New JAMA Review Identifies Best Practices for Millions Living With Atrial Fibrillation

Atrial fibrillation, a condition affecting more than 10 million American adults, is associated with an increased risk of stroke, heart failure, heart attack, dementia, chronic kidney disease, and mortality. A new review published in JAMA summarizes epidemiology, pathophysiology, clinical presentation, prognosis, and treatments for AF.

The 2023 Guideline for the Diagnosis and Management of Atrial Fibrillation from the American College of Cardiology, American Heart Association, American College of Clinical Pharmacy, and Heart Rhythm Society proposes four stages of AF progression and recommends lifestyle and risk factor modifications across all stages:

• Stage 1 – At risk for AF: Patients with AF-associated risk factors like obesity or hypertension
• Stage 2 – Pre-AF: Evidence of atrial pathology without diagnosed AF
• Stage 3 – Clinical AF: Recurrent or continuous episodes of AF
• Stage 4 – Permanent AF: AF that is no longer managed with rhythm control strategies

Stroke prevention is a cornerstone treatment in AF

AF causes the formation of a blood clot in the left atrial appendage, which can embolize to the brain and cause ischemic stroke. In patients with an estimated risk of stroke and thromboembolic events of 2% or greater per year, anticoagulation with a vitamin K antagonist or direct oral anticoagulant reduces stroke risk by 60% to 80% compared with placebo. In most patients, a direct oral anticoagulant, such as apixaban, rivaroxaban, or edoxaban, is recommended over warfarin because of lower bleeding risks. Percutaneous left atrial appendage occlusion is now offered to patients with a contraindication to an oral anticoagulant.

Inappropriate aspirin use increases the risk of bleeding

“Inappropriate aspirin use in AF is quite common,” said Dr. Darae Ko, MD, MSc, assistant scientist II at the Hinda and Marcus Institute for Aging Research, a practicing cardiologist, and the first author of the review. “Using aspirin as an alternative to an oral anticoagulant in patients with AF will not prevent AF-related stroke and will increase bleeding risk.”

According to Dr. Ko, it is important to reassess the need for aspirin in patients who are on dual therapy — aspirin plus an oral anticoagulant — because the dual therapy may not be needed beyond one year after a patient has been treated for a heart attack.  

Early rhythm control is important to reduce the burden of AF

The 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of AF recommends early rhythm control with antiarrhythmic drugs or catheter ablation to restore and maintain sinus rhythm for some patients with AF. Catheter ablation is a first-line therapy in patients with symptomatic paroxysmal AF to improve symptoms and slow the progression to persistent AF. Catheter ablation is also recommended for patients with AF who have heart failure with reduced ejection fraction to improve quality of life, left ventricular systolic function, and cardiovascular outcomes, such as rates of mortality and heart failure hospitalization.

“As the population ages, the number of patients with AF and the associated complexity of managing these patients are expected to increase. Lifestyle and risk factor modification combined with stroke prophylaxis and rhythm control in appropriate patients are critically important to improve quality of life and health outcomes in millions of patients with AF,” said Dr. Ko.

About Hebrew SeniorLife

Hebrew SeniorLife, an affiliate of Harvard Medical School, is a national senior services leader uniquely dedicated to rethinking, researching, and redefining the possibilities of aging. Hebrew SeniorLife cares for more than 4,500 seniors a day across campuses throughout Greater Boston. Locations include: Hebrew Rehabilitation Center-Boston and Hebrew Rehabilitation Center-NewBridge in Dedham; NewBridge on the Charles, Dedham; Orchard Cove, Canton; Simon C. Fireman Community, Randolph; Center Communities of Brookline, Brookline; Jack Satter House, Revere; and Leyland Community, Dorchester. Founded in 1903, Hebrew SeniorLife also conducts influential research into aging at the Hinda and Arthur Marcus Institute for Aging Research, which has a portfolio of more than $98 million, making it one of the largest gerontological research facilities in the U.S. in a clinical setting. It also trains more than 500 geriatric care providers each year. For more information about Hebrew SeniorLife, follow us on our blog, Facebook, Instagram, Threads, and LinkedIn.

About the Hinda and Arthur Marcus Institute for Aging Research

Scientists at the Marcus Institute seek to transform the human experience of aging by conducting research that will ensure a life of health, dignity, and productivity into advanced age. The Marcus Institute carries out rigorous studies that discover the mechanisms of age-related disease and disability; lead to the prevention, treatment, and cure of disease; advance the standard of care for older people; and inform public decision-making.