Episode 216: 216. AFIB- RATE or ABLATE-- New guidelines

ACC/AHA just came out with new guidelines on AFIB if you need some light reading material! (big take home rhythm not rate, and not equal, read below for more information)

A HUGE piece of new is that now ablation is the cool kid on the block!!

More recent information has shown that ablation for AF is more effective than antiarrhythmic drugs for both persistent and paroxysmal AF and that earlier implementation of rhythm control strategies is an important factor for improving AF ablation success rates

I know we use to be all about rhythm and rate control are ‘equal’ and don’t worry the guidelines still say,

“Although selection of a rhythm-control therapy within a year of AF diagnosis may be considered to reduce the risk of adverse cardiovascular outcomes, early rate control may still be appropriate.” (aka you can do it acutely but that is only to get a hold of the acute situation)

BUT

Catheter ablation of AF is now a strong class 1 recommendation—FIRST LINE in selected patients which includes those with heart failure and reduced EF. This is with good reason ---

In STOP-AF, patients who had failed ≥1 antiarrhythmic drug (approximately 70% and 30% for 1 or 2 failed drugs, respectively) were randomized to either another antiarrhythmic drug or catheter ablation. At 1 year follow-up, catheter ablation was associated with a treatment success rate of 70%!!!

-I have long complained based on previous guidelines a new onset afib didn’t need to be admitted and could be set home on medication and follow up with cardio BUT NOW admit and consider ablation per these guidelines!

What are the patients that the guidelines recommend ablation for????

Generally younger with few comorbidities) with symptomatic paroxysmal AF-- However, clinical trials have demonstrated improved cardiovascular outcomes with rhythm control, even with median ages in the 70s.

Patients with minimal atrial enlargement have the best outcomes, whereas increased myocardial fibrosis and more persistent forms of AF are associated with higher rates of recurrence or failure.

Basically, what they are saying is if you are going to ablate them then do it early before there is remodeling to the heart.

However it is not just healthy patients, there is also a strong recommendation for appropriate patients with AF and HFrEF who are on GDMT, and with reasonable expectation of procedural benefit, catheter ablation is beneficial to improve symptoms, QOL, ventricular function, and cardiovascular outcomes.

This is a HUGE HUGE HUGE HUGE HUGE change to what we have done for so long now and you need to be aware of it AND when you are getting ready to discharge after ablation the recommendation is,

In patients with AF who undergo successful cardioversion or ablation resulting in restoration of sinus rhythm, anticoagulation should be continued for at least 4 weeks postprocedure.