AFib: Rhythm, Rate, and Risk Reduction

July 2, 2024|Lisa Maher

Diagnosis and treatment of atrial fibrillation (AFib) necessitates a balance of rate, rhythm, and risk reduction strategies to help control and manage symptoms and lower patient risk for stroke. Assessing and managing the disease requires a team-based mentality with the patient at the center.

AFib is the most common cardiac arrhythmia in clinical practice and is associated with an increased risk of cardiovascular and cerebrovascular events and related deaths.1 It is estimated that at least 3-6 million people in the US have AFib, and it is expected to expand to nearly 16 million people by 2050.2 AFib increases the risk of stroke 5-fold and causes up to 25% of ischemic strokes, both in the US and globally.3

Awareness and early detection are key to effective management and risk reduction. Yet, a claims database review found that over half a million individuals with AFib are estimated to be undiagnosed each year. It is incumbent on each healthcare professional to be aware of this growing health problem and help identify and treat the disease to improve individual and population health.

As always, healthcare professionals must be aware of how social determinants of health potentially impact patient diagnosis and treatment rates.

Is it enough to focus on rate control?

Focusing solely on rate control is not enough. For optimal patient outcomes, maintaining heart rate, restoring a normal heart rhythm, and preventing blood clots from forming is required.

New and consistent evidence has led to the incorporation of early—and continued—management of patients with AFib, which includes maintaining a regular sinus rhythm and reducing the burden of AFib.

The 2023 guideline update has several different components. The following is a brief synopsis; please refer to the full guideline for details and specific examples.

The new guideline provides AFib classification based on stages within a continuum of disease. Each stage requires a different set of strategies.

  • Regardless of whether or not a patient has AFib, treating the modifiable risk factors is an important overall step
    • Lifestyle modification is a pillar of AF management to prevent onset, progression, and adverse outcomes.4 From lifestyle modifications (e.g., smoking cessation, heart-healthy diet) to clinical interventions for comorbidities (e.g., hypertension, obesity, dyslipidemia, etc.), these steps can make a big difference in improving overall health.
  • Screening for AFib
    • Information about potential AFib may come from a variety of sources:
    • Patients recognizing irregularities in their pulse or heart rate
    • Indications from a wearable device that triggers a notification
    • Clinical presentations of pulse, irregular beats
    • EKG tracings
  • When AFib is confirmed, several simultaneous responses are warranted. These are reviewed regularly to determine if the disease is stable or if symptoms or pathophysiology is changing
    • Symptom treatment (rhythm, rate)
    • Stroke risk assessment; therapies
    • Monitor AFib symptoms, disease burden
    • Assess for AFib-associated pathophysiological changes

How do I balance bleeding risk with AFib treatments?

Anticoagulants, including oral anticoagulants (OACs), significantly reduce the risk of thromboembolism among at-risk patients with AFib.5 Current guidelines strongly support the use of anticoagulants, including OACs, in men and women with AFib. Yet research indicates that up to 50% of patients who are eligible for OACs are not treated with them, and for those who are on OACs, many are dosed at sub-optimal levels.3

Balancing the right dose of the right pharmacotherapy requires balancing the risk of stroke with the risk of potential bleeding. A shared decision-making process with patients should be utilized.

A validated tool, such as the CHA2DS2-VASc, to predict stroke risk is essential for further stratification; however, it may need to be used with other clinical risk scores to predict optimal patient outcomes.

Are there any other takeaways from the guideline update to keep in mind?

There are other considerations for healthcare professionals who help diagnose and manage patients with AFib.4

  • Catheter ablation of AFib receives a Class 1 indication in appropriate patients with heart failure with reduced ejection fraction. In these patients, recent randomized studies have demonstrated the superiority of catheter ablation over drug therapy for rhythm control.
  • There have been updates to recommendations related to device-detected AFib.
  • Left atrial appendage occlusion devices have been upgraded to a Class 2a recommendation for patients with long-term contraindication to anticoagulation.
  • There is an emphasis on the risk of AFib recurrence following the discovery of AFib during a noncardiac illness, surgery, and other precipitant events.

AFib Risk Reduction Resources

What did you learn?

We’d love to hear what you learned from this article.

The article helped improve my understanding of the updated AFib guideline for clinical practice.
Which of the following is the most important consideration when managing AFib?
Which of the following is true about the diagnosis and management of AFib?

References

  1. Michaud GF, Stevenson WG. Atrial fibrillation. N Engl J Med. 2021;384(4):353-361.
  2. Kornej J, Börschel CS, Benjamin EJ, Schnabe RB. Epidemiology of atrial fibrillation in the 21st century: novel methods and new insights. Circ Res. 2020;127(1):4-20.
  3. Barnes GD, Piazza G; Global Anticoagulation Roundtable Working Group. Barriers to stroke prevention in atrial fibrillation: insights from the Global Anticoagulation Roundtable. Int J Cardiol Heart Vasc. 2022;42:101096.
  4. Wiggins B, Cibotti-Sun M, Moore MM, et al. 2023 Atrial Fibrillation Guideline-at-a-Glance. JACC.2024;83(1):2801-284.
  5. Hindricks G, Potpara T, Dagres N, et al. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS): The Task Force for the diagnosis and management of atrial fibrillation of the European Society of Cardiology (ESC) Developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC. Eur Heart J. 2021;42(5):373-498.

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