomatic paroxysmal afi in whom rhythm control is desired. Catheter ablation is useful as a first line therapy. So that means you come into the, er, and we'll go through two studies that this is drived on, you go into the, er, with a FB um, symptomatic, you can ablate right away. You do not need to do anything. You don't have to fail molte, you don't have to put on rate controlling drugs. It's not saying that you have to do that, but it is reasonable. Um In patients with symptomatic, clinically significant atrial flutter catheter ablation is useful for improving symptoms. This I think we've known for a long time. I think we do a better job of this uh typical atrial flutter in particular has a really high recurrence rate and healthcare utilization re related to atrial flutter is really high. And so um ablating these patients is actually quite paramount if you ask me. Um another really important uh I think feature here of the these guidelines um is uh the persistent A FB, this is kind of the same as the second one. So it's basically the same persistent is a two a recommendation, whereas Parex ISOL is a level one and then the last one. So in selected patients with asymptomatic or mini minimally symptomatic, a FB catheter ablation may be useful for reducing progression of a FB and its associated complications. I bet you that people debated this one for about 10 dates. I think what they're trying to say here is in patients who come in, they say, you know, I don't feel so bad in a FB, but their left atrium is large and they have moderate mi regurgitation and their pulmonary pressures are high and they've got tri tricuspid regurgitation and say, ok, well, long term, you might be better off just from a remodeling perspective so that you don't get heart failure. If we ablate you, I will tell you in my experience, I would say more than level two B for that. I think there are patients that do better in normal rhythm, but it's just hard to randomize these patients. And so it's hard to kind of get an answer for these patients. So I think that's why it's level two B. I bet there were people who didn't want to put it in the guidelines and I bet there are people that wanted it to be two A. All right. So, um what about what about heart failure? So this is, I think one where we, we're doing a better job of but in, in patients who present with new diagnosis of HEF R uh and a FB arrhythmia induced cardiomyopathy should be suspected in an early aggressive approach to a F rhythm control is recommended. I wanna be clear about what that says. That's not talking necessarily about ablation, that's also talking about cardioversion. So if you have a patient that comes in to the hospital and they have a FB and, and their EF is newly down, it's probably be better not to put them on anticoagulation for 30 days and bring them back for a cardio version. You should probably do att E cardio version before they leave. Um Just because the earlier they get rhythm control, the better they can start to remodel. If you think it's arrhythmia mediated um in terms of ablation itself, that's right below there. And appropriate patients with a F and hef ref who have goal directed medical therapy and reasonable expectation of procedural benefit, catheter ablation is beneficial. What is a reasonable expectation of procedural benefit? I think you could ask 10 eps and get different answers. So I think that's the reason it was worded that way. I will tell you we've had a patient and I know we talked about this in shock where a patient came in basically on uh by a support uh with um with atrial fibrillation. Uh that was basically refractory to cardioversion, amiodarone. Um And um I took the patient for an a frill their ef I think it was like 10 at the time. Um It's now 60 off goal directed medical therapy. He was weaned off emo like the day after um he's doing wonderful as an outpatient follows with John Hurry. Um That's an extreme dramatic example, not all patients do that well, but I think sometimes who we think is too sick for ablation is probably requires a little bit of reconsideration. Um This here, I think is an important point to the last point in patients with a F induced cardiomyopathy who have recovered LV function. Long term surveillance can be beneficial to detect recurrent A FB. In view of the high recurrence of arrhythmia induced cardiomyopathy. What that means is if you ablate somebody, their ef normalizes if they get a FB, again, because a FB ablation is not perfect, they have a high likelihood of developing heart failure again. So you better have a robust strategy that may be somewhere where again, you use cardio or Apple watch or Lup recorder and then uh uh you know, a big thing is what do you do about their goal directed medical therapy? And we talk about the, about this with the heart failure, physicians all the time. Do, do you wean them off goal directed medical therapy? Do you leave them on goal directed medical therapy? I think you get 10 different answers. And I think the answer is you gotta work as a team. All right. Um I'm gonna let div talk about this a little bit later, but basically, this is a cool tool that the AC C has now where you can basically put in a bunch of things and, and they'll basically give you a recommendation as to whether a patient might benefit from an a fibrillation as a, as a first line therapy. I'm sure that'll be something that they'll use in the A FB clinic. Ok. So where do those, uh we went through the guidelines of how to ablate, where does this come from? So, um there were two trials that came out, um I guess it's been a while now, but almost five years, it felt like it was just yesterday that basically randomized patients who had early A FB. Um So one was, you had to have one or more episodes of symptomatic A FB. There was another one where we had to have two episodes of symptomatic A FB generally where paroxysmal um hadn't been on anti arrhythmic drugs before left, atrial sizes were normal. Um And they, they randomized to ablation or standard basically monitoring and um you know, anticoagulation rate control, et cetera, et cetera. The outcomes are basically a FB recurrence quality of life need for a redo ablation. Um And these were the, these were the uh KM curves. They were both New England Journal uh papers in the same uh article actually. And what you saw is um at one year with modern technology, there was a 75% freedom from a FB period. And if you look at the composite outcomes, so treatment success, there's a 30% improvement uh with ablation in the stop A F first trial in the early A F trial, the reason the numbers look smaller is all those patients had loop recorders. So you just see more if you look more. Uh But the Delta is pretty similar and they had a 90% freedom from symptomatic A FBI one year. Um just as an aside. So this is gonna be a at Hard Rhythm Society this year. This is gonna be one of like the new Hyde Park talks where it's just gonna be a 30 minute debate of when to ablate first. Um And so this is Jason Andretti who's from Canada, who's, who wrote the early fa F trial. So I, I got the pleasure of the con argument. So I get to debate Jason Andretti about not to a, a blade a FB early. Um So that, that's gonna be fun for me. Um So, ablation and heart failure, where does that come from? There's a myriad of different trials. I didn't even put in the cabana heart failure trial up there. But um basically, this is the camera MRI trial, the Castle A F trial that showed a mortality and ef benefits to a FB ablation. We've all experienced this. But basically, the A FB population is even more important than all the other populations. We've shown um I've used these slides before in other talks. So if they, if you've seen them before, I apologize, but just, I think it's important to answer that. Is there an age cut off, cut off for ablation the answer is no, this isn't commented on, particularly in the guidelines, but I think it's worth going through the data. Most clinical trials exclude patients who are 8080 years and older and that's why they're not gonna be in guidelines very often. There's actually a lot of good data in octogenarians. And my experience is essentially matches what you see in the published data. And that's basically complications are a little bit higher. If you're over the age of 80 the procedures tend to last longer. You tend to have to ablate more non pulmonary vein triggers. The success rates tend to be a little bit lower, but they're still pretty good. Uh And so I don't think we should not necessarily offer an ablation to a healthy 80 year old. I think if you're using, you know, um if you're bed bound, if you have some other sort of um significant comorbidity and you're not gonna really affect again, heart failure or quality of life, then, then maybe reconsider, but age isn't, it, isn't everything, can they be be too obese? Well, there's data that if you have bariatric surgery and you basically normalize your weight, your outcomes are similar to if you were never obese. But if you don't treat the comorbid factors, uh that you will see degradation and outcomes over time. Now, this is a little bit older data and I think with newer technology, we're, we're getting a little bit better. Um I also don't know where Ozempic is gonna fit in this. I think there's some early data using drugs like Ozempic may actually, um you know, get us closer to the bariatric surgery curve, which is the blue curve on the graph. But I think again, that's why the guidelines, they focus more, more on, you know, prevention and then treatment of com comorbid conditions. But we shouldn't necessarily not abate uh morbidly obese patients. And as the EP lab knows, uh we still do um this is more for the eps in the room. But when you see notes that we write in the um you know, after being in the lab and you'll see what, what, what the heck does P VIP Wymv line, you know, like what, what the heck are they talking about? If you look at the data on what to do, the only thing that we really have, you know, the highest level of evidence and recommendation level for is um is for pulmonary vein isolation. So, um that's what hasse initially showed in bordeaux was the, was the trigger for atrial fibrillation, things like posterior wall. Um lobbies and cafes and rotors is uncertain that's the level to be indication. Um But a lot of us still do it uh because we know that there are areas other than the pulmonary veins that, that contribute in uh persistent atrial fibrillation. It's just, unfortunately, we don't really know what they are on all patients and So it's kind of a, you know, imperfect solution. Um I think some other important things are that in the new guidelines, basically, we're not holding blood thinners for ablation. Um After you've had an ablation recommended to be on three months of uninterrupted blood thinner. This actually was news for me. I didn't know this. When I was looking through this, I sometimes will stop it after a month if somebody has an urgent procedure. And I think it's probably still fine to do, but three months is, is, is better. And then patients who have a FBS, there's a blanking period, right? So patients will have inflammation. So sometimes using um an rhythmic drugs or something to suppress uh for a while, uh may use useful just to kind of prevent heart failure and recurrent hospitalization. Um This is just the data in terms of, we say that to be indication of where else to a blade. Um this was um the right race A F trial. It came out two years ago that basically showed that if you do voltage guided mapping in your blade, different areas uh other than the pulmonary veins, you can have uh better outcomes. And so I think, you know, Phil and div and I, I think attest to that and a lot of the other eps um use that. So um I'm gonna turn it over now to doctor Patel and he's gonna kind of go through the less boring stuff Yeah, I just wanna comment but I do, I would ask caution in terms of saying it is class three for antic coagulation for device found uh a bit between six minutes and priority. If you look at the, you know, the author's uh discussion regarding that New England journal, they actually felt the other way. Uh Well, it's to be, it's to be in the guidelines. It's not right, but I wouldn't call it. I, I don't think that the, that it's gonna be clear that it's class three. And I think particularly when we get more data, you know, looking, using uh you know, apple watches and other things like that to guide into coagulation. I think, you know, putting it into the full spectrum of risk is quite different from someone who's, who's very low risk, you know, a 01 versus somebody who's, who's a, you know, a five or a six. but also down the road too, we're potentially gonna have newer agents than R as well. So I think stroke risk reduction needs to still be considered, but I think it's how you do it. I think, I think my point is that it should not be reflexive. And I think the other thing, if you look at the comorbidities associated with patients who have devices, they are higher and so their stroke risk is higher, their bleeding risk may also be higher because they're, they tend to be older. They tend to you know, have heart failure and other things. And so the Apple watch data that's gonna come out with, with whether you use a blood thinner or not is gonna be highly instructive. I agree. Um So I'm gonna turn over to div who's got the more fun part of the talk. Um He's gonna talk about how do we deal with this? Oh Yeah. All right. So, uh the second part of the talk is basically how do we implement all of this to sort of innovate in the space of a FB care? So the first part is we have expanding indications for a FB ablation. So as doctor Kiel talked about, we're seeing more and more patients who are candidates for ablation. The second bullet point is important because eps are the least um graduating fellowship, fellowship spots aren't being filled and that has to do with reimbursement longer training. And there, the HR S and AC C are working on shorter pathways from internal medicine to cardiology, shortening cardiology from 3 to 2 years to allow for that, but we still don't have enough EPS to take care of the population. Um And then the third part is patients are being referred for ablation too late in the disease process. Um Eric knows uh serving on the peninsula, we see a lot of patients who have been cardioverted 67, maybe, sometimes even eight times uh before they're referred for ablation. And so these are some of the challenges as we think about innovation in this space. So these are some of the consequences of the status quo. So these are three large papers from huge databases. The left papers from Doctor Puccini at Duke, which shows that the mean diagnosis deviation time was five years. And is if you can see as the time from diagnosis, the ablation gets longer, hospitalization increases by 8%. Recurrence of A FB goes up by 20% and the effectiveness of catheter ablation goes down. So as you're moving from an paroxysmal to persistent to long standing persistent atrial fibrillation, we see remodeling of the atrium where just A PB I won't be enough for their A FB. And so it becomes more challenging to treat their atrial fibrillation with ablation. A second uh study from Ontario Canada showed that the mean referral uh to ablation was 218 days and they had a large proportion of patients about a quarter of patients being rehospitalized or going to the er with delays in ablation. And the last paper from Inner Mountain also shows that mortality increases if the longer you delay to ablation. So these are consequences of doing the same thing over and over again. Uh So the these are four different ways of how we need help and how to get these patients ablated sooner. So the first is uh Doctor Gramas and Doctor Kiel are working on an er to EP and PC P to ep referral pathways. And the reason behind that is sometimes patients have a hard time getting into clinics. So our wait times in cardiology and electrophysiology are longer uh by the day, sometimes it takes 2 to 3 months just to see a cardiologist in the office. And so if we could bypass that, um w where we can bypass general cardiology and just go to EP for a FB management. Um I think the patients would get sooner care. The second is a FB access clinics. So as care in cardiology is becoming more specialized, there are structural heart centers. Uh A lot of centers have adopted a FB clinics. And the reason for that is we as electrophysiologist, deal with not just a FIB as management, but we see VT we see devices, we see extractions, um We see SVTS and we see non a management of arrhythmias and a lot of patients are complex. If you have a lone diagnosis of a fib, this might be better served by an A PC clinic uh that can do more of the teaching of anticoagulation. They can do a plan if you get a FIB and you're at home. What do I do? Do I take an extra metoprolol? Do I call the A FB access clinic the next day where they can set up a cardio version if I send in a cardia recording. So these are some of the things um to think about to prevent rehospitalization, prevent er care. The, the third point is administrative support for efficient technology and investment. Lab personnel as the ablations get shorter and shorter. Uh Phil probably remembers when ablations were 7 to 8 hours long. Um these days ablations um are anywhere from an hour and a half to two hours. Um And so as they become faster and we'll talk about new technology in P fa, it's becoming more important to invest in um faster turnover times more lab space. Um and things like that um to really get more patients treated earlier and then prioritization of early rhythm control. So, cardioversion and ablation, and this again, talks about the team approach of needing anesthesia, needing all of the resources um to be successful in the space of treating patients with a FB. So these are some of the papers um and things that people have proposed. Um the top part is from Locka Reddy's group which shows an er to ep pathway reduces the time from ablation in the control group. 100 80 days to 52 days length of stay was driven down. Er visits for heart related issues were significantly lower and that kind of pathway really promotes getting um care earlier. And you can see on the bottom um Eric put my picture up but this, this was a thing um at HR S last year where I talked about getting patients ablated before they left the hospital. If they had a new diagnosis of tachy induced cardiomyopathy. Right now, we don't have the resources to support that. Just because the patients, we have, we have long wait times to get people into the lab. But you would think in the future that patients come in with a new diagnosis of tech induced cardiomyopathy and atrial fibrillation, they get optimized, they get a right heart cath, they're euvolemic right before they leave the door, you could say, instead of doing a cardioversion, you could actually do an ablation if they look, OK, and then discharge them eric and I both have done sick, cardiogenic shock patients because they failed cardioversion. You could think of that in patients who might not be that sick. And if the wait times were shorter, you could ablate them as they leave the door. And this was a nice uh talk by Mandla and other people. A after the Castle HTX trial showing is a FB ablation, the fifth pillar in heart failure care. So in addition, the GDMT, we're talking about ablating patients with atrial fibrillation earlier. So, non surgical site ablation, um this slide basically shows um the growth you could see on the right between care plaque. Doctor Kiel set that up with uh Doctor Haran. Uh and then I sort of came on last year and you could see this the pretty much exponential growth in the ablation volumes uh being done at a non main hospital. And so I think the future is that we'll see more and more ablations and they're doing the same thing at Beach Beach has grown its volume as well where you'll see ablations go from the main hospital to the community hospitals and you'll see the main hospital save for more complex cases or sicker patients and things like that. Um And the next frontier is gonna be A S CS uh where the patient experience is uh better than a cer a hospital on site. These are some of the newer technologies we have that can help us do ablations faster. So this is a Q dot Catheter. It's been FDA approved. Um Multiple sites are using it and it's a high power short duration type of catheter. It allows three second lesions at 90 watts. So currently we burn at 40 to 50 watts. It's a 90 watt catheter. And you could see that the effectiveness of this catheter was the same as our conventional catheter, but it allowed the speed to go down by uh 20%. This is the newest technology and we're gonna see it in the next year if we're participating in a lot of trials, but it's called pulse field ablation. So right now we use heat energy or freeze energy. So cryoablation or radio frequency, pulse field ablation basically provides a little bit of energy. Uh and it relate, it causes electroporation. So the cell dies on itself and the advantage of pulse field uh ablation is it's tissue selective. So one of the most feared complications of a FB ablation is an atrios sohal fistula, uh which happens in less than one in 10,000 cases, but is a feared complication. And if you have something that's tissue selective, you could think of it that it, it'll just affect the heart tissue and not affect the esophagus. Same thing with the Fren nerve. Uh it's rare but we see Frenn nerve injury, time to time because of just the heat energy or freeze energy, damaging peripheral structures. And this, if it's tissue selective is able to get rid of that uh feared complication. So here's the trial, this is done by Boston scientific in the fair pulse trial. So it's been approved in Europe for at least the last two years and they've um shown great data behind this. Uh We are doing Phil Vencat and Ian are the operators on the advantage A F trial um in persistent A F. But you can see here that pulse field ablation is just as effective as thermal ablation. I think some of us as eps thought pulse field would be more effective. Uh then thermal evolution. We're not seeing that. But what we're seeing is similar efficacy. It's a faster procedure. It's a 20 minute L A dwell time procedure. So when you go Tral, it's 20 minutes and there is no evidence of frantic or esophageal injury and less evidence of PV stenosis. So I think the procedures are gonna get faster with pulse field. And you can see that this is uh the AERO trial. So this is a dual energy uh radio frequency in pulse field. It actually started when Eric called me when I was a fellow at Cleveland and said, hey, we're doing pulse field trials. Do you have any cool technology? And I was like, oh there's this cool catheter called the era. Um and they've enjoyed it. The data comes out um in at HR S. Um it's gonna be a late breaking breaking clinical trials and Santero was fortunate to be one of the largest us sites. Um And then we have Boston Scientific Abbot trials and rolling for both pulse technologies. So we've become a hub for a FB care um and innovation in that field. And so here's our EP team, here's uh all nine of us that do a F populations around and you could refer to any of us. Published February 1, 2024 Created by Related Presenters Erich Kiehl, M.D. Sentara Cardiology Specialists View Full Profile Divyang Patel, M.D. Sentara Cardiology Specialists View Full Profile
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