2019 Atrial Fibrillation Guidelines Update
Today I will be discussing the 2019 Atrial Fibrillation Guideline Update. For those of you who are not aware, there are major cardiology society groups, such as, the American College of Cardiology and the Heart Rhythm Society, which every few years, release joint statements on guidelines about how to manage atrial fibrillation. They usually incorporate items that have had major changes that can influence the management of patients with atrial fibrillation. In 2019, they released a focused update. It's not a complete overhaul of the previous guidelines from 2014, but it did emphasize some new treatment guidelines.
1. New Blood Thinners are Preferred
The first thing in the new guideline was a change about blood thinners, that the newer category of blood thinners, sometimes called NOACs or DOACs, which includes newer blood thinners like Eliquis, Xarelto, Pradaxa, or Savaysa, are now preferred over Warfarin. Meaning, these are the preferred medications to take for blood thinners over an older generation medication like Warfarin. There are several reasons for this. One of the main reason is that these newer blood thinners have an overall stable blood thinning effect, unlike Warfarin, where the levels fluctuate on a daily basis affecting whether you are in the therapeutic range of Warfarin or not. In addition, in some cases, the bleeding profile is actually better than Warfarin, so that's why it's been recommended to start with newer blood thinner medications like Eliquis or Xarelto over older medications like Warfarin. The authors of the guidelines also hope that, from a cost standpoint, that if they emphasize that these are preferred medications, that insurance companies will also provide better coverage of these medications as well.
2. Changes for the CHADsVASc Stroke Risk Score
Another thing that was emphasized on the guideline updates was a change about the influence of female sex for stroke risk. The most common stroke risk scoring system for atrial fibrillation is called the CHADsVASc risk score. In part of that scoring system, female sex was given an additional point, and so female sex was led to have a higher risk of stroke and was more likely to need blood-thinning medication due to female sex. There has been recent controversy regarding that aspect of the scoring system, how much did a female sex versus a male sex really influence risk of stroke and need for blood thinning medication? In this guideline update, they've actually removed the emphasis of the female sex as a point for the scoring system. So now, for the scoring system, if you have a CHADsVASc risk score of two if you're a male or a score of three if you're a female, then it is typically recommended to use blood-thinning medication.
3. Recommendations for Aspirin Removed
Next, the recommendation of an aspirin for stroke risk reduction has been removed. It's been common that if patients were at lower risk for stroke or they didn't want to take a blood thinner, that their doctor would recommend aspirin. This was based off of clinical trials that are over 20 years old. When studies were compared between aspirin and Warfarin, it was found that aspirin had a very small amount of a benefit for stroke risk reduction, but less of a benefit when compared to warfarin. However, as the years have gone by and more studies have come out, it seems that aspirin really doesn't have any significant benefit for patients in terms of atrial fibrillation for reducing risk of stroke.
Now, it's very beneficial for other types of heart problems, such as coronary artery disease or patients that have stents in their heart. But, when it comes to atrial fibrillation, it’s shown that it's really not giving much of a benefit. In general, now the recommendation is preferably to take a stronger blood thinner, like I just mentioned, like Xarelto or Eliquis. However, if your risk of stroke is low, it is not recommended to take an Aspirin anymore, it's better to just take nothing. But always discuss with your doctor your individual stroke risk and which medication is correct for you.
4. Recommendations for Patients with Coronary Artery Disease and Atrial Fibrillation
In this guideline there were recommendations for patients whom have both coronary artery disease and atrial fibrillation. For patients who have stents put in their heart, frequently these patients can end up on up to three blood thinning medications. They may be on Eliquis, or they may also be on Aspirin and Plavix, and these are all blood thinning medications, which can significantly affect a person's bleeding risk. They did make some clarifications about patients who have gotten stents, who also have atrial fibrillation that it's typically only needed to be on two blood thinners, and three blood thinners are not typically needed. A typical recommendation would be for one anticoagulant, like Eliquis, and one antiplatelet medication, such as Plavix. See my previous article for more information on the complex management of patients with atrial fibrillation and coronary artery disease.
5. Recommendations for Left Atrial Appendage Closure- such as a Watchman Procedure
Next was a recommendation on left atrial appendage closure procedures, what you might commonly know as a Watchman procedure, but there are also a couple of other procedures as well, which emphasize closure of the left atrial appendage. What they did is they gave it a recommendation of a level 2B recommendation. What that basically means is that it's not the preferred treatment option for patients with atrial fibrillation, but it can be used in the proper patient population. But what does that mean? The guideline authors want to emphasize, and I've also emphasized in previous articles, the primary method for reducing risk of stroke is blood-thinning medication. Blood-thinning medication has been studied for many years and there are now many different options for blood thinning medications. These medications are the primary method for reducing risk of stroke. However, procedures like Watchman can be very beneficial for people who legitimately cannot tolerate those types of medications. So in those types of patients who cannot tolerate blood thinners, such as if you've had bleeding problems while on blood thinners, then a Watchman can be a very good alternative option for reducing risk of stroke.
6. Atrial Fibrillation Management in Patients with Congestive Heart Failure or CHF
Another recommendation discussed the specific population of people who also have congestive heart failure, also known as CHF. There have been some recent studies that have come out in the last few years that specifically looked at the role of ablation in patients who have atrial fibrillation, as well as congestive heart failure. It was shown that in these studies that, doing an ablation and significantly improving the AFib burden in people who also have congestive heart failure led to significant improvements. Improving AFib kept them out of the hospital, and helped them potentially live longer as well. So in that certain population who has CHF, or congestive heart failure, there has been more of an emphasis on aggressively treating atrial fibrillation, whether that is with medications or specifically catheter ablations, because it can significantly reduce the rate of recurrent hospitalization. See my previous article for more information on the complex management of patients with both atrial fibrillation and congestive heart failure.
7. Emphasis on Weight Loss for the Management of Atrial Fibrillation
Lastly, diet and weight loss recommendations made it into the guidelines. In 2015, there was an important study called the Legacy Trial, which looked at weight loss and how it can improve a person's atrial fibrillation. It showed in people who lost over 10% of their weight had over six-fold improvement in their AFib burden over a five-year study period. It really put an emphasis to doctors, when they're managing patients that, weight loss should be a very strong recommendation for patients who have atrial fibrillation. Weight management and weight loss for overweight patients is an essential strategy for the long-term management of atrial fibrillation. See my previous article on how weight loss can improve atrial fibrillation.
Hopefully this summary of the 2019 Guideline Update will help you identify new treatment options, but always discuss with your doctor which treatments are correct for you.
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