Key Updates in the 2023

ACC/AHA/ACCP/HRS
Guideline for the Diagnosis
and Management of Atrial
Fibrillation

Harsh Patel, MD-PGY5

Dr. Labedi
SIU Division of Cardiology
12/22/2023
Objectives:

• Identify updates between 2014/2019 and 2023 AHA/ACC/HRS guidelines in the

classification and Risk Assessment of AF

• Identify updates between 2014/2019 and 2023 AHA/ACC/HRS guidelines in the

Diagnosis of AF

• Identify updates between 2014/2019 and 2023 AHA/ACC/HRS guidelines in the

Management of AF
Prevalence, Incidence, Morbidity and Mortality of AF
Prevalence and Incidence of AF is increasing and
projected to double between 2010 and 2030

Overall lifetime
AF is associated
risk:
with increased
• 30-40% in White
50 individuals
risks:
estimated individuals • 1.5-to 2-fold risk of
million
with AF worldwide in • 20% in African death
2020 American individuals
• 2.4-fold risk of stroke
• 15% in Chinese
At least 5.6 • 1.5-fold risk of CI/
In Medicare individuals
dementia
million beneficiaries, the
individuals with most frequent • 1.5-fold risk of MI
outcome in 5-yrs • 2-fold risk of SCD
AF in USA in
- about 11% estimated after AF diagnosis
2015 cases were was death (19.5% at • 5-fold risk of HF
undiagnosed
1-yr; 48.8% at 5-yrs) • 1.6-fold risk of CKD
AF accounted for $28.4 billion/ year in US healthcare spending
• 1.3-fold risk of PAD
in 2016
Abbreviations: AF indicates atrial fibrillation; CI, cognitive impairment; CKD,
chronic kidney disease; HF, heart failure; MI, myocardial infarctions; PAD,
peripheral arterial disease; SCD, sudden cardiac death; yr, year; and yrs, 3
years.
Joglar, J. A. et al., 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation.
Circulation.
 Key Take Home Messages for 2023 AF guidelines
1:

• Stages of AF:

• Previous Classification: based on arrhythmia duration, tended to emphasize

therapeutic interventions

• New classification: Recognizes AF as a disease continuum that requires a variety

of strategies at different stages, from prevention , lifestyle and risk factors
modification, screening, and therapy
 AF Stages: Evolution of Atrial Arrhythmia Progression
At Risk for Pre-AF AF Permanent
AF
Presence of modifiable and Evidence of structural or
Patients may transition among different AF
substages of AF No further attempts
nonmodifiable risk factors electrical findings further at rhythm control
associated with AF. predisposing a patient to AF: Paroxysmal Persistent Long- Successful
• Atrial enlargement AF (3A) AF (3B) standing AF ablation after discussion
Modifiable risk factors: • Frequent atrial ectopy AF that is AF that is persistent (3D) between patient and
• Short bursts of atrial intermittent continuous AF (3C) No AF identified clinician
• Obesity • Diabetes tachycardia
• Lack of fitness and and sustains AF that is after
• Atrial Flutter
• Hypertension • Other high AF risk terminates for >7d and continuous for percutaneous
• Sleep apnea scenarios* within 7 d of requires >12mo in or surgical
• Alcohol onset intervention duration intervention to
Nonmodifiable risk factors:
• Genetics eliminate AF
• Male sex
• Age

Treat Modifiable Risk Factors

Consider heightened Ongoing monitoring as clinically appropriate for

surveillance AF burden
Is AF associated with pathophysiological
changes
Stroke risk assessment and therapy if
appropriate
Treat symptoms

Note: *Heart failure, valve disease, coronary artery disease, hypertrophic cardiomyopathy, neuromuscular disorders, thyroid disease
 Key Take Home Messages for 2023 AF guidelines
2:

• AF risk factor modification and prevention:

• Recognizes lifestyle and risk factor modification as pillar of AF management to

prevent onset, progression and adverse outcomes

• Recommends: - Weight loss with BMI >27 kg/m2

- Moderate to vigorous exercise training to target of 210 mins/week
- Tobacco cessation
- Alcohol moderation
- Blood pressure control
- Screening for sleep-disordered breathing
Primary Prevention
 Key Take Home Messages for 2023 AF guidelines
3:

• Flexibility in using risk scores and expanding beyond CHA2DS2VASc for

prediction of stroke and systemic embolism

• Recommendations for anticoagulation are now based on yearly thromboembolic event

risk

• Patients with intermediate annual risk score with uncertainty about anticoagulation
benefit can benefit from other risk variables
Risk Stratification Schemes
Additional Risk Factors That Increase
Risk of Stroke Not Included in
CHA2DS2-VASc
 Key Take Home Messages for 2023 AF guidelines
4:

• Early rhythm control:

• Emphasizes the importance of early and continued management

of patients with AF that should focus on maintaining sinus
rhythm and minimizing AF burden
Goal of Therapy with Rhythm Control
Patient and
clinical
considerations
for choosing
between Rhythm
and Rate control
 Treatment
Algorithm for
pharmacologi
cal
Conversion of
AF to Sinus
Rhythm
 Treatment
Algorithm for
Drug Therapy
for
Maintenance
of Sinus
Rhythm
 Key Take Home Messages for 2023 AF guidelines
5:

• Catheter Ablation receives a Class 1 indications as 1st line

therapy in selected patients:

• Recent randomized studies showed superiority of catheter ablation over drug therapy for
rhythm control

• In view of the most recent evidence, we upgraded the Class of recommendation

AF Catheter Ablation
AF Catheter Ablation
 Key Take Home Messages for 2023 AF guidelines
6:

• In patients with HFrEF and AF, arrhythmia-induced cardiomyopathy should be

suspected and early aggressive approach to AF rhythm control is
recommended
 Key Take Home Messages for 2023 AF guidelines
7:

• Recommendations regarding device-detected AF:

• In view of recent studies, more perspective recommendations are provided with patients
with device-related AF that consider the interaction between episode duration and
patient’s underlying risk of thromboembolism.

• This includes considerations for patients with AF detected via implantable devices and
wearables.
Silent AF and Stroke of
Undetermined Cause
 Key Take Home Messages for 2023 AF guidelines
8:

• Recommendations regarding LAAO devices:

• In view of additional data on safety and efficacy of LAAO devices, COR has been upgraded
to 2a in patients with long term contraindications to anticoagulation.
Percutaneous Approaches to
Occlude the Left Atrial Appendage
(LAA)
Contraindications to long-term
anticoagulation
 Key Take Home Messages for 2023 AF guidelines
9:

• Recommendations regarding AF identified during medical illness or surgery:

• Emphasis is made on the risk of recurrent AF after AF is discovered during noncardiac

illness or other precipitants, such as surgery.
Prevention of AF after cardiac
surgery
Treatment of AF after cardiac
surgery
Treatment of AF after cardiac
surgery
Acute Medical Illness or Surgery
Acute Medical Illness or Surgery
 Key Take Home Messages for 2023 AF guidelines
10:

Recommendations regarding Special Patient Population:

1. Hyperthyroidism
Athletes
Pregnancy
Pregnancy
Thank you