Atrial fibrillation – what do current guidelines say?

Atrial fibrillation is the most common sustained cardiac arrhythmia and is associated with significantly increased mortality and morbidity. Therefore, timely diagnostic and therapeutic measures are required. The current ESC guidelines recommend regular pulse monitoring in patients with appropriate risk factors and initiation of further investigations if necessary. Treatment includes medication, interventional and lifestyle measures, and it is important to include any comorbidities.

Patients with atrial fibrillation (AF) are hospitalized more frequently compared with the age- and sex-matched general population [1]. Mortality is increased by a factor of 1.5 in men and 1.9 in women [2]. Approximately 20-30% of all VHF patients develop heart failure and 16-20% develop depression. Furthermore, 20-30% of all ischemic strokes are associated with VHF [1,2]. Clinical symptoms depend on the duration of the VHF and ventricular frequency as well as individual perception [3]. Depending on the frequency transmitted to the ventricles, palpitations and the perception of irregular heart action may occur, especially in tachycardia. Some patients also suffer from pain in the thoracic region. Vegetative symptoms such as dizziness or sweating and nausea are possible. Auscultation and palpation of the pulse may reveal a pulse deficit in addition to arrhythmia. Depending on the severity, exercise intolerance, fatigue and dyspnea manifest. However, about one-third of people affected by VHF do not experience any noticeable or distressing symptoms [4].

Identify and screen at-risk population

The guidelines of the European Society of Cardiology (ESC) recommend opportunistic screening as a measure for the early detection of AF [2]: If patients are suspected of having atrial fibrillation due to their advanced age or certain concomitant diseases, their pulse should be checked regularly. If the pulse proves to be conspicuously high or irregular, there is an indication for an electrocardiogram (ECG) [4]. The risk for VCF increases, especially in the presence of concomitant hemodynamic or mechanical atrial stress [3]. For a reliable and unambiguous diagnosis of VCF, a well analyzable ECG recording is required (box) .

Common risk factors for VHF

The most common risk factors and comorbidities of VCF include arterial hypertension, diabetes mellitus, obesity, and sleep apnea [1,6]. The current ESC guidelines recommend that these should always be included in the assessment and treatment [2]. The same is true for bronchial asthma and chronic obstructive pulmonary disease (COPD) [1].

• Arterial hypertension: this is the most common risk factor, present in 49–90% of VHF patients [2,7]. The risk for the occurrence of VCF is increased 1.7-fold in individuals with arterial hypertension [2]. Selection of antihypertensives and treatment goals can be guided by the ESC recommendations for arterial hypertension [8].
• Diabetes mellitus (type 1 and 2): The more microvascular complications exist – which is especially the case with long-standing diabetes and inadequate glycemic control – the more likely VHF is to occur. Sufficient glycemic control one year before intervention may improve the success rate of rhythm control by ablation [2,9].
• Obesity: in the presence of obesity (body mass index, BMI ≥30 ^kg/m2), the risk of developing VCF is increased by 1.5-fold [10]. As BMI increases, the risk for the occurrence and persistence of AF increases [10]. Weight reduction of at least 10% and a target BMI ^≤27kg/m2 [10] may reduce VHF burden. To achieve this, in addition to dietary changes and exercise, the use of a glucagon-like peptide-1 (GLP1) agonist such as liraglutide or bariatric surgery has been shown to be helpful [9,11,12].
• Obstructive sleep apnea syndrome (OSAS): In the presence of OSAS – occurring in about half of VHF patients – the risk of cardiovascular events is increased and the likelihood of successful rhythm control is decreased [2,13]. To date, it is unclear whether continuous positive airway pressure (CPAP) therapy reduces the risk of recurrence after pulmonary vein isolation [2,9].
• Bronchial asthma: asthmatics have a 1.5-fold increased risk of developing VCF. Those with uncontrolled asthma are at highest risk, so effective asthma therapy should be sought [14].
• Chronic obstructive pulmonary disease (COPD): Approximately 23% of VHF patients with have COPD. In affected individuals, the success rate of electrocardioversion and ablation is lower. Currently, it is not clear whether treatment of COPD has a beneficial effect on VCF [15].

Heart failure and VHF: Who benefits from ablation?

Atrial fibrillation and heart failure are frequently associated – an estimated one-third of heart failure patients develop VCF, and patients with VCF have a greatly increased risk of developing heart failure during their course [2,16]. VHF patients who develop heart failure have a threefold increased risk of mortality, whereas heart failure patients with subsequent VHF have a twofold increased risk of mortality. Researchers have developed the ANTWERP score to predict response to ablation in patients with heart failure and impaired ejection fraction (LVEF<50%). The score is based on four parameters:

• QRS width >120 ms (2 points)
• Heart failure etiology (2 points).
• paroxysmal atrial fibrillation (1 point)
• pronounced atrial dilatation (1 point)

The total score ranges from 0 to 6, with a lower score predicting better prospects for LVEF recovery after ablation. In the ANTWOORD study, external validation of the ANTWERP score was performed in a large European cohort. The researchers retrospectively identified patients with heart failure, limited LVEF, and atrial fibrillation who underwent ablation procedures at eight European centers. The ANTWERP score was found to predict LVEF improvement after ablation with an area under the curve (AUC) of 0.86 (95% CI: 0.82-0.89; p<0.001) [18]. For total scores of 0, 1, 2, 3, 4, and 5-6, the respective response rates were 94%, 92%, 82%, 51%, 40%, and 17%. The results were presented at this year’s EHRA Congress [17].

Literature:

1. Karnebeck V, et al.: Fokus Risikofaktoren und Begleiterkrankungen. «Vorhofflimmern – und jetzt?». Swiss Med Forum 2023; 23(18): 1042–1045.
2. Hindricks G, et al.: ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association of Cardio-Thoracic Surgery (EACTS) Eur Heart J 2020; 42: 373–498.
3. «Vorhofflimmern», www.medix.ch/wissen/guidelines/vorhofflimmern, last modified 03/2022, (last accessed 07/11/2023).
4. «Vorhofflimmern: Diagnose oft nur mit Langzeit-EKG», https://herzstiftung.de/infos-zu-herzerkrankungen/herzrhythmusstoerungen/vorhofflimmern/vorhofflimmern-diagnose (last accessed July 11, 2023).
5. Noti F, Fuhrer J: Vorhofflimmern und Vorhofflattern: so ähnlich und so verschieden! Swiss Med Forum 2015;15(40): 890–897.
6. Schleberger R, et al.: Update Vorhofflimmern: Die ESC-Leitlinien 2020 sowie aktuelle Daten zur frühen antiarrhythmischen Therapie [Update atrial fibrillation: the 2020 ESC guidelines and recent data on early rhythm control]. Herzschrittmacherther Elektrophysiol 2021; 32(2): 257–263.
7. Lip GYH, et al.: Hypertension and cardiac arrhythmias: a consensus document from the European Heart Rhythm Association (EHRA) and ESC Council on Hypertension, endorsed by the Heart Rhythm Society (HRS), Asia-Pacific Heart Rhythm Society (APHRS) and Sociedad Latinoamericana de Estimulacion Cardiaca y Electrofisiologia (SOLEACE). EP Europace 2017: 19(6): 891–911.
8. Williams B, et al.: 2018 ESC/ESH Guidelines for the management of arterial hypertension: The Task Force for the management of arterial hypertension oft her European Society of Cardiology /ESC) and the European Society of Hypertension (ESH). Eur Heart J. 2018; 39: 3021–3104.
9. Chung MK, et al.: Lifestyle and Risk Factor Modification for Reduction of Atrial Fibrillation: A Scientific Statement From the American Heart Association. Circulation 2020; 141: e750–e772.
10. Wang TJ, et al.: Obesity and the Risk of New-Onset Atrial Fibrillation. JAMA 2004; 292(20): 2471–2477.
11. Wilding JPH, et al.: Once-Weekly Semaglutide in Adults with Overweight or Obesity. N Engl J Med 2021; 384: 989–1002.
12. Haloot J, Mahmoud M, Badin A: Liraglutide Mortality Effect on Atrial Fibrillation Patients. Authorea. December 04, 2021.
13. Gami AS, et al.: Association of atrial fibrillation and obstructive sleep apnea. Circulation 2004; 110: 364–367.
14. Tattersall MC, et al.: Persistent Asthma Is Associated With Increased Risk for Incident Atrial Fibrillation in the MESA. Circ Arrhythm Electrophysiol 2020; 13: e007685.
15. Simons SO, et al.: Chronic obstructive pulmonary disease and atrial fibrillation: an interdisciplinary perspective. Eur Heart J 2021; 42: 532–540.
16. Gopinathannair R, et al.: Managing atrial fibrillation in patients with heart failure and reduced ejection fraction: a scientific statement from the American Heart Association. Circ Arrhythmia Electrophysiol 2021;14: e000078.
17. ANTWOORD study, ‘Late Breaking Science – Today and tomorrow’, EHRA 2023, 16–18 April 2023, Barcelona, Spain.
18. «Novel score predicts heart failure improvement after atrial fibrillation ablation», www.escardio.org/The-ESC/Press-Office/Press-releases/novel-score-predicts-heart-failure-improvement-after-atrial-fibrillation-ablatio (letzter Abruf 11.07.2023)

HAUSARZT PRAXIS 2023; 18(8): 38–39