Linking To The 2024 ESC Guidelines On Atrial Fibrillation “4. Patient pathways and management of AF”

Today, I review and link to Today, I review and link to The European Society of Cardiology‘s 2024 Guidelines on Atrial Fibrillation, 4. Patient pathways and management of AF.

All that follows is from the above resource.

4. Patient pathways and management of AF

4.1. Patient-centred, multidisciplinary AF management

4.1.1. The patient at the heart of care

A patient-centred and integrated approach to AF management means working with a model of care that respects the patient’s experience, values, needs, and preferences for planning, co-ordination, and delivery of care. A central component of this model is the therapeutic relationship between the patient and the multidisciplinary team of healthcare professionals (Figure 2). In patient-centred AF management, patients are seen not as passive recipients of health services, but as active participants who work as partners alongside healthcare professionals. Patient-centred AF management requires integration of all aspects of AF management. This includes symptom control, lifestyle recommendations, psychosocial support, and management of comorbidities, alongside optimal medical treatment consisting of pharmacotherapy, cardioversion, and interventional or surgical ablation (Table 9). Services should be designed to ensure that all patients have access to an organized model of AF management, including tertiary care specialist services when indicated (see Supplementary data online, Table S1, Evidence Table 4 and Additional Evidence Table S3). It is equally important to maintain pathways for patients to promptly re-engage with specialist services when their condition alters.

Figure 2

Multidisciplinary approach to AF management.

Principal caregivers are involved in the community and hospital settings to provide optimal, patient-centred care for patients living with AF. AF-CARE, atrial fibrillation—[C] Comorbidity and risk factor management, [A] Avoid stroke and thromboembolism, [R] Reduce symptoms by rate and rhythm control, [E] Evaluation and dynamic reassessment.

Table 9

Achieving patient-centred AF management

Components of patient-centred AF management:
Optimal treatment according to the AF-CARE pathway, which includes:
∘ [C] Comorbidity and risk factor management
∘ [A] Avoid stroke and thromboembolism
∘ [R] Reduce symptoms by rate and rhythm control
∘ [E] Evaluation and dynamic reassessment
Lifestyle recommendations
Psychosocial support
Education and awareness for patients, family members, and caregivers
Seamless co-ordination between primary care and specialized AF care
How to implement patient-centred AF management:
Shared decision-making
Multidisciplinary team approach
Patient education and empowerment, with emphasis on self-care
Structured educational programmes for healthcare professionals
Technology support (e-Health, m-Health, telemedicine)a

 

AF, atrial fibrillation; AF-CARE, atrial fibrillation—[C] Comorbidity and risk factor management, [A] Avoid stroke and thromboembolism, [R] Reduce symptoms by rate and rhythm control, [E] Evaluation and dynamic reassessment.

 

^ae-Health refers to healthcare services provided using electronic methods; m-Health, refers to healthcare services supported by mobile devices; and telemedicine refers to remote diagnosis or treatment supported by telecommunications technology.

© ESC 2024

4.1.2. Education and shared decision-making

Clear advice about the rationale for treatments, the possibility of treatment modification, and shared decision-making can help patients live with AF (see Supplementary data online, Table S2).⁹² An open and effective relationship between the patient and the healthcare professional is critical, with shared decision-making found to improve outcomes for OAC and arrhythmia management.^93,94 In using a shared approach, both the clinician and patient are involved in the decision-making process (to the extent that the patient prefers). Information is shared in both directions. Furthermore, both the clinician and the patient express their preferences and discuss the options. Of the potential treatment decisions, no treatment is also a possibility.⁹⁵ There are several toolkits available to facilitate this, although most are focused on anticoagulation decisions. For example, the Shared Decision-Making Toolkit (http://afibguide.com, http://afibguide.com/clinician) and the Successful Intravenous Cardioversion for Atrial Fibrillation (SIC-AF) score have been shown to reduce decisional conflict compared with usual care in patients with AF.^93,94 Patient-support organizations can also make an important contribution to providing understandable and actionable knowledge about AF and its treatments (e.g. local support groups and international charities, such as http://afa-international.org). As AF is a chronic or recurrent disease in most patients, education is central to empower patients, their families, and caregivers.

4.1.3. Education of healthcare professionals

Gaps in knowledge and skills across all domains of AF care are consistently described among cardiologists, neurologists, internal medicine specialists, emergency physicians, general practitioners, nurses, and allied health practitioners.^96–98 Healthcare professionals involved in multidisciplinary AF management should have a knowledge of all available options for diagnosis and treatment.^99–101 In the STEEER-AF trial,⁹⁹ real-world adherence to clinical practice guidelines for AF across six ESC countries was poor. These findings highlight the critical need for appropriate training and education of healthcare professionals.¹⁰²

Specifically targeted education for healthcare professionals can increase knowledge and lead to more appropriate use of OAC for prevention of thromboembolism.¹⁰³ However, educational interventions for healthcare providers are often not enough to sustainably impact behaviour.¹⁰⁴ Other tools may be needed, such as active feedback,¹⁰³ clinical decision support tools,¹⁰⁵ expert consultation,¹⁰⁶ or e-Health learning.¹⁰⁷

4.1.4. Inclusive management of AF

Evidence is growing on differences in AF incidence, prevalence, risk factors, comorbidities, and outcomes according to gender.¹⁰⁸ Women diagnosed with AF are generally older, have more hypertension and heart failure with preserved ejection fraction (HFpEF), and have less diagnosed coronary artery disease (CAD).¹⁰⁹ Registry studies have reported differences in outcomes, with higher morbidity and mortality in women, although these may be confounded by age and comorbidity burden.^110–112 Women with AF may be more symptomatic, and report a lower quality of life.^41,113 It is unclear whether this is related to delayed medical assessment in women, or whether there are genuine sex differences. Despite a higher symptom load, women are less likely to undergo AF ablation than men, even though antiarrhythmic drug therapy seems to be associated with more proarrhythmic events in women.¹⁰⁹ These observations call for more research on gender differences in order to prevent disparities and inequality in care. Other diversity aspects such as age, race, ethnicity, and transgender issues, as well as social determinants (including socioeconomic status, disability, education level, health literacy, and rural/urban location) are important contributors to inequality that should be actively considered to improve patient outcomes.¹¹⁴

4.2. Principles of AF-CARE

The 2024 ESC Guidelines for the management of AF have compiled and evolved past approaches to create principles of management to aid implementation of these guidelines, and hence improve patient care and outcomes. There is growing evidence that clinical support tools^115–118 can aid best-practice management, with the caveat that any tool is a guide only, and that all patients require personalized attention. The AF-CARE approach covers many established principles in the management of AF, but does so in a systematic, time-orientated format with four essential treatment pillars (Figure 3; central illustration). Joint management with each patient forms the starting point of the AF-CARE approach. Notably, it takes account of the growing evidence base that therapies for AF are most effective when associated health conditions are addressed. A careful search for these comorbidities and risk factors [C] is critical and should be applied in all patients with a diagnosis of AF. Avoidance of stroke and thromboembolism [A] in patients with risk factors is considered next, focused on appropriate use of anticoagulant therapy. Reducing AF-related symptoms and morbidity by effective use of heart rate and rhythm control [R] is then applied, which in selected patients may also reduce hospitalization or improve prognosis. The potential benefit of rhythm control, accompanied by consideration of all risks involved, should be considered in all patients at each contact point with healthcare professionals. As AF, and its related comorbidities, changes over time, different levels of evaluation [E] and re-evaluation are required in each patient, and these approaches should be dynamic. Due to the wide variability in response to therapy, and the changing pathophysiology of AF as age and comorbidities advance, reassessment should be built into the standard care pathway to prevent adverse outcomes for patients and improve population health.

Figure 3

Central illustration. Patient pathway for AF-CARE (see Figures 4, 5, 6, and 7 for the [R] pathways for first-diagnosed, paroxysmal, persistent and permanent AF).

AF, atrial fibrillation; AF-CARE, atrial fibrillation—[C] Comorbidity and risk factor management, [A] Avoid stroke and thromboembolism, [R] Reduce symptoms by rate and rhythm control, [E] Evaluation and dynamic reassessment; CCS, chronic coronary syndrome; CHA₂DS₂-VA, congestive heart failure, hypertension, age ≥75 years (2 points), diabetes mellitus, prior stroke/transient ischaemic attack/arterial thromboembolism (2 points), vascular disease, age 65–74 years; DOAC, direct oral anticoagulant; ECG, electrocardiogram; HFrEF, heart failure with reduced ejection fraction; INR, international normalized ratio of prothrombin time; OAC, oral anticoagulant; OSA, obstructive sleep apnoea; PVD, peripheral vascular disease; SGLT2, sodium-glucose cotransporter-2; VKA, vitamin K antagonist. ^aAs part of a comprehensive management of cardiometabolic risk factors.

AF-CARE builds upon prior ESC Guidelines, e.g. the five-step outcome-focused integrated approach in the 2016 ESC Guidelines for the management of AF,¹¹⁹ and the AF Better Care (ABC) pathway in the 2020 ESC Guidelines for the diagnosis and management of AF.¹²⁰ The reorganization into AF-CARE was based on the parallel developments in new approaches and technologies (in particular for rhythm control), with new evidence consistently suggesting that all aspects of AF management are more effective when comorbidities and risk factors have been considered. This includes management relating to symptom benefit, improving prognosis, prevention of thromboembolism, and the response to rate and rhythm control strategies. AF-CARE makes explicit the need for individualized evaluation and follow-up in every patient, with an active approach that accounts for how patients, their AF, and associated comorbidities change over time. The AF-CARE principles have been applied to different patient pathways for ease of implementation into routine clinical care. This includes the management of first-diagnosed AF (Figure 4), paroxysmal AF (Figure 5), persistent AF (Figure 6), and permanent AF (Figure 7).

Figure 4

[R] Pathway for patients with first-diagnosed AF.

AF, atrial fibrillation; AF-CARE, Atrial fibrillation—[C] Comorbidity and risk factor management, [A] Avoid stroke and thromboembolism, [R] Reduce symptoms by rate and rhythm control, [E] Evaluation and dynamic reassessment; LVEF, left ventricular ejection fraction. After following the pathway for first-diagnosed AF, patients with recurrent AF should enter the AF-CARE [R] pathway for paroxysmal, persistent, or permanent AF, depending on the type of their AF.

Figure 5

[R] Pathway for patients with paroxysmal AF.

AF, atrial fibrillation; AF-CARE, atrial fibrillation—[C] Comorbidity and risk factor management, [A] Avoid stroke and thromboembolism, [R] Reduce symptoms by rate and rhythm control, [E] Evaluation and dynamic reassessment; b.p.m., beats per minute; HFmrEF, heart failure with mildly reduced ejection fraction; HFrEF, Heart failure with reduced ejection fraction; LVEF, left ventricular ejection fraction. ^aIn patients with HFrEF: Class I if high probability of tachycardia-induced cardiomyopathy; and Class IIa in selected patients to improve prognosis.

Figure 6

[R] Pathway for patients with persistent AF.

AF, atrial fibrillation; AF-CARE, Atrial fibrillation—[C] Comorbidity and risk factor management, [A] Avoid stroke and thromboembolism, [R] Reduce symptoms by rate and rhythm control, [E] Evaluation and dynamic reassessment; b.p.m., beats per minute; HFmrEF, heart failure with mildly reduced ejection fraction; HFrEF, heart failure with reduced ejection fraction; LVEF, left ventricular ejection fraction. ^aIn patients with HFrEF: Class I if high probability of tachycardia-induced cardiomyopathy; and Class IIa in selected patients to improve prognosis.

Figure 7

[R] Pathway for patients with permanent AF.

AF, atrial fibrillation; AF-CARE, Atrial fibrillation—[C] Comorbidity and risk factor management, [A] Avoid stroke and thromboembolism, [R] Reduce symptoms by rate and rhythm control, [E] Evaluation and dynamic reassessment; b.p.m., beats per minute; CRT, cardiac resynchronization therapy; HF, heart failure; LVEF, left ventricular ejection fraction. Permanent AF is a shared decision made between the patient and physician that no further attempts at restoration of sinus rhythm are planned. ^aNote that the combination of beta-blockers with diltiazem or verapamil should only be used under specialist advice, and monitored with an ambulatory ECG to check for bradycardia.

Recommendation Table 4: Recommendations for patient-centred care and education (see also Evidence Table 4)