Experts debate management of patient with recent onset atrial fibrillation
This ‘Beyond the Guidelines’ feature is based on a discussion held at the General Medicine Grand Rounds conference held on 26 September 2024
Abstract: https://www.acpjournals.org/doi/10.7326/ANNALS-24-03490
URL goes live when the embargo lifts
In a new Annals “Beyond the Guidelines” feature, two physicians discuss treatment recommendations for a patient with atrial fibrillation (AF) in the context of the collaborative guideline addressing care of patients with AF published in 2023 by the American College of Cardiology, American Heart Association, American College of Chest Physicians and the Heart Rhythm Society. AF is the most common arrhythmia and substantially increases the risk for stroke and is associated with higher rates of mortality. Clinical decisions regarding the management of existing AF are complex and require the consideration of many factors. As such, asking “How would you manage this patient with recent onset atrial fibrillation?” is an important clinical question.
They reviewed the case of Dr. G, a 63-year-old man who noticed an irregular heart rate while biking to work and an electrocardiogram confirmed AF. Dr. G has a history of hypertension and hyperlipidemia and his family history is significant for AF. He was prescribed apixaban, 5 mg twice daily, and metoprolol tartrate, 25 mg twice daily, which he never took because his episodes were limited. He saw a cardiologist who recommended an ablation, but Dr. G did not go through with it because he did not have any further episodes. He obtained a second opinion, and that cardiologist gave three options: an ablation, use a ‘pill-in-pocket’ approach; or defer procedure and monitor symptoms. Dr. G remains uncertain about the best way to proceed.
The first discussant, Eli Gelfand, MD, is a general cardiologist, member of the Division of Cardiology at Beth Israel Deaconess Medical Center and an Assistant Professor of Medicine at Harvard Medical School, Boston, Massachusetts. Dr. Gelfand notes optimal blood pressure control, weight loss and multi-factor risk management should be used for primary and secondary prevention of AF. He also notes that when deciding to administer anticoagulation, clinical risk scores for stroke such as CHA2DS2-VASc and GARFIELD-AF, should be used as a starting point for management recommendations. In the case of Dr G, Dr. Gelfand notes his low risk for stroke and major bleeding, active lifestyle, good control of hypertension and low burden of AF as reasons for recommending against anticoagulation, catheter ablation or chronic antiarrhythmic therapy. He emphasizes that the risks and benefits of starting Dr G on anticoagulation should be reassessed regularly.
The second discussant, Patricia Tung, MD, is a cardiac electrophysiologist, is a member of the Division of Cardiology at Beth Israel Deaconess Medical Center and an Assistant Professor of Medicine at Harvard Medical School, Boston, Massachusetts. Dr. Tung asserts that both sleep apnea and physical inactivity are important risk factors for AF and advocates for moderate exercise as a primary strategy for AF prevention. She agrees that anticoagulation is not required in the case of Dr G and recommends continued monitoring for AF. Dr. Tung recommends proceeding with ablation once Dr G’s AF episodes become more frequent.
All “Beyond the Guidelines” features are based on selected clinical conferences at Beth Israel Deaconess Medical Center (BIDMC) and include multimedia components published in the Annals of Internal Medicine.
Media contacts: For an embargoed PDF, please contact Angela Collom at acollom@acponline.org. To speak with corresponding author Gerald W. Smetana, MD, please email Kendra McKinnon at Kmckinn1@bidmc.harvard.edu.
