Biggest overhaul in practice guidelines in a decade consolidates latest research findings, advocates holistic approach to patient care
Clinicians should treat atrial fibrillation as more than an isolated rhythm disorder because it signals the urgent need for a much broader approach to patient care, says the co-chair of the expert multidisciplinary panel that developed the newest treatment guidelines.
In what is the most robust revision of practice recommendations in a decade, the Canadian atrial fibrillation (AF) guidelines advocate for considering AF as a symptom of larger and more complex cardiovascular disease. The most effective way to tackle AF is by focusing beyond the heart rhythm disorder, and managing cardiovascular risk factors, says Vancouver cardiologist and AF guidelines co-chair Dr. Jason Andrade. “This is a major philosophical shift.”
Guidelines place strong emphasis on management of high blood pressure, diabetes, obesity, physical inactivity, sleep apnea, and other risk factors. In addition to delivering the latest information on drug therapies and new technologies, recommendations also call for dedicated multidisciplinary clinics to treat people with AF in a holistic way to improve overall health and wellbeing.
“We’ve become more aware that atrial fibrillation is a comprehensive multi-system disease,” Dr. Andrade says. “People who have atrial fibrillation generally have other cardiovascular risk factors and cardiac conditions. If we focus only on the arrhythmia, the abnormal heartbeat, we miss a huge opportunity to improve quality and quantity of life.”
While the concept of risk factor management was introduced in 2018, the latest recommendations broaden the emphasis and underscore the need for full-scale action.
As many as a million Canadians live with atrial fibrillation, an irregular rhythm or rapid heart rate. This growing epidemic can lead to days of lost work, large and disabling strokes, heart failure, anxiety, depression, and reduced life expectancy.
“If you look at North American data, there are much higher rates of atrial fibrillation than in other parts of the world,” Dr. Andrade says. In the general population, the rate has risen from one per cent to three per cent in recent years. In people over age 80, the rate of AF can be as high as 10 per cent.
In addition to human costs, atrial fibrillation and related care consumes an estimated $1 billion a year in health-care budgets.
Developed by a pan-Canadian expert panel that meticulously reviewed 10 years’ worth of research evidence, the newest Canadian Cardiovascular Society/Canadian Heart Rhythm Society Comprehensive Guidelines for the Management of Atrial Fibrillation centralize the latest knowledge in a searchable format with easy-to-access recommendations and graphics.
“The guidelines are designed to be the comprehensive resource for clinicians to address most of the questions encountered in practice,” Dr. Andrade says. “This is meant to be the go-to resource for Canadian specialists, primary care practitioners, pharmacists, emergency doctors, and neurologists – essentially anyone who would encounter atrial fibrillation patients – to guide them to provide the best possible care.”
University Health Network Pharmacy Specialist Dr. Kori Leblanc, a member of the expert panel, explains: “One of the goals of repackaging this entire 10-year update is to include everything in one place.”
In addition to the emphasis on risk factors, the newest guidelines highlight:
- the need to screen for atrial fibrillation during routine medical visits of those aged 65 and over, especially when known risk factors are present;
- the need for integrated, multidisciplinary AF clinics focused on the whole patient. Great benefits come from having pharmacists, dietitians, exercise physiologists and physicians in a multidisciplinary clinic targeting risk conditions that lead to AF;
- advances with antithrombotic drugs to prevent stroke, which is especially important because strokes caused by AF are usually larger, more severe, and more likely to result in significant disability, institutionalization or death. Over the past 10 years, novel anticoagulant regimens have substantially reduced the stroke risk without increasing the risk of bleeding over previous standard of care;
- new evidence on how to best support stroke prevention in complex patients, and prescribing and adjusting anticoagulation. This includes patients with coronary artery disease, stents, chronic kidney or liver diseases, and obesity;
- greater understanding of how to return patients to normal heart rhythm through pharmacological or electrical cardioversion therapy, antiarrhythmic drugs, and catheter ablation; and
- improvements to procedures like catheter ablation. Catheter ablation, which eliminates the triggers in the heart, has evolved substantially in the past 10 years and should be a frontline therapy for eligible patients.
Clear and accessible guidelines are especially important because AF is “a major public health issue,” says cardiologist Dr. Chris Cheung, a member of the guidelines panel. “There has been so much change in management and diagnosis over the last decade. These guidelines summarize our current understanding of AF and deliver recommendations on how to improve lives.”
One thing is very clear: The sooner AF can be treated and managed, the better. If AF persists, it can lead to the development of scar tissue in the heart and changes in heart structure, making it harder to keep people in normal rhythm. “A normal rhythm can lead to better outcomes, including fewer strokes, hospitalizations, and death. The goal is really to identify people early on in the disease process,” Dr. Cheung says.
Atrial fibrillation is complicated, and often misunderstood. For some people, symptoms are overwhelming and, for others, symptoms are non-existent. At the same time, atrial fibrillation evolves and changes, moving from being episodic to persistent, and then eventually permanent.
Along with managing complex medication, pharmacists can play a big role in helping to identify and manage risk factors for AF because they are the most accessible health-care provider, and often are already involved in supporting the patient regularly with things like their diabetes or hypertension, says Dr. Leblanc.
Dr. Leblanc compiled and published a list of top takeaways targeted specifically at pharmacists. It appears in the Canadian Pharmacists Journal. Particularly applicable to pharmacy practice is information on how to deal with special circumstances around anti-coagulation and how to approach stroke prevention.
“The whole team’s approach is to manage our patients’ symptoms and optimize their quality of life, manage their stroke risk using the best prevention strategy for them, and try to keep them out of hospital,” she says.
Check out the newest Guidelines in the Canadian Journal of Cardiology and visit ccs.ca for the latest updates and knowledge translation tools.
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