Streamlined European AF Guidelines Emphasize ‘Whole’ Patient

LONDON, England—The new version of the European atrial fibrillation (AF) guidelines presents a pathway, called AF-CARE, to conceptualize management of patients with the arrhythmia, and does so in a streamlined format.

The paradigm incorporates the following key elements of managing the condition:

• C: comorbidity and risk factor management
• A: avoidance of stroke and thromboembolism
• R: reduction of symptoms by rate and rhythm control
• E: evaluation and dynamic reassessment

“The core of atrial fibrillation is actually managing the other conditions because [it] is a very intermittent and often progressive condition, but in order to get the best out of the treatments, in order to prevent strokes and heart failure and all that sort of stuff, the key is actually to treat the patient as a whole,” said Dipak Kotecha, MBChB, PhD (University of Birmingham, England), who co-chaired the guideline writing committee along with Isabelle Van Gelder, MD, PhD (University Medical Center Groningen, the Netherlands).

“That’s why ‘C’ . . . is now elevated to kind of the central position,” he explained to TCTMD. “So thinking about the patient, actually managing their diabetes, their high blood pressure, their obesity, giving them information about physical activity—all of that stuff is not only going to help them as a patient, but also prevent the atrial fibrillation from recurring. And if you're giving them treatments, it's going to make the treatments work much better. So, that is the core change in the guideline.”

The European Society of Cardiology (ESC) developed the guidance, which updates the 2020 iteration, in collaboration with the European Association for Cardio-Thoracic Surgery, and with help from the European Heart Rhythm Association. The European Stroke Organisation endorsed the document. It was published last week in the European Heart Journal and discussed here at the ESC Congress 2024.

Treatment Recommendations

Regarding various treatments, Kotecha pointed out that there have been strong recommendations for use of direct oral anticoagulants (DOACs) in previous documents, adding that “obviously now the evidence is pretty overwhelming.”

The vast majority of patients are already taking DOACs, however, but getting them on the right dose is key, Kotecha said. “I think the avoidable strokes are happening because people are inadvertently using the lower dose. And we see that all the time in clinical practice. . . . Well, actually, all you're doing is making them more likely to have a stroke, not less likely to have a bleed. So, it's about using the dosage correctly.”

The guidelines now contain a class III (level of evidence B) recommendation against using a reduced DOAC dose, unless patients meet specific criteria, in order to prevent underdosing and avoid excess thromboembolic risk.

As for left atrial appendage occlusion (LAAO) as an alternative to chronic anticoagulation, Kotecha said there still isn’t enough information comparing the procedure with DOAC therapy. “We still suggest percutaneous LAAO is really there for people who have an absolute contraindication for anticoagulation,” he said, noting that patients still require some type of antithrombotic therapy after having their appendage closed.

Surgical closure of the LAA is another option discussed in the guidelines, “but all the data we have is that those patients, if they can, should still be on anticoagulants,” Kotecha said. “Because it's not just the LAA that has the stroke risk. It's the whole body.”

Rethinking Risk Assessment

The recommendations found in these European guidelines and the latest US version are “fairly similar,” Kotecha said.

But one aspect that differs is that the ESC guidelines have moved away from the CHA₂DS₂-VASc score as a central component of risk assessment for deciding on when to start anticoagulation. “The reason we've done that is because of the gender issue,” Kotecha said, pointing out that the threshold has been different for men and women (2 for men and 3 for women) since female sex adds 1 point.

“All you're doing is adding a point on and then taking it off again, so what we've tried to do is to simplify that by using CHA₂DS₂-VA and taking away the [sex component],” he said. “The change is intended to equalize the approach to oral anticoagulation and make it more likely that both women and men with any risk factors for thromboembolism receive appropriate oral anticoagulation.”

He stressed that all risk scores are “quite poor” at predicting which patients will eventually have a stroke. “Stroke and thromboembolic risk is a continuum, and these arbitrary cutoffs are actually very bad. . . . We're only slightly better than tossing a coin,” said Kotecha.

The guidelines contain a new class I (level of evidence A) recommendation for oral anticoagulation in patients who have clinical AF and an elevated thromboembolic risk, with a separate class I (level of evidence C) recommendation to use a CHA₂DS₂-VA score of 2 or more as an indicator of risk sufficient to start treatment.

Still, there is an emphasis in the new guidelines on empowering clinicians to assess a patient’s risk of stroke without relying simply on risk scores, Kotecha indicated.

“There’s a bigger focus now on looking at the patient as a whole, their risk of thromboembolism, using tools where they're useful, but not relying on them in their entirety because actually the evidence is not there that those tools can help you to predict who should get anticoagulation,” he said.

Implementation and the Patient Voice

Asked about the potential impact of these new guidelines, Kotecha noted that he and Van Gelder were leading the STEEER-AF trial in parallel with developing the document. The aim of the study was to assess how well the medical community was adhering to prior versions of the European AF guidelines and whether a focused educational intervention for healthcare professionals could improve the situation. “That has really driven these new 2024 AF guidelines,” he said.

And as Kotecha reported during a Hot Line session at the meeting, STEEER-AF showed that “there's a massive implementation gap in the real world. Clinicians might know what to give, but they're not actually doing that.”

For that reason, the 2024 AF guidelines have been designed to ease implementation, he said, with a “completely” changed structure. “We have patient pathways. We've reworded and taken out every single recommendation and put them together from scratch. We now have a consistent way of talking about the recommendation—we look at the intervention that's being proposed, we have the population that it applies to, we have the value to the patient or health system, and then we have any exceptions. And that is repeated in every single recommendation in the same way.”

In addition, the guidelines are more concise compared with prior versions. “We've gotten rid of all the accessory recommendations, and we've really cut [the guidelines] so they're very easy to implement in clinical practice,” Kotecha said.

With a simpler approach, the hope is that it’ll eventually help improve outcomes for patients with AF, which is increasing in prevalence around the world as the population ages, he said. “And so if we can improve implementation, which we're trying to do with these guidelines, then that's the best step forward really.”

Importantly, he noted, there is a patient version of the guidelines that came out at the same time as the full document. “The idea is that we empower communication between the patients” and their physicians, he said.

During a press conference, Kotecha said, “If you don’t make decisions together, then those decisions are not going to last.”