Atrial Fibrillation Guideline Update: Part I

Atrial fibrillation is the most common clinical arrhythmia. The newest guidelines have significant changes in diagnosis, assessment, and treatment. Join host, Geoff Wall, as he evaluates the first half of the guidelines in this two-part episode.

The GameChanger
Different stratifying types of atrial fibrillation no longer exist. Additionally, left atrial occlusive devices are now recommended as first-line therapy for the prevention of stroke, though anticoagulants are the treatment of choice.
 
Host
Geoff Wall, PharmD, BCPS, FCCP, BCGP
Professor of Pharmacy Practice, Drake University
Internal Medicine/Critical Care, UnityPoint Health
 
Reference
Joglar JA, Chung MK, Armbruster AL, et al. 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. J Am Coll Cardiol. 2023 Nov 23:S0735-1097(23)06465-3. doi: 10.1016/j.jacc.2023.08.017. Epub ahead of print. PMID: 38043043.

https://www.jacc.org/doi/10.1016/j.jacc.2023.08.017

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CPE Information
 
Learning Objectives
Upon successful completion of this knowledge-based activity, participants should be able to:
1. Describe new definitions of atrial fibrillation and risk factors for stroke
2. Discuss mechanical prevention of stroke in high risk patients

0.05 CEU/0.5 Hr
UAN: 0107-0000-23-401-H01-P
Initial release date: 12/25/2023
Expiration date: 12/25/2024
Additional CPE details can be found here.

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Transcript

Speaker 1: 0:08

Welcome to the Game Changers podcast, where we have clinical conversations that impact your pharmacy practice. Let's listen in as our team discusses this week's clinical practice game changer. Hello and welcome again to.

Speaker 2: 0:18

Game Changers Clinical Conversations. I'm your host, jeff Wall, professor of pharmacy practice at Drake University. Today we have the first of a two part podcast series that we're going to talk about the brand new American Closer Cardiology. American Heart Association guidelines on atrial fibrillation, and this is a in depth as I've not really seen before. This is truly a primer on the treatment of atrial fib, well worth reading, and we're going to have a link to the guidelines and the show notes because they are free for the taking. Again, unless you want to cut down a whole bunch of trees, I'm not sure you want to print them out because it's a quite long document but really does give you everything you need to know, based on the latest evidence, to kind of diagnose and treat these patients. It's a really good set of guidelines.

Speaker 2: 1:07

So this the guidelines themselves kind of talk about how they had a slightly different approach and they note the approaches called the knowledge chunk format.

Speaker 2: 1:18

I've never heard of that before, but I get what they're trying to do, that rather than try and just talk to people into the ground with their guidelines or have a one sentence synopsis, which is traditionally, I think what a lot of these guidelines do is they start off and they say, okay, well, you know, recommendation one here's the sentence, that's the recommendation, and if you actually want to know why we recommended that, you have to do a deep dive into the actual text behind it.

Speaker 2: 1:45

And in this case these set of guidelines didn't do that. They kind of had a hybrid where, yes, they had that one sentence, but even within the summary they summarized what the literature was, so that if you don't have the time to really do a deep dive into the text, you don't have to, and so I guess that's the knowledge chunk format. But apparently it really does help with user friendliness and it really helps explain what they're doing without having to take an hour to read every little thing about this. So the guidelines have more than I've ever seen before flow diagrams, charts, algorithms that really help you quickly locate and walk through when you have a clinical conundrum that you're trying to deal with.

Speaker 2: 2:27

So, again, well worth reading in my opinion, and something that I think most primary care providers and pharmacists are really going to be using. The guidelines, of course, are kind of the standard set of guidelines where they take the latest information, they review it. They did not do an individual systematic review and meta-analysis. Some organizations are doing that. I think that would have made this paper about three times as long. So I'm kind of glad they didn't do that in all honesty, and I think that in the world of cardiology that may largely not be needed. You traditionally have some pretty decent randomized control trials to guide therapy or not relying on a whole bunch of small studies or retrospective studies. They did use all the standard tools to pull studies, review them and then apply the standard grade criteria to the level of recommendation and the strength of that space. So why is this important? Well, as everyone knows, h-r-o-fib is the most common clinical arrhythmia that you are going to run into. The reason I always tell my students why is because the ventricular rhythm is 10 to kill you right away, whereas atrial rhythm is people can live with for years and not even know that they've got them. But we are seeing a lot of it because to the biggest risk factors for developing atrial fibrillation is age and they estimate that patients over age 80, that 10 percent of them will have atrial fibrillation and the rising tide of obesity, because obesity is another risk factor for developing atrial fib. And so currently it's estimated that about five million patients have atrial fibrillation in the United States, but with the aging of the population, that's expected to more than double by the year 2030, and that's just incredible, I think. And so you're absolutely going to see this over and over again as the population ages, and I think we're just going to have to get used to the fact that a significant minority of our patients over age 65 are going to carry the diagnosis of atrial fibrillation and are going to be treated as such. So I think that's that's. That's something that we're going to have to kind of come to terms with as a medical community.

Speaker 2: 4:31

Now we know that the two big problems of atrial fibrillation are the complications. So, beyond the symptoms of palpitation, shortness of breath and sometimes even syncope, it's the two long term complications of stroke and systemic thromboembolism. And, as we all know, that the you know, if you look just look at all comers the overall risk of developing a stroke while you have atrial fibrillation is about 5 percent cumulatively per year and that number can go up as you start adding more risk factors. Of course. That's the whole Chats Vast scoring system. Right, and remember that if you have the highest number in the Chats Vast scoring system, you have an almost 20 percent per year risk of having a stroke. That's absolutely amazing to say so. That's one of the big things we're trying to prevent with atrial fib and that's what we're going to focus really a lot on in this podcast. The other, of course, is tachycardiomyopathy. Patients are not designed to walk around with heart rates in the one 20s, one 30s all day long. Eventually we'll develop heart failure from that and we try to avoid that with rate and rhythm control, which we're going to talk about in our next pod.

Speaker 2: 5:35

But it is also worth noting that that by itself, even when you take those out of the equation, that retrospective studies have been noted that atrial fibs is just associated across the board with an increased risk of death and and and so you know by itself, even if a patient didn't have a lot of symptoms, had a normal EF, et cetera, et cetera, it is worth treating atrial fibrillation because of this increased risk of death. That includes an increased risk of stroke, as we've talked about. There's a one point five fold increased risk of cognitive impairment or dementia, probably because you're having small strokes. An increased risk of myocardial infarction, an increased risk of sudden cardiac death, and of course they've all about a part that is we've talked about. So you know, even if you take away all those things of the too big, I think, complications of atrial fib, what we always talked about, by itself it is a malignant condition and really should be assessed and treated aggressively, even patients who don't have a ton of symptoms or don't have a lot of structural problems with their heart.

Speaker 2: 6:38

So, before we get into talking about where I wanted to focus on with this pod, which is anticoagulation, they do have a brand new classification scheme for atrial fibrillation that is, I think, a lot more comprehensive. I mean, for many, many years we had the paroxysmal, persistent, permanent sort of atrial fibrillation. Now there's a continuum of five different categories and I think that one of the nice parts about this is it does help us focus on risk factor adjustment before people actually get atrial fibrillation and they note that stage one of this continuum is patients who are at risk. Now, of course, there's something you can't do about, that right. You can't do anything about age. You can't do anything about, you know, maybe genetic risk factors, stuff like that.

Speaker 2: 7:24

But if you can control obesity, if you can control hypertension, if you can control sleep apnea, if you can watch your alcohol intake, those all decrease your risk for atrial fibrillation. So if you have a patient who has a lot of these things, I think working with aggressive counseling to help with those risk factors makes sense. Who knows, maybe the GOP one drugs at some point in time will be approved for use in patients who are obese because they have a risk of developing atrial fibrillation. That'd be kind of interesting to see. Stage two of this classification scheme is patients who have evidence of structural or electrical findings that further predispose the patient atrial fib.

Speaker 2: 8:03

The two big ones of course are atrial enlargement, so the larger the atria get the more likely it is that you're going to develop this, this reentered circuit that leads to the fast heart rate of atrial fibrillation, and also patients who have atrial flutter, which is a related arrhythmia that can devolve into atrial fibrillation as time goes on. So those patients are going to be at high risk and are noted as pre atrial fibrillation patients and new guidelines. And then when we get to atrial fibrillation, we still have the paroxysmal, the persistent and the permanent, but there's actually a couple of more categories. Category three is atrial fib, which is further subdivided into paroxysmal, which is considered atrial fib that is terminated within seven days of onset. Persistent, which is last more than seven days and requires intervention. Longstanding, persistent, which is new, and that's atrial fibrillation last more than a year in duration. So now across the continuum we have three A, which is just regular paroxysmal, that ends in seven days.

Speaker 2: 9:06

Persistent, which is more than seven days and requires intervention. Longstanding, persistent, which is 3C, which is it requires or is atrial fib more than 12 months in duration. And then successful A of ablation. So patients who have had atrial fibrillation but have had a successful ablation procedure and no longer have atrial fibrillation and that's still considered the 3D category of atrial fib. And then category four is permanent atrial fibrillation, where they make no further attempts at rhythm control, largely because it won't be successful. So really the reason for this new scheme is that you know, we should be treating modifiable risk factors way back in the first score and we should be looking at obviously treating patients aggressively in all the stages three and then want to treat symptoms, of course, in all stages three, as well as assessing patients for stroke risk and putting them on therapy as well.

Speaker 2: 10:09

The next section of the guidelines talk about risk stratification and population screening, and I'm talking not just only about risk for stroke. I think we're all well aware of the of the ChazVASC scoring system, but there's it's worth noting that there's a number of other scoring systems out there and in fact the guidelines note that there's over 20 risk prediction models for incident atrial fibrillation in the community and that any of them really can be used. They all kind of have their plus and minuses and things along those lines. So we're again, we're not necessarily talking about risk for anticoagulation and stroke, we're talking about patients who should be assessed for the development of atrial fibrillation. So they know, one of probably the most commonly used one is the Charge AF score. There's another one called this chest score, but it's C2HEST that looks at these and basically notes that in patients who are at risk, patients again are in that kind of stage one and two the application of increased monitoring should probably be considered in patients who have a high score.

Speaker 2: 11:22

And then they're on one of these, one of these scoring systems the Charge AF score, etc. Etc. They then move on to the risks of stroke in patients and using scoring systems for them. And again they know that the ChazVASC score is by far the most commonly clinically used scoring system for that. However, they note that there there have been. Since the ChazVASC have come out, there are several new ones.

Speaker 2: 11:45

I think one of the big changes in this set of guidelines for previous guidelines is, while they don't recommend one over another, they really do note the advantages of the Garfield HF calculator. And the Garfield HF calculator is a web-based tool for predicting stroke and mortality. It includes the effects of different anticoagulants. If it looks at bleeding risk and mortality, they'll both share decision making. Now, for many years I've been using SparkTool, sparctol, which was developed by a pharmacist in California that does some of this, that does some of this stratification by different types of anticoagulation. I went to the Garfield AF website and we'll have again that website in our show notes and this is, I would say, much more in depth and, I think, does have a lot of other factors you can enter into the calculation.

Speaker 2: 12:43

Actually, it has 16 questions that you can enter into the calculator.

Speaker 2: 12:48

That really gives you, I think, a much more precise estimate of stroke, much more precise estimate of mortality, and does a very, very good job talking about bleeding risks and avoidance of stroke with all the various anticoagulants out there. So while I still use SparkTool, I'm going to start using this Garfield AEP tool. I guess it's the cardiology people out there have been using this for a while because apparently it's been around for a while. I had actually never heard of it, so it was a kind of eye opening for me and, having messed around a little bit online, I was very impressed with it. So I think if you're looking for a free, web-based tool that really breaks down the exact risks of being on anticoagulation, the exact risks of stroke and mortality, given a lot of risk factors the patient has, the Garfield AEP tool really is a good risk calculator. So then we move on to anticoagulation. As we all know, patients who have, for example, a CHADS BASCOR of at least two and many times even one should be considered for anticoagulation.

Speaker 2: 13:55

Of course DOACs have really led the scene here for the last 10 years. I was thinking the other day that Dabigatran, which is now just turning generic, has been out now for about 14 years. Just amazing to me, but I guess that's how time flies. The anti-factor 10 drugs have been out for about 10 or 12 years now. So those few of us are still calling them NOACs for novel oral anticoagulants. I guess we can't call them that anymore, because anything that's been over here on the market for over a decade probably can't call them novel anymore. Of course they are superior to Warfarin in a number of ways. They're much easier to dose. They don't have the litany of drug interactions Though there are some drug interactions to note they don't require frequent lab draws for monitoring, et cetera, et cetera. The guidelines do note that they are recommended in over Warfarin for atrial fibrillation, except in patients who have significant valvular disorders, and there's a lot of confusion about what that is and I'm glad the guidelines really lay out that it's really only patients who have moderate severe mitral stenosis or a mechanical heart valve. Everybody else can be on a DOAC. So I've been asked a lot about bioprostatic valves. Someone has a bioprostatic valve. No, those patients can be on DOACs too. It's really only patients who have severe metral stenosis or mechanical heart valves, and I guess that's why Warfarin is never going to completely go away in those patients.

Speaker 2: 15:23

They note that the four DOACs on the market a PIXA band, dabigatran and DOXA band and River Oxaban have all shown either superiority or non-imperiority. Warfarin and prevention of stroke and systemic embolism in patients with atrial fibrillation. They note that they also lower the risks of bleeding. In particular, they note PIXA band has showed a statistically significant decrease in their study with bleeding compared to Warfarin. It's worth noting that they excluded a lot of patients in that study who are at risk of bleeding, so I'm not that it doesn't do that, but it's something to kind of keep in mind. And they note that, more importantly, head bleeds and other life-threatening bleeds across the board are decreased with all the DOACs compared to Warfarin. So for all those reasons, doacs should really be the drugs of choice.

Speaker 2: 16:15

Now they note that GI bleeds are higher with several of the medications. They note most notably Dabigatran and River Oxaban. But they also note that any of the drugs can be used and I think they do take care in the study to not necessarily recommend one DOAC over another, probably because there aren't any head-to-head studies and probably never will be. So I think a lot of it kind of comes down to individual patient factors, things like age and renal function and body weight and things along those lines. So they also note that if you have a patient who can't be on anticoagulation or has had strokes while on anticoagulation or bleeds while on anticoagulation, there is an alternative agent which is, in studies now been shown to be as effective at preventing stroke, and those of course are left atrial occlusion devices, things like the Watchman device. We're not going to talk about that just because it's beyond the scope of the pod. You could probably do an entire lecture on those and an entire podcast about which one would you pick? And the paraprocedural anticoagulation that goes with it, et cetera, et cetera. So I think suffice it to say that DOACs are the preferred drug in almost all patients with atrial fibrillation, once you've determined they are candidates for anticoagulation.

Speaker 2: 17:37

Now, of course, there are issues associated with all drugs and I don't think we're ever going to come up with an anticoagulant that doesn't have bleeding, so major side effect is just the bottom line is that any drug that's going to cause anticoagulation is probably going to have bleeding as a side effect.

Speaker 2: 17:55

So then, how do you approach that and these are questions I get asked all the time right?

Speaker 2: 17:59

So somebody comes in, they're on a DOAC and we need to do a procedure in them. So, whether it's a low risk procedure like a paracentesis or thoracentesis or major surgery, when should we hold these? How long should we hold these medications? And I was very heartened to see that there's a nice chart in the guidelines that pretty much lay out the fact that in patients with normal renal function, you really only need to hold them, even for high risk procedures, for 48 hours from the last dose. I know that's not what's done clinically, especially here in my neck of the woods, that we have people who are so routinely holding these drugs for four or five days. That's just absolutely not necessary to do. The drug is long gone in patients with normal renal function for 48 hours, and even with an impaired renal function, 72 hours. Most of these drugs are completely out of the system. So these long holds for various procedures aren't really done and only one day that needs to be held for low risk procedures again like paracentesis, thoracentesis and stuff like that.

Speaker 2: 19:01

Then they talk about reversal of the do-axe when it comes to bleeding and again I was heartened to see that they have a really nice algorithm that kind of walks you through. You know how to reverse these patients. They know that you know, for active bleeding associated with an anticoagulant, that if it's minor bleeding, usually don't need to do anything right.

Speaker 2: 19:26

Again, these drugs have very short durations of action and you can just pull the anticoagulant until hemostasis is achieved. But they do also talk about life-threatening bleeding which is either going to be major GI bleeds or patients who's had a trauma or an intracranial hemorrhage, something like that. For warfarin, of course, they recommend forfactor PCC or K-centra with intravenous vitamin K, and that's what they recommend at a 1A level recommendation. For Dabagatran they recommend Braxbine, which of course is the direct reversal agent for Dabagatran. That's a 1B level recommendation, but they also recommend that that's not available. There's 2A recommendation for using K-centra in those patients as well.

Speaker 2: 20:11

I haven't seen a lot of Dabagatran. I think Dabagatran is kind of fallen by the wayside with the rise of the factor 10 drugs, primarily because they're better tolerated from a GI standpoint. Dabagatran has a lot of stomach problems associated with it. However, since Dabagatran has gone generic, I've already seen a couple of cases where insurance companies are actually now shifting their patients to that medication to save money. So I actually think we're actually going to see a big spike in the use of Dabagatran, depending on a patient's insurance plan. So something to kind of keep in mind. And then me again. Most patients are on factor 10 inhibitors. There is a reversal agent for the factor 10 drugs which of course is a dexanet alpha. They do recommend that a dexanet alpha is reasonable at a 1B level recommendation for Epixaban or Riveroxaban and a lower level for Adoxaban. But I have to admit I was somewhat relieved to see where 4-factor PCC is also recommended at just a 1C level. So they're both level 1 recommendations, just a little bit different level in just a little bit different level in level of evidence and given the unbelievable cost differences between a dexanet alpha and 4-factor PCC.

Speaker 2: 21:22

I think that's that causes most directors of pharmacy in hospitals across the country to kind of breathe a sigh of relief. I know this guidelines came out before the dexanet 1 study, which still hasn't been published, has come out. I'm not sure that's going to significantly change these recommendations. So it's interesting to see They've note then, in patients with mechanical bowels that warfarin is still the treatment of choice and that in patients with significant anticoagulations disorders, in particular patients who are triple positive for anaphozylid antibody syndrome, they note that warfarin is still the drug of choice. So again, we're still going to have plenty of patients who are on warfarin.

Speaker 2: 22:05

I don't think warfarin is going to completely disappear, though it is worth noting that just today on rounds, I had my residents. We had a patient who came in who had to be on warfarin for reasons I won't go into, and my residents really didn't know how to dose warfarin because they've never really had to. We just don't see a lot of patients on warfarin anymore, and the ones we do see, of course, are often handled by anticoagulation services and not by primary care physicians. So I thought that was quite interesting. So then the guidelines talk about some more practical stuff and we're going to go into some of these more practical recommendations which, again, I think, answer a lot of clinical questions that a lot of providers have, and we're going to do that after we're more sponsored CE impact.

Speaker 1: 22:52

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Speaker 2: 23:22

So we are back talking about primarily anticoagulation in this part of our two-part series. In our next pod we will be talking with Dr Matt Boyd, our cardiology clinical pharmacist, about the antirhythmics and rate control strategies in these patients so well, but today we're going to be focusing on anticoagulation. As I noted, the last part of the guidelines, I think, do a very nice job talking about some special circumstances when would you use one of these drugs versus another, which is nice, and also when can you restart these medications? For example, they note that in patients with atrial fibrillation and patients that have a high risk of thromimolic events, such as mechanical heart valves or other things like that that even after an intercranial hemorrhage, early resumption of anticoagulation is actually reasonable and they know within one to two weeks. I don't think that's done in my neck of the woods very much and I think that would make a lot of my docs a little bit nervous, but I think that is what the guidelines recommend. It's a relatively low level of recommendation, it's a 2A recommendation, but it's worth noting that just because you've had an intercranial hemorrhage, if you recover from that well and you have this high risk of thromimolic disease, the guidelines really say that the benefit or resumption of anticoagulation outweighs the risk of another bleed. That's worth noting. However, they also know that the patient does not have super high levels of thromimolic risk, that you should probably wait a little longer. But they don't say again, it's an absolute contraindication there to say it's a risk versus benefit assessment and, if so, that resumption at either one or two months might be reasonable in these patients. But again, if the patient is deemed to have a higher risk of intercranial hemorrhages or other severe bleeding that those of the patients, obviously, who would be candidates for left atrial appendage devices and things like that.

Speaker 2: 25:25

They talk about the use of anti-platelet agents and the DOAX. I see this all the time and it's definitely one of my soap boxes. I get on. But it was nice to see that they reaffirmed previous guideline recommendations that if you have somebody who is on taking, for example, both a baby aspirin and for chronic coronary disease and has atrial fibrillation, if they're beyond one year, revascularization or they have never required revascularization they that you can use DOAC monotherapy, older combination therapy of the Anticoagulant and a single anti-platelet agent those are. That leads way back into warfarin studies done in the 1970s. Warfarin is actually a pretty good drug for cardiovascular prevention. It just had a lot of bleeding and since aspirin was very similar to it, had a lot less bleeding. That's why we went with aspirin. But Anticoagulants actually have very good evidence to support them preventing myocardial infarction. Again, if a patient is on an aspirin and you're going to start a DOAC because now they're diagnosed with atrial fibrillation, it is perfectly reasonable to stop the aspirin if they haven't had a recent revascularization.

Speaker 2: 26:39

What about chronic kidney disease? Again, I get questions about this all the time. It's worth noting that we really have no clinical trials in patients with the DOACs, or at least severe chronic kidney disease with the DOACs in atrial fibrillation. They note that patients with chronic kidney disease stage 3 or less, that patients should probably be on and they do call out the direct factor 10 inhibitors. Note that they do not stress one factor 10 inhibitor versus another. They don't know atpixaban versus. Note that they do not stress one factor 10 inhibitor versus another. They do not stress one factor 10 inhibitor versus another. That have looked at patients with NSAIDs, renal disease and Epixaban and have found that because Epixaban is less renaly cleared than some of the other DOAX, that it seems to have pretty similar anti-factor 10A levels and pretty similar pharmacokinetic levels. There's been some case series and some retrospective studies that have not suggested an increased risk of bleed in those patients. So what I usually tell people when I get asked about this.

Speaker 2: 28:30

I have a dialysis patient who now has atrial fibrillation. What should I put them on? I usually try to recommend Warfarin first line because, again, warfarin is probably the drug of choice in these patients. But if they have a reason they can't be on Warfarin or they're not gonna be compliant or any of another reason, then yeah, I think at that point you're probably recommending a dose or appropriate Epixaban in those patients.

Speaker 2: 28:55

And then they talk finally about obese patients and they know that again and none of the atrial fib studies with the DOAX looked at patients with who are morbidly obese and they just know that there is no absolute cutoff weight. They really need to just take a look at the patient and have a risk versus benefit discussion. I think in the very, very morbidly obese patients that Warfarin is still probably the way to go. But in patients who have morbid obesity up to about 150 kilograms there's been several studies with both of the DOAX. I would argue that the data probably leans a little bit more toward Warfarin and those patients that have found that basically, even in patients up to 150 kilograms, that the pharmacokinetic parameters and anti-factor 10A levels with these drugs is the same as patients who don't have morbid obesity.

Speaker 2: 29:48

So, that's it for this week of Game Changers, and at our next pod we're going to talk about again rhythm versus rate control in these patients, and so please join us next week for that, and my guest, special guest star, dr Matt Boyd, for that. We will see you next week. And remember, time flies. I don't know where it's going, but the most important day is today. We'll see you next week.

Speaker 1: 30:09

Jen here. Be sure to check out our education at cempackcom. You'll find it to be your one stop shop for all the CE resources you need. Become a pharmacist by design member today to access it all for free, including CE for this podcast. Thanks for listening. We'll talk to you next week on Game Changers Clinical Conversations.