AF Symposium 2015

Dr. Hugh Calkins

AHA/ACC/HRS Treatment Guideline Changes: The Term “Lone” A-Fib is No Longer Useful

By Steve S. Ryan, PhD

Dr. Hugh Calkins from Johns Hopkins University in Baltimore, MD, discussed the new AHA/ACC/HRS A-Fib Treatment Guidelines and how they now differ somewhat from the European (ESC) Guidelines.

European and American Differences in Guidelines

In particular, the ESC CHA2DS2-VASc stipulates that anyone with a score of 1 (except females) should be on anticoagulants. Even though all females with A-Fib get an automatic score of 1, Dr. Calkins states that if the only risk factor is female gender, anticoagulants aren’t required. (According to these European guidelines, almost everyone with A-Fib should be on anticoagulants.)

The AHA/ACC/HRS guidelines, however, give doctors and patients more discretion. Someone with a score of 1 has the option of either no antithrombotic therapy or anticoagulant therapy or aspirin.

Dr. Calkins acknowledged that this was an ongoing topic of discussion—“did the guidelines get it right?”

(AHA stands for the American Heart Association, ACC the American College of Cardiology, HRS the Heart Rhythm Society.)

“Permanent” A-Fib Not Necessarily Permanent and Uncurable

The meaning of “Permanent” A-Fib as a management strategy doesn’t imply that permanent A-Fib is untreatable or that ablation can not be performed.

The Term “Lone” A-Fib is No Longer Useful

This is a major change in the guidelines (and not one this author understands), though it is more theoretical and won’t have much effect on patient treatment. What they are basically saying is that all A-Fib is caused by something, even though today we may not be able to identify what that something is.

Approximately ½ of all cases of A-Fib have no currently obvious causes, triggers or co-morbidities like hypertension, obesity, smoking, diabetes, sleep apnea, binge drinking, etc. (For example, I developed A-Fib at age 54 and was in perfect health at the time. [I was cured by a catheter ablation and have been A-Fib free for 16 years.])

European (ESC) Guidelines Prefer NOACs to Warfarin

In the ESC guidelines the new NOACs (Novel Oral Anticoagulants) are the preferred mode of anticoagulation. Whereas in the AHA/ACC/HRS guidelines, NOACs are listed as alternatives to warfarin.

More Support for Rhythm Control and Ablation

Catheter ablation is generally considered a class 1 recommendation, but for someone who wants to move directly to catheter ablation as a first-line or first choice option, it is a reasonable recommendation (class 2A).

The new guidelines give greater support to rhythm control strategies but don’t give any formal recommendation. There was a lot of discussion about what happens to someone when you leave them in A-Fib (do not cardiovert [or ablate] them). This can result in permanent remodeling and can prevent them from having a successful rhythm control strategy later on. Dr. Calkins gave the example of a 55-year-old who develops A-Fib for the first time. If you leave him in A-Fib for three years, his atrium will have remodeled. You may not be able to get him back into sinus rhythm.

Editor’s Comments:

Aspirin no longer recommended as first-line therapy: Though not a new finding, it should be noted that aspirin has been downgraded from class 1 in the 2006 guidelines to class 2B in the 2014 guidelines. In a Danish registry study, aspirin didn’t show any benefit for stroke prevention.¹ As mentioned above, in the European ESC guidelines, aspirin is not recommended as first-line therapy for patients with a CHA2DS2-VASc score of 1.² 

Gender-bias in Guidelines: Should every woman with A-Fib be given a point on the Guidelines risk scale? There has to be a difference between a 45-year-old woman with A-Fib in otherwise perfect health and a 45-year-old man with hypertension and A-Fib.

Women in their child-bearing years are much less at risk of an A-Fib stroke than men. Their menstrual cycle naturally thins their blood. Women do wind up having more strokes than men, but that’s because they live longer. Stroke is age-related. (See Women in A-Fib Not at Greater Risk of Stroke and Israeli Study: Being Female Not a Risk Factor for Stroke)

From my observations it seems that most EPs are embarrassed by the new CHA2DS2-VASc guidelines which they have to follow no matter what they think of them. Otherwise they’d certainly lose any malpractice suit.

What Happens to Someone on Anticoagulants for Years?: Leaving someone on anticoagulants for ten or twenty years is a horrendous fate that no one wants to think about. All anticoagulants cause bleeding and are inherently dangerous. The guidelines don’t address these concerns. We’ve heard of cases where someone on warfarin for ten years developed micro bleeds in the brain and dementia. Will this happen with the NOACs?

Unlike what you hear in today’s advertising, anticoagulants are not like taking vitamins. No one should be on anticoagulants unless there is a real risk of an A-Fib stroke—not something fabricated by drug companies and doctors with heavy-duty conflicts of interest.

Concern About Leaving Patients in A-Fib: Some Cardiologists still think that just controlling an A-Fib patient’s heart rate by rate control drugs and leaving them in A-Fib is the way to go. But that is so wrong! As Dr. Calkins pointed out, leaving someone in A-Fib for years risks remodeling their heart, producing more and more fibrosis which is irreversible, stretching and expanding the atrium to the point where its function is compromised, etc. If you leave someone in A-Fib, you may never be able to get them back into sinus rhythm.   

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Last updated: Thursday, August 13, 2015