New Staging System for AFib Allows for More Nuanced Treatment, Experts Say

Rachel Murphy
·6 min read
Teresa Otto / Getty Images
Teresa Otto / Getty Images

Fact checked by Nick Blackmer

Key Takeaways

  • The American College of Cardiologists and the American Heart Association released new guidance for how to diagnose and treat atrial fibrillation.

  • Atrial fibrillation received a new classification structure, emphasizing the complex nature of the condition.

  • Surgical solutions such as catheter ablation were moved to a class 1 recommendation.

  • Lifestyle modifications receive greater emphasis as a treatment option.



While most people strapped on a fitness watch for the first time to count their steps or check their heart rates, some are finding more than they bargained for: This technology has revealed a swath of people experiencing some form of atrial fibrillation (AFib). AFib affects roughly 6 million Americans and results in 450,000 hospitalizations each year. While AFib is the most common form of heart arrhythmia, many don’t experience acute symptoms.

The American College of Cardiology (ACC) and the American Heart Association (AHA) have now released new guidelines to help categorize AFib and recommend new best practices for treatment. The new guidelines, published in Circulation and the Journal of the American College of Cardiology, outline a new standard for diagnosing various stages of AFib, as well as three updated methodologies for treating the condition.



What is Atrial Fibrillation?

Atrial fibrillation occurs when the upper two chambers of the heart beat in an irregular rhythm, most often too fast, resulting in inefficiently pumping the blood. AFib is technically an electrical problem; your heart isn’t getting the correct electrical pulses to cause the full opening and contracting of the atria, leaving open the possibility of blood clots from pooled blood that didn’t exit the atria when it was supposed to. Symptoms of AFib include chest pains, heart palpitations, feeling light-headed or faint, and shortness of breath in times of rest, and tiring easily.



New Stages of AFib

Prior to the new guidelines, AFib was classified only by how long the patient had experienced the condition. The ACC has introduced four stages of AFib that include:

  • Stage one (at risk for AFib) patients present risk factors that providers may see as problematic. Those could be unhealthy lifestyle choices such as smoking, physical activity levels, advanced age, or genetic predisposition.

  • Stage two (Pre-AFib) patients have displayed structural or electrical findings that forecast AFib as a high likelihood in the future.

  • Stage three (AFib) patients have shown documentable evidence of AFib in one of its various levels of acuity, rated 3A–D.

  • Stage four (Permanent AFib) patients have discussed their continuing AFib issues with their physician and decided not to attempt to control it through pharmaceuticals, surgical options, or lifestyle changes.

The new guidelines offer more insight into the complexity of atrial fibrillation, Bradley Serwer, MD, interventional cardiologist and chief medical officer at VitalSolution, told Verywell.

“The new AFib classification is now a spectrum with a progression from those ‘at risk,’ all the way to permanent AFib,” he said.

This rejiggering of the classification system partners well with the new treatment guidelines, with an emphasis placed on early intervention through lifestyle changes, surgical options, and pharmaceutical therapies.

A Focus on Lifestyle Changes

While AFib is very common, it’s also very treatable through lifestyle modifications, and the ACC and AHA recommend a stronger focus on those for newly diagnosed patients. Lifestyle and risk factor modification (LRFM) involves directly addressing changeable risk factors, such as alcohol abuse, smoking, sleep apnea, and obesity.

Physicians have known for a long time that certain lifestyle characteristics affect the incidence of atrial fibrillation, Alexander Postalian, MD, a cardiologist at the Texas Heart Institute, told Verywell.

“The disease has a prominent non-modifiable genetic component, but there is a lot patients can do to reduce the risk of developing atrial fibrillation, or to reduce the frequency of arrhythmia if a patient develops it,” Postalian said. “Even though this is not new information, these guidelines do a better job at emphasizing this, which is welcome.”

Related: Symptoms of Atrial Fibrillation

Early and Aggressive Surgical Adoption

Lifestyle changes may be enough for patients who are stage one or two, but for those who have empirical evidence of recurring AFib, the new guidelines advise cardiologists to pursue surgical options such as cardiac ablation as a first line of defense for stage three patients. Serwer says that this shift allows more patients to qualify for the surgery than were previously eligible, and skip a time-consuming and often uncomfortable trial period on anti-AFib pharmaceutical options.

“Previously, to qualify for an AFib ablation, the patient had to try and fail antiarrhythmic medical therapy or not tolerate the medicine. Now we no longer have to try these medications first for certain patients,” Serwer said.

Related: How Atrial Fibrillation (A-Fib) Is Treated

Serwer explained that many antiarrhythmic medications have significant side effects, and must be started in the hospital in case of an extreme reaction such as ventricular tachycardia (which can be a complication of a heart attack). Bypassing medicinal treatment in favor of surgical options may reduce AFib-related deaths.

Postalian noted that not all patients do better with ablations. Older patients and those who have had AFib for a sustained amount of time may do better with medications. However, removing roadblocks to surgery allows cardiologists to make more personalized decisions with their patients for the best methodology for their situation.

Ablations aren’t the only procedure that received a higher recommendation. Serwer said that left atrial appendage closure was also moved to a class 2a recommendation for patients with a high bleeding risk. This less-invasive surgery allows providers to close a finger-like appendage in the left atrium that is prone to producing blood clots, which can lead to embolic strokes.



What Is Catheter Ablation?

Catheter ablation is a minimally invasive procedure that uses radio frequency energy to damage heart tissue that is causing an irregular heartbeat. Once the tissue is damaged, the electrical pulses should return to normal. There are two methods for ablations: burning tissue or freezing it, both with the same results. Cryoablations are less common, but potentially come with fewer side effects.



Flexible Guidance on Stroke Risk and Anticoagulants

Since AFib can be a contributing factor to strokes, many AFib patients have historically been placed on anticoagulants such as aspirin, based only on CHA2DS2-VASc scores (congestive heart failure, hypertension, age less than 75 years, diabetes mellitus, stroke double weight). The updated guidance broadens the considerations taken into account. In addition to bleeding risk scores, providers should take into account other comorbidities and risk evaluations when determining whether to begin, continue, or stop blood thinners.



What This Means For You

Atrial fibrillation can have a wide range of symptoms, from no discernible symptoms to heart palpitations, shortness of breath, and chest pain. If you notice some irregularities in your heartbeat, either anecdotally or when using a fitness wearable, it’s smart to talk to your doctor immediately. Early AFib can be treated with lifestyle modifications.



Read the original article on Verywell Health.