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Chapter 5: Guideline Recommendations: Which AAD and for Whom?
Thomas F Deering1, James A Reiffel2, Allen J Solomon3
1Piedmont Healthcare, Atlanta, GA, USA.
Insights
Guidelines for managing atrial fibrillation (AF) focus on antiarrhythmic drug (AAD) selection. Inappropriate drug choices and patient selection were common in a recent survey, indicating a gap in guideline-directed care for AF treatment.
Area of Science:
- Cardiology
- Clinical Guidelines
- Pharmacology
Background:
- Atrial fibrillation (AF) management guidelines from AHA/ACC/HRS and ESC provide frameworks for antiarrhythmic drug (AAD) selection.
- AAD choice is influenced by patient factors such as structural heart disease (SHD), coronary artery disease, and heart failure (HF) type.
Purpose of the Study:
- To discuss current guidelines for AF management, focusing on appropriate AAD selection.
- To identify patient populations suitable for AAD treatment and evaluate adherence to guideline-directed care.
Main Methods:
- Review of AHA/ACC/HRS and ESC guidelines for AF management.
- Analysis of data from the AIM-AF survey, a multinational study of AF management practices among cardiologists and electrophysiologists.
Main Results:
- Guideline recommendations for AAD selection are based on safety, considering SHD, CAD, and HF.
- The AIM-AF survey revealed inconsistent application of guideline-directed care, with inappropriate AAD selection and patient targeting observed across various drug classes and patient groups.
- Notable findings include overuse of amiodarone in patients without SHD and inappropriate use of sotalol in patients with HFrEF.
Conclusions:
- There is a significant gap between established guidelines for AF management and actual clinical practice regarding AAD selection.
- Improved adherence to guideline-directed care is necessary to optimize safety and efficacy in antiarrhythmic drug therapy for atrial fibrillation.
- Further education and implementation strategies are needed to ensure appropriate patient selection and drug choice in AF management.
Abstract:
This chapter discusses the American College of Cardiology/American Heart Association/ Heart Rhythm Society (AHA/ACC/HRS) and European Society of Cardiology (ESC) guidelines for atrial fibrillation (AF) management with particular focus on antiarrhythmic drug (AAD) selection and the identification of individuals for whom AAD treatment is appropriate. Discussion includes AAD indications, when to start an AAD, choosing among AADs, how to minimize proarrhythmic risk, how to determine efficacy, and the use of adjuvant interventions. The indications for all AADs are based on safety; the current AHA/ACC/HRS and ESC guidelines state that the choice of AAD is based on the presence or absence of structural heart disease (SHD), coronary artery disease, or heart failure (HF), with further recommendations in the ESC guidelines based on HF type (e.g., HF with reduced ejection fraction [HFrEF] versus HF with preserved ejection fraction [HFpEF]). The chapter closes with a discussion of the lack of consistent use of guideline-directed care, with a review of supportive data from the recently reported AIM-AF survey-a multinational survey on AF management that involved both cardiologists and electrophysiologists. In AIM-AF, inappropriate drug selection in terms of suitable candidate selection and drug choice occurred with all types of drugs and in most patient groups. Most notable was the overuse of amiodarone in patients without SHD, and the widespread use of sotalol, including its use in patients with HFrEF. Chapter 5 is summarized as follows.
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