Shared Decision Making In Atrial Fibrillation From The AHA 2023 Atrial Fibrillation Guideline

Bottom Line: No good evidence that the shared decision making aids below lead to better outcomes.

Today, I review, link to, and excerpt from

from 2023 ACC/AHAr/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines [PubMed Abstract] [Full-Text HTML] [Full-Text PDF]. Circulation. 2024 Jan 2;149(1):e1-e156. doi: 10.1161/CIR.0000000000001193. Epub 2023 Nov 30.

All that follows is from the above resource.



There are wide variations in how SDM is implemented in clinical care settings.5,6 Decision aids may provide standardization of SDM approaches for better informing patients about stroke reduction therapies and improve patient-reported measures but to date have not consistently been developed with recommended frameworks, have rarely been tested in systemically disadvantaged populations (low health literacy, UREGs, low socioeconomic status, rural geography, older adults), and have had variable impact on adherence and clinical outcomes.1–8 Ongoing work will measure health and digital literacy and strengthen the evidence for the impact of decision aids on decisional quality, adherence to treatment, and health outcomes.9

Symptom severity strongly correlates with QOL; thus, minimizing symptoms is an essential component of patient-centered AF management decisions. Rhythm control strategies improve QOL, particularly when maintenance of sinus rhythm or low AF burden is achieved.10 Notably, few SDM decision aids are focused on rate or rhythm control treatment options, and few have measured QOL as an outcome.3,5

Recommendation-Specific Supportive Text

  1. Recently, 2 comprehensive reviews of decision aids for stroke reduction therapies were conducted to determine the impact of these tools on patient-reported measures of decisional quality, while considering other important outcomes including oral anticoagulant (OAC) uptake, medication adherence, and the effect on bleeding and stroke.3,4 Most decision aids focused on patient- reported measures, and few underwent rigorous pilot testing or correlated the aid with clinical outcomes, such as stroke and bleeding. Decision aids consistently demonstrate improvements in patient knowledge. The pooled analysis by Song et al noted lower decisional conflict using decision aids and enhanced OAC uptake (risk ratio, 1.03 [95% CI, 1.01-1.05]).4 Decision aids have historically shown marginal improvement in 3-month measures of adherence, and the 2 largest randomized trials to date showed no improvement in adherence between decision aids and usual care at 1 year.1,2 There is a paucity of data on the impact of decision aids on stroke, thromboembolic events, or bleeding, and when assessed the benefit has been minimal or neutral.4,11 Despite the US Centers for Medicaid & Medicare Services coverage decision requirement for SDM for percutaneous left atrial appendage occlusion (LAAO), only 1 tool was identified that incorporated this option (Table 5).5

Table 5. Publicly Available Decision Aids
Agency Website Focus Area
American College of Cardiology Colorado Program for Patient Centered Decisions Stroke risk reduction therapies
Anticoagulation Choice Decision Aid Stroke risk reduction therapies
Ottawa Hospital Research Institute
Developer Healthwise AF ablation
Stroke risk reduction
Stanford Stroke risk reduction therapies

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