435. Atrial Fibrillation: Chronic Management of Atrial Fibrillation with Dr. Edmond Cronin

CardioNerds (Dr. Kelly Arps, Dr. Naima Maqsood, and Dr. Elizabeth Davis) discuss chronic AF management with Dr. Edmond Cronin. This episode seeks to explore the chronic management of atrial fibrillation (AF) as described by the 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. The discussion covers the different AF classifications, symptomatology, and management including medications and invasive therapies. Importantly, the episode explores current gaps in knowledge and where there is indecision regarding proper treatment course, as in those with heart failure and AF. Our expert, Dr. Cronin, helps elucidate these gaps and apply guideline knowledge to patient scenarios. Audio editing for this episode was performed by CardioNerds intern Dr. Bhavya Shah.

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Pearls

Review the guidelines- Catheter ablation is a Class I recommendation for select patient groups

Appropriately recognize AF stages- preAF conditions, symptomatology, classification system (paroxysmal, persistent, long-standing persistent, permanent)

Be familiar with the EAST-AFNET4 trial, as it changed the approach of rate vs rhythm control

Understand treatment approaches- lifestyle modifications, management of comorbidities, rate vs rhythm control medications, cardioversion, ablation, pulmonary vein isolation, surgical MAZE

Sympathize with patients- understand their treatment goals

Notes

Notes: Notes drafted by Dr. Davis.  

What are the stages of atrial fibrillation?

The stages of AF were redefined in the 2023 guidelines to better recognize AF as a progressive disease that requires different strategies at the different therapies

Stage 1 At Risk for AF: presence of modifiable (obesity, lack of fitness, HTN, sleep apnea, alcohol, diabetes) and nonmodifiable (genetics, male sex, age) risk factors associated with AF

Stage 2 Pre-AF: presence of structural (atrial enlargement) or electrical (frequent atrial ectopy, short bursts of atrial tachycardia, atrial flutter) findings further pre-disposing a patient to AF

Stage 3 AF: patient may transition between these stages

Paroxysmal AF (3A): intermittent and terminates within ≤ 7 days of onset

Persistent AF (3B): continuous and sustained for > 7 days and requires intervention

Long-standing persistent AF (3C): continuous for > 12 months

Successful AF ablation (3D): freedom from AF after percutaneous or surgical intervention

Stage 4 Permanent AF: no further attempts at rhythm control after discussion between patient and clinician

The term chronic AF is considered obsolete and such terminology should be abandoned

What are common symptoms of AF?

Symptoms vary with ventricular rate, functional status, duration, and patient perception

May present as an embolic complication or heart failure exacerbation

Most commonly patients report palpitations, chest pain, dyspnea, fatigue, or lightheadedness. Vague exertional intolerance is common

Some patients also have polyuria due to increased production of atrial natriuretic peptide

Less commonly can present as tachycardia-associated cardiomyopathy or syncope

Cardioversion into sinus rhythm may be diagnostic to help determine if a given set of symptoms are from atrial fibrillation to help guide the expected utility of more aggressive rhythm control strategies.

What are the current guidelines regarding rhythm control and available options?

COR-LOE 1B: In patients with reduced LV function and persistent (or high burden) AF, a trial of rhythm control should be recommended to evaluate whether AF is contributing to the reduced LV function

COR-LOE 2a-B: In patients with