I’m gonna be write about the 2019 Atrial Fibrillation Guideline updates. For those of you not aware, we have major cardiology groups and other physiology groups like the American College of Cardiology and the Heart Rhythm Society, which every few years, release joint statements about how to manage atrial fibrillation. They usually incorporate things that have had major changes that can influence and 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 or new treatment options and new treatment guidelines for doctors and patients out there, which I wanted to emphasize to you today.
So the first thing in the guideline was that changes into blood thinners that the newer category of blood thinners, sometimes called NOACs or DOACs, which includes new blood thinners, like Eliquis or Xarelto or Pradaxa or Savaysa, are now preferred over warfarin, meaning these are the preferred medications to take for blood thinners over older generation medication like warfarin. And there’s 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 of warfarin. So that’s why it’s been 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, that insurance companies will also provide better coverage of these medications, as well. 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. It’s something that I’ve talked about in past videos, as well.
In part of that scoring system, female sex was given an additional point, and so female sex was led to have a higher risk of stroke and were 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, and 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 an aspirin has been removed. It’s been commonly for a long that if people were lower risk for stroke or they didn’t wanna take a blood thinner that they would recommend aspirin because aspirin is one of the original things that were 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 feels that aspirin really doesn’t have any 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. So in general, the recommendation is either you are taking a stronger blood thinner like I just mentioned like Xarelto or Eliquis or if your risk of stroke is low, it’s not really recommended to take a aspirin. It’s better to just take nothing. And so that was a new change, as well. They did do some clarifications, as well, for people who have other types of heart disease, that’s 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 it 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, they made a recommendation on left atrial appendage closure procedure, what you might more commonly know as a watchman procedure, but there’s also a couple of other procedures, as well, that which emphasize closure of the left atrial appendage. What they did is they actually gave it a recommendation of a to be recommendation, and 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 wanna emphasize, and I’ve also emphasized here in previous videos, that the primary method for reducing risk of stroke is blood thinning medication, and blood thinning medication has been studied for many years and many different types of blood thinning medications, and that is 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 medications, and so those types of patients who cannot tolerate blood thinners, you’ve had bleeding problems, watchman can be a very good alternative option for reducing 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 years that specifically looked at the role of ablation in people who have atrial fibrillation as well as congestive heart failure. And 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 outta the hospital and helped potentially live longer, as well, and so, and that certain population will have CHF or congestive heart failure, also known as a weak heart.
There have been more of an emphasis on more aggressively treating atrial fibrillation whether that be with medications or specifically catheter ablations ’cause can significantly reduce the amount of hospitalization. And then lastly, number seven, lastly, number seven, the 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, that they had over six-fold improvement in their AFib burden over a five year study period. And that was such major data that a fact that this made it into the guidelines. It really put an emphasis to 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 my main highlight from the 2019 AFib Guideline updates. A lotta the other things still stayed the same, but those are the main changes for 2019.