What Can You Do About AF in Primary Care?

This transcript has been edited for clarity.

Matthew F. Watto, MD: Welcome back to The Curbsiders. I'm Dr Matthew Frank Watto, here with my very good friend, Dr Paul Nelson Williams. Paul, what are we going to discuss in this short video?

Paul N. Williams, MD: We will recap one of our Peabody Award–winning podcasts. (I honestly hope that's not copywritten; one of these days I'm probably going to get sued.) On this podcast we talked about the management of atrial fibrillation with the amazing Dr James Furgerson, who talked us through his guideline-driven approach and gave us a lot of really practical tips that we as outpatient internists can use to manage our patients with atrial fibrillation.

Atrial Fibrillation in Primary Care

Williams: One thing that spoke to me is that as atrial fibrillation seems to become more and more complicated — if you ever read the notes from our electrophysiology colleagues about pulmonary vein isolation ablation and quieting and damping and stuff like that — you can get a little bit confused. But if you go back to the fundamentals, a lot of what we do as primary care doctors can actually help control both the incidence of atrial fibrillation and its symptoms, which I found really comforting.

Watto: Yes, Paul, we are relevant.

Williams: We specifically touched on obesity. There's a very clear-cut correlation between weight loss and a decrease in the frequency and the symptoms of atrial fibrillation. Weight management is always a goal for many of our comorbid disease processes. But with atrial fibrillation, it also makes a huge difference. That's been well studied and well proven. If you screen aggressively for obstructive sleep apnea and treat appropriately, you can decrease the burden of atrial fibrillation, and even things like glycemic control in your patients who are living with diabetes will help. Metformin seems to actually have some kind of benefit for these patients, and the concomitant glycemic control seems to decrease the incidence and the symptoms of fibrillation. So a lot of the stuff that we do makes a difference.

A nice paper by Chung et al talks about the four pillars of management of atrial fibrillation. They talk about the primary care doctor's role in terms of lifestyle changes and the approaches that you typically think about with atrial fibrillation, like anticoagulation, rhythm control, and rate control. But this fourth pillar feels very much my domain; making lifestyle modifications that help to control other chronic diseases feels good to me.

Coffee and Alcohol

Watto: You're talking about lifestyle changes. I want to know: I can drink as much alcohol and coffee as I want and it will not affect my Afib? Give me the good news.

Williams: It's half good news. A recent study actually looked at caffeine consumption and arrhythmias. It turns out you can drink coffee to your heart's content. It adds to a burgeoning body of research about how coffee will save us all and decrease mortality. Good news: Coffee doesn't seem to affect Afib at all.

The bad news is that alcohol isn't recommended due to cardiotoxicity. We can't recommend alcohol consumption in any quantity for our patients living with atrial fibrillation.

Watto: Well, one out of two isn't bad. I'll take the coffee. But your Irish coffee is probably out.

Rhythm Control vs Ablation

Watto: You mentioned the four pillars. For me, what has always been the most like a black box is who gets rhythm control and who gets ablation.

If you have younger patients who are ultra athletes who are having these little bouts of Afib and they're symptomatic with them, Dr Furgerson said he thinks about sending those patients for rhythm control or possible ablation — people with pre-excitation, like those with Wolff-Parkinson-White, because you don't want that fast, chaotic rhythm going down an accessory pathway and directly stimulating the ventricles, which could get those people into trouble. The other group that you should think about is anyone who can't be controlled adequately or their symptoms are really poorly controlled. Those are the patients you might think about referring for rhythm control earlier.

Is there anything you want to add?

Williams: No, that was my main takeaway, other than the subgroups that you will talk about that have become more obvious with subsequent research. The long and short of it is that the symptoms matter. So the patients who are really bothered by symptoms are the relatively easy referrals to make to electrophysiology to consider ablation or some other form of rhythm control.

Watto: Dr Furgerson talked about CABANA, a negative trial of radiofrequency ablation for all-comers. They were trying to decrease major adverse cardiac events. A smaller trial that was done in patients with Afib and heart failure with reduced ejection fraction (the CASTLE-AF study) showed that ablation seemed to have some benefit. Since that time, they've gone back and looked at the CABANA trial and seen that the subset of patients with heart failure seemed to have a decrease in cardiac events as well. Most of those were patients with heart failure and preserved ejection fraction. So it seems that you might want to send patients with any type of heart failure, especially if they're symptomatic, to electrophysiology to get evaluated for rhythm control or ablation. That was my take-home message from that part. Did you did you take it any differently?

Williams: No, I think that's exactly right. And we were talking before we started recording that even 10 years ago it was rhythm control and anticoagulation for someone with risk factors, and you felt pretty good about it. But there's so much nuance now and so much more they can do, that most patients with atrial fibrillation probably warrant a referral to your electrophysiology colleagues, at least to make sure you're not missing an opportunity. There's almost no reason not to do it. There's so much evolving information and new things coming out. They have new indications that are being uncovered, so if you have access, I would refer your patients at least to be evaluated.

Watto: In primary care, as you mentioned, the pillars of anticoagulation and rate control are bread and butter for us. We can at least do that, and then you have some time.

The third thing that I wanted to talk about was this EAST-AFNET 4 trial. They used either antiarrhythmic medications or ablation vs rate control. In this study, it seemed that patients with less than a year of atrial fibrillation did have some benefit from attempts at rhythm control. This is one of those other nuances starting to come out where people with a recent onset of Afib (less than a year), it might be worth getting those people over to your colleague. If you diagnose Afib in your clinic, you can really control them. You can put them on anticoagulation. You can refer them to electrophysiology within the first year that you discover it and see what they want to do if they think the patient is a candidate for rhythm control or ablation.

Paul, take us home. There was another recent update that I thought was really fun.

While You Are in There Anyway…

Williams: This was just published in The New England Journal of Medicine this year by Whitlock and colleagues. Correct me if I'm misunderstanding this, because I still haven't quite wrapped my head around it, but they were looking at LAAO (left atrial appendage occlusion) in patients who had atrial fibrillation, who were going under cardiac surgery for another indication. So it was very much a kind of while-you-are-in-there study. They randomized some of those patients to get LAAO if they were going to be mucking around in the heart already to see if that actually impacted subsequent stroke or systemic embolism, with about a 4-year follow-up.

It turns out that this was a positive study. Those patients whose appendage was closed during surgery seemed to do better. One of the editorialists looking at this thought that this will probably become the standard of care sooner or later. But it was a fascinating design and a fascinating outcome. I'm looking forward to seeing the guidelines evolve in response to that.

Watto: This just made me laugh. I just love the "while you're in there mucking around, you might as sew this thing closed." Maybe we should do that with more surgeries — just sew off random orifices.

Williams: This has been another recap of another episode of The Curbsiders, bringing you a little knowledge food for your brain. If you enjoyed this, I would encourage you to click on Afib Triple Distilled or the original podcast on atrial fibrillation and our excellent show notes. Until next time, I remain Dr Paul Nelson Williams.

Watto: And I'm Dr Matthew Frank Watto. Thank you for watching and good night.

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