Doctors may be adding new drug options, using less aspirin and more radio frequency ablation to treat atrial fibrillation patients as a result of comprehensive new guidelines for the medical and surgical treatment of this common heart problem.
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“If I were a patient with afib, these guidelines should make me feel a lot better. This document is important and very good,” said Oussama Wazni, MD, Director of the Outpatient Electrophysiology Department and Co-Director of the Ventricular Arrhythmia Center. “As a physician, it also gives a lot more direction,” he said.
The American Heart Association, American College of Cardiology and the Heart Rhythm Society, in collaboration with the Society of Thoracic Surgeons, developed the new guidelines after experts reviewed clinical findings, researched results and many other documents. Experts updated the previous document in 2011. Some changes are subtle; others are potential game changers in treatment.
Atrial fibrillation basics
Atrial arrhythmias originate in the upper (atrial) chambers of the heart. Many impulses begin and spread through the atria, creating a rhythm that is disorganized, rapid and irregular. Because the impulses are traveling through the atria in a disorderly fashion, heart contraction loses its usual rhythm.
Patrick Tchou, MD, Co-director of Cleveland Clinic’s Ventricular Arrhythmia Center and Associate Section Head of the Section of Electrophysiology and Cardiac Pacing, collaborated on the new guidelines. In a whiteboard video, Dr. Tchou describes atrial arrhythmia in more detail.
Main changes in treatment
The 2014 guidelines direct doctors to act on four main changes in the approach to treatment of atrial fibrillation.
1. Increased emphasis and use of radio frequency ablation for non-valvular atrial fibrillation (rhythm disorders that do not occur because of valve disease)
In an ablation procedure, doctors create scars that block any inappropriate impulses firing from the treated areas. “This document does a very good job of taking all the data we have and all the evidence that’s in the literature about ablations. We’ve been seeing a trend that if a patient is very symptomatic and medications have failed to control their afib, then an ablation is warranted,” Dr. Wazni said.
2. Inclusion of three new anticoagulant drugs in the treatment of non-valvular atrial fibrillation
Previous guidelines recommended only warfarin. The new drugs, dabigatran, rivaroxaban and apixaban, might have benefits for certain patients. “Evidence and studies show some of these new anticoagulants are more effective than Coumadin (warfarin), so if they’re not more effective, they’re as effective and safer from a bleeding standpoint. It’s important to have these new medications in our repertoire for our patients because I believe they improve safety, and the document provides clear guidelines on who to prescribe the newer anticoagulants,” said Dr. Wazni.
3. A diminished role of aspirin as a preventive treatment for patients with atrial fibrillation
“As we know from past experience, aspirin is not very effective in stroke prevention and it can cause bleeding. This document does a very good job at guiding physicians and patients on when it’s appropriate to use aspirin and when it’s not. There is less dependence now on using aspirin,” Dr. Wazni said.
4. Creation of a new risk calculator for complications due to atrial fibrillation
“This document goes into a more granular calculation of the risk of stroke,” Dr. Wazni said, adding that the new score incorporates some more information about the patient into the risk calculator. “It’s going to be very beneficial to patients because if we have a better idea of their stroke risk, then we can prevent and manage it better.”
The 2014 Guideline for the Management of Patients with Atrial Fibrillation appears in the Journal of the American College of Cardiology, Circulation and HeartRhythm.