a multidisciplinary and dynamic approach

LThe European Society of Cardiology has just updated its recommendations regarding the management of atrial fibrillation (AF) [1]the last version of which dated from 2020.

Little change in the classification of AF, the therapeutic management of which is guided by the duration of episodes :

• paroxysmal : return of AF to sinus rhythm spontaneously in 2 to 7 days ;
• persistent : an intervention, most often pharmacological or electrical cardioversion, is necessary to return to sinus rhythm ;
• permanente : maintenance of sinus rhythm cannot be achieved.

After ABC, the CARE strategy

In terms of care, the previous strategy ABC (pour Anticoagulation, Bafter control, Comorbidity) leaves room for CAREof which the four shutters are :

• THE Comorbidities ;
• l’Anticoagulation ;
• the Rsymptom reduction ;
• l’ANDassessment/reassessment.

The patient is at care centeras part of a multidisciplinary approach, integrating the management of comorbidities and symptoms.

How to manage comorbidities ?

The management of comorbidities is a point central of treatment. FA is in fact considered as a “ social disease », whose incidence could be reduced thanks to better control of risk factors.

This goes through :

• screening of high blood pressure (HTA) and blood pressure control ;
• recognition of heart failure (grade 1) ;
• adaptation of treatments ;
• blood volume control ;
• the care of overweight and obesity with a goal of losing at least 10% of initial weight ;
• the avoidance of the consumption ofalcoholwhich must be less than 3 glasses per week ( 30 g of alcohol).

The establishment of a physical activity programindependent of daily activities, is recommended at a rate of 140 minutes per week at 70% of the theoretical maximum frequency.

Note that systematic screening for sleep apnea by questionnaire is not recommended, because its management does not modify the result of the ablation or the cardioversion.

When to implement anticoagulation ?

The anticoagulation component, which aims to reduce the risk of stroke and thromboembolic events, is independent of the others. The approach is identical regardless of the type of episodes and the treatment offered elsewhere.

CHADSVA replaces CHADSVASC

The classic CHADSVASC score (C for chronic heart failure, H for hypertension, A for Age > 75 years, D for Diabetes, S for history of stroke or TIA, V for vascular damage, A for Age between 65 years and 74 years, SC for Sex Category) is replaced by the CHADSVA score, reflecting theabandon of taking into account the sex of the patient (SC) for the sake of simplification. Each item is worth 1 point, except age > 75 years and history of stroke or TIA which are worth 2 points.

In practice, the indications for anticoagulation are unchanged in the event of :

• score CHADSVA > 2 (class I) ;
• CHADSVA score 1 (class IIa).

The indication for anticoagulation remains systematic if AF is associated with hypertrophic cardiomyopathy or cardiac amyloidosis (class IB).

HAS-BLED disappears

For the assessment of bleeding risk, the HAS-BLED score disappears.

As in the 2020 recommendations, the choice is first-line direct oral anticoagulants (AOD), easier to manage and associated with lower morbidity and mortality than antivitamines K. The latter remain the treatment of choice in patients with mechanical valves and in cases of mitral stenosis.

Auricle occlusion may be proposed (class IIb) when anticoagulation is not possible.

What rhythm control strategy ?

In case of paroxysmal AF, l’ablation is now recommended on the front line (class I recommendation), such as antiarrhythmic treatment according to the assessment and preferences of the patient within the framework of a shared decision.

In the case of persistent AF, antiarrhythmic treatment is recommended on the front line (class I). L’ablation is offered in second intention in case of failure or intolerance to antiarrhythmic drugs, because it gives less good results in this context (class IIb).

In cases of heart failure, ablation is recommended as first intention (class I).

Three types of energy are now available for ablation or isolation of heart tissue causing the arrhythmia :

• the radio frequency (which generates a high temperature) ;
• the cryoenergy (cold) ;
• the pulsed electric field (electroporation).

Overall, all three techniques give good results, each having its advantages and disadvantages.

The risk of severe complications (such as atrioesophageal fistula or stroke) associated with thermo-ablation is currently very low (less than 0.1%).

Electroporation, which has the advantage of its specificity for cardiac tissue, is only suitable for the ablation of pulmonary veins and exposes itself to its own complications.

In total, whatever the energy used, ablation is today a mature and safe technique in experienced hands.

What frequency control strategy ?

The slowing of the heart rate mainly concerns permanent AF, because there is a risk of deterioration of cardiac function.

The target frequency is ≤ 110/mn.

The choice of treatment, which aims to reduce heart rate and symptoms, is guided by left ventricular ejection fraction (LVEF) :

Assess and reassess the patient

Through the E of the CARE acronym, the new European recommendations emphasize the need to regularly evaluate and re-evaluate patients with AF, as part of multidisciplinary monitoring. AF is in fact a rhythm disorder that evolves with age, the underlying physiopathological mechanisms (electrical, neuro-hormonal, hemodynamic), risk factors and comorbidities, which requires dynamic management.

According to an interview with Professor Jean-Claude Deharo, head of the Cardiology-Rhythmology department, La Timone hospital, Marseille, secretary general of the office of the French Society of Cardiology.