2019 Atrial Fibrillation Guideline updates.
Major cardiology groups and other physiology groups like the American College of Cardiology and the Heart Rhythm Society have released joint statements about how to manage atrial fibrillation.
They incorporate things that have had a major influence on the management of patients with atrial fibrillation. And so in 2019, they released a focused update. It’s not a complete overhaul of the guidelines, but it did emphasize some new treatment options and new treatment guidelines for doctors and patients which we wanted to emphasize to you today.
So the first thing in the guideline was the changes in recommended blood thinners that include the newer category of blood thinners, sometimes called NOACs or DOACs, like Eliquis or Xarelto or Pradaxa or Savaysa, are now preferred over warfarin. These are now the preferred medications to take for blood thinners over older generation medication like warfarin and there are several reasons for this.
Part 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 whether you’re truly in the therapeutic range or not, these newer blood thinners have a stable blood thinning effect, and in some cases, the bleeding profile is actually better than these older medications like warfarin. That’s why it’s now recommended to start with newer blood thinner medications like Eliquis or Xarelto over older medications like warfarin. The authors also hope that from a cost standpoint that if they emphasize that these are preferred medications, insurance companies will also provide better coverage of these medications, as well.
The second thing that was emphasized on the guideline updates was the influence of female sex for stroke risk. The most common risk score scoring system for atrial fibrillation is called the CHADS-VAS risk score. In part of that scoring system, female sex was given an additional point, and so female sex was thought to have a higher risk of stroke and women where more likely to need blood-thinning medication just for being female, but that has always been a kind of a controversial aspect of that scoring system, how much did a female sex versus a male sex really influence the terms of risk of stroke and need for blood thinning medication? So in this guideline update, they’ve actually kind of removed the emphasis of the female sex as a point for a scoring system.
And so now for the scoring system, if you have a CHADS-VAS risk score of two if you’re a male or three if you’re a female, then it is typically recommended to use blood thinning medication.
Number three, the recommendation of aspirin has been removed. It was common for a long that if people were at lower risk for stroke or they didn’t want to take a blood thinner their doctors would recommend aspirin because aspirin is one of the original things that was studied back in the day.
When studies were compared between aspirin and warfarin, it was found to have a small bit of benefit for stroke risk reduction. However, as the years have gone by and more studies have come out, it really looks like aspirin doesn’t have much 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, but when it comes to atrial fibrillation, as time has gone along, it’s shown that it’s really not getting much of a benefit.
In general, if you are taking a stronger blood thinner like Xarelto or Eliquis or if your risk of stroke is low, it’s not really recommended to take an aspirin. It’s better to just take nothing.
Number four, for people who have stents put in their heart. Frequently, these patients end up on three blood thinners. They may be on Eliquis or they may also be on aspirin and Plavix, and these are multiple blood thinning medications, which can significantly affect the person’s bleeding risks, and the study did make some clarifications in patients who have gotten stents who also have atrial fibrillation that it’s typically only needed to be on two blood thinners and three are not typically needed.
Number five, a recommendation on left atrial appendage closure procedure, what is more commonly know as a watchman procedure, but there’s also a couple of other procedures, as well, which emphasize closure of the left atrial appendage. 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. What does that mean? The guideline authors want to emphasize that the primary method for reducing risk of stroke is blood thinning medication, and blood thinning medication has been studied for many years and should be 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 blood thinner medications or have had bleeding problems and can be a very good alternative option for reducing the risk of stroke.
Number six, number six is talking about the specific population of people who have congestive heart failure. There have been some recent studies to come out in the last couple of years that specifically looked at the role of ablation in people 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 in people who also have congestive heart failure kept them out of the hospital and helped them potentially live longer, as well. So in that certain population with CHF or congestive heart failure, also known as a weak heart, there has been more of an emphasis on aggressively treating atrial fibrillation whether that be with medications or specifically catheter ablations because this can significantly reduce their amount of hospitalization.
And then lastly, number seven, diet recommendations made it into the guidelines. In 2015, there was a pretty landmark study called the Legacy Trial, which looked at weight loss and how it can improve a person’s atrial fibrillation, and 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. This really put an emphasis on doctors when they’re managing patients that weight loss should be a very strong recommendation for patients who have atrial fibrillation. So those are sort of our main highlights from the 2019 AFib Guideline updates. A lot of the other things still stayed the same, but those are the main changes for 2019.
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