Comparison of Radiofrequency Catheter Ablation Between Asymptomatic and Symptomatic Persistent Atrial Fibrillation: A Propensity Score Matched Analysis

2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation" provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation.

METHODS

A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate.

STRUCTURE

Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" and the "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed.

2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Patients With Atrial Fibrillation" provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation.

METHODS

A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate.

STRUCTURE

Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" and the "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed.

[Asymptomatic atrial fibrillation : Screening and therapy]

Atrial fibrillation (AF) is the most common cardiac arrhythmia affecting millions of people worldwide and poses a significant burden to the health care system. AF screening of the general population or of a specific higher-risk population could not only lead to earlier detection of AF but also to a prompt initiation of an adequate therapy to prevent complications such as stroke or death and consecutively to a potential reduction of health care costs, especially in asymptomatic AF patients. To conduct screening programs, accessible new technology devices such as "wearables", smartwatches, and implantable event recorders provide an innovative solution. However, as data regarding screening are inconclusive, routine AF screening of the population is currently not recommended by the European Society of Cardiology. Recently published studies have indicated that anticoagulation and early rhythm control of asymptomatic AF could avoid occurrence of clinical endpoints. This article reports on the scientific results of the current literature as well as gaps of evidence and discusses possible treatment options of asymptomatic AF.

Katheterablation bei asymptomatischem Vorhofflimmern – Wer profitiert?

Die Katheterablation von paroxysmalem oder persistierendem Vorhofflimmern hat sich in den letzten Jahren als überlegene Therapiebehandlung zur Rhythmusstabilisierung gegenüber Antiarrhythmika etabliert. Allerdings wird diese Behandlung nach den aktuellen Leitlinien nur bei symptomatischen Patienten empfohlen. Ein großer Teil der Vorhofflimmerpatienten bleibt jedoch asymptomatisch. Ältere Studien konnten keinen Vorteil bezüglich der Letalitäts- oder Apoplexreduktion durch Rhythmusstabilisierung nachweisen. Eine aktuelle randomisierte Studie zeigt erstmalig eine Reduktion der kardiovaskulären Ereignisse, aber nicht der Gesamtletalität. Ist nach aktueller Datenlage eine Katheterablation im Falle von asymptomatischen Patienten berechtigt und wer könnte davon profitieren?

A novel and simple scoring system for assessing the indication for catheter ablation in patients with atrial fibrillation: The HEAL-AF Score

INTRODUCTION

A scoring system to determine indications for catheter ablation (CA) in atrial fibrillation (AF) is desired.

METHODS AND RESULTS

Among 2898 consecutive patients with AF, CA was performed in 938 (32.4%). A new HEAL-AF score has been developed by six variables, all of which were independently associated with CA by multivariate analysis and for each 1 point was assigned: heart failure ≥ NYHA II, elderly patients (age ≥75 years), asymptomatic AF, long-standing persistent AF, atrial dilation (left atrial diameter ≥ 50 mm), and female sex. Low HEAL-AF score was associated with high incidence of CA performance (52.0% for 0, 36.5% for 1, 15.1% for 2, and 5.6% for ≥ 3) and the predictive capability of this score by AUC of ROC curve was 0.720 (95% CI 0.701-0.739, P < .001). The rates of freedom from AF/AT recurrence were 73.2% in HEAL-AF score 0, 71.0% in 1, 60.0% in 2, and 50.0% in ≥ 3 (log-rank test, P = .004). HEAL-AF score 2 and ≥ 3 were significantly associated with recurrence of atrial tachyarrhythmia as compared with HEAL-AF 0 (HR 1.755, P = .002, and HR 2.211, P = .007, respectively).

CONCLUSIONS

A new HEAL-AF score was associated with patient indication for and the recurrence of atrial tachyarrhythmia after CA in patients with AF. Prescription of CA should be considered carefully in AF patients with HEAL-AF score of 2 and ≥ 3.

Catheter ablation for atrial fibrillation: current indications and evolving technologies

Catheter ablation for atrial fibrillation (AF) has emerged as an important rhythm-control strategy and is by far the most common cardiac ablation procedure performed worldwide. Current guidelines recommend the procedure in symptomatic patients with paroxysmal or persistent AF who are refractory or intolerant to antiarrhythmic drugs. The procedure might also be considered as a first-line approach in selected asymptomatic patients. Data from large registries indicate that AF ablation might reduce mortality and the risk of heart failure and stroke, but evidence from randomized controlled trials is mixed. Pulmonary vein isolation using point-by-point radiofrequency or with the cryoballoon remains the cornerstone technique in AF ablation. Additional atrial ablation can be performed in patients with persistent AF, but its benefits are largely unproven. Technological advances in the past decade have focused on achieving durable vein isolation, reducing procedure duration and improving safety. Numerous exciting new technologies are in various stages of development. In this Review, we discuss the relevant data to support the recommended and evolving indications for catheter ablation of AF, describe the different ablation techniques, and highlight the latest advances in technology that aim to improve its safety and efficacy. We also discuss lifestyle modification strategies to improve ablation outcomes.

Atrial fibrillation catheter ablation: an updated review of current guidelines and expert consensus documents

Although atrial fibrillation (AF) is the most common cardiac arrhythmia, its management remains complex and depends on several variables. Over the past decade, catheter ablation has been widely used as an effective method for rhythm control in AF patients. Therefore, AF ablation has been the focus of many studies in recent years. Given the complexity of AF management and catheter ablation, several guidelines have been developed to regulate and direct management of AF patients. The European Society of Cardiology (ESC), together with the European Heart Rhythm Association (EHRA) and the European Association of Cardiothoracic Surgeons (EACTS), has been regulating the European guidelines, while the American Heart Association (AHA), along with the American College of Cardiology (ACC) and the Heart Rhythm Society (HRS), is publishing the US guidelines. Additionally, HRS, EHRA, and the Society of Thoracic Surgeons, along with representatives from heart rhythm societies from different parts of the world, have developed an "expert consensus statement on catheter and surgical ablation of AF." This article reviews and compares the most recent guidelines and consensus document on AF catheter ablation.

Comparison of continuous 24-h and 14-day monitoring for detection of otherwise unknown atrial fibrillation: a registry to identify Japanese concealed atrial fibrillation (REAL-AF)-based study

Early detection of atrial fibrillation (AF) is desirable for preventing strokes. Not only does AF often go undetected in patients being followed up for various disease conditions, but the optimal detection method also remains to be elucidated. In a prospective observational study of 24-h Holter monitoring versus 14-day external loop recording performed for detection of previously undiagnosed AF in 868 Japanese outpatients (aged 75 ± 6 years), with a CHA2DS2-vasc score ≥ 1, but no prior AF episodes, AF was detected during the initial monitoring period in 16 (1.8%) patients, in 7 (1.1% [7/645]) by 24-h monitoring and 9 (4.0% [9/223]) by 14-day monitoring (P = 0.005), and overall in 32 (3.7%) during the 1-year study period. Absence of a beta-blocker therapy and the serum N-terminal pro-brain natriuretic peptide level were independent predictors of a new detection of AF. Oral anticoagulation (OAC) therapy was given to 22 (69%) of the 32 patients in whom AF was detected, and no difference in the incidence of subsequent major adverse events was found between the patients managed with and without oral OAC therapy. Previously unknown AF was documented at a prevalence of 3.7% per year among Japanese with a notable CHA₂DS₂-VASc score, and 14-day external loop monitoring was significantly more effective for detection of the disorder. A large-scale prospective AF screening study conducted to clarify the type or types of patients who would benefit from "early" OAC therapy for primary stroke prevention is warranted.

Management of asymptomatic arrhythmias: a European Heart Rhythm Association (EHRA) consensus document, endorsed by the Heart Failure Association (HFA), Heart Rhythm Society (HRS), Asia Pacific Heart Rhythm Society (APHRS), Cardiac Arrhythmia Society of Southern Africa (CASSA), and Latin America Heart Rhythm Society (LAHRS)

Asymptomatic arrhythmias are frequently encountered in clinical practice. Although studies specifically dedicated to these asymptomatic arrhythmias are lacking, many arrhythmias still require proper diagnostic and prognostic evaluation and treatment to avoid severe consequences, such as stroke or systemic emboli, heart failure, or sudden cardiac death. The present document reviews the evidence, where available, and attempts to reach a consensus, where evidence is insufficient or conflicting.

Should We Perform Catheter Ablation for Asymptomatic Atrial Fibrillation?

Since the original description of atrial fibrillation ablation, numerous studies have demonstrated the superiority of catheter ablation over pharmacological therapy for maintenance of sinus rhythm in patients with both paroxysmal and persistent atrial fibrillation. However, to date, no randomized studies have been powered to demonstrate a mortality or stroke reduction benefit of rhythm control with catheter ablation over a rate control strategy. The results of such ongoing studies are not expected until 2018 or 2019. Thus, the only indication for atrial fibrillation ablation in recent guidelines has been the presence of symptoms. However, up to 40% of an atrial fibrillation population may be asymptomatic. In 2017, in the absence of randomized studies, are there nevertheless data that support atrial fibrillation ablation in asymptomatic patients?