How Differences in Afib Guidelines Influence Care

Guidelines for the management of atrial fibrillation in different parts of the world are largely in agreement on how to handle the condition, but differences can help shed light on alternate approaches to more complicated cases.

A comparison of the most recent clinical guidelines on the management of atrial fibrillation from the United States, Europe, and Canada was conducted by Julian Wolfes, MD, a cardiologist at Münster University Hospital in Münster, Germany, and colleagues, and published online in JACC: Clinical Electrophysiology.

Guidelines often have differences in the way they evaluate or approach the same issues, so comparing them is useful. “It’s interesting to see what triggered those differences and how they translate into clinical practice,” Wolfes said.

The comparison of the three sets of guidelines could allow cardiologists to see how similar problems are approached around the world, and some issues might be better described in a different guideline, he explained.

“About 80% of the time, the next step is clear,” he said. “But in more complex cases, it’s worth looking at what other guidelines recommend in that situation.”

The guidelines have minor but potentially important differences in the way they classify atrial fibrillation and in their assessment of screening, rate-control targets, and indications for oral anticoagulation, rhythm control, and catheter ablation.

The most interesting difference, according to Wolfes, is in the way the guidelines approach catheter ablation in patients with persistent atrial fibrillation who are not taking antiarrhythmic drugs.

Approach to Catheter Ablation

The European guidelines are conservative in their recommendation for early ablation, he said, whereas the American guidelines are more liberal and recommend ablation much earlier.

This is largely the result of the way studies that support the recommendation — which tend to indicate that ablation is good for paroxysmal but not persistent atrial fibrillation — are interpreted. The restrictive European recommendation is based on the limited data supporting early ablation for persistent atrial fibrillation.

But the American guidelines suggest the difference between paroxysmal and persistent atrial fibrillation is not clear cut so early ablation can benefit both.

“That’s closer to our daily experience,” said Wolfes. “Patients with paroxysmal atrial fibrillation can have persistent episodes, so perhaps it’s not the best way to classify patients.”

All three sets of guidelines are largely in agreement when you look at the big picture, and the differences are largely cosmetic, said Jose Joglar, MD, a cardiologist at the University of Texas Southwestern Medical Center in Dallas and chair of the committee that wrote the American guidelines.

“All the guidelines do the same thing, but they get there in a different way,” he explained. “It’s a reminder that this is not an exact science.”

It is important to remember these are guidelines and not clear regulations for how patients should be treated. “A lot of physicians hope we will tell them what to do, but it doesn’t work like that,” said Joglar. “Patients need more nuance, and doctors should approach atrial fibrillation management in a more holistic way, not only managing the rhythm.”

We also “need to talk about alcohol cessation, weight loss, risk factor management, and prevention,” he said.

Wolfes and Joglar had no financial disclosures to report.