we thought we would you know go through some of the things that are new since the last set of guidelines the last set of guidelines came out about 10 years ago and uh there was an update in 2019 focusing on just a few uh Hot Topics at that time um but there's been a lot that has happened in in the last 10 years and in fact if if you look at the text um in the 2014 guidelines it's about 50 pages of text and figures and tables um it's more than doubled that now so it's so a lot has happened uh in in between all right so uh so just want to introduce the first concept here that we talked about uh which was this introduction of uh AF stages so we we sort of took this a little bit from the heart failure uh guidelines but the concept here is that you know we still have this this idea of parisal persistent long-standing persistent um but we introduced a couple of Concepts here one is that you know you don't really know how to label people who've had a successful ablation and we thought about using the word remission and something Ong those lines but um in the end just decided on this sort of successful ablation um stage um and then we also introduced these concepts of uh sort of what happens to you before you develop Atri fibrillation um obviously the population at large may have some risk factors and these are just people who have risk factors for aib in the general population they're just at risk for aib um but then there's there's a whole set of category here um called pre aib and that's a little bit different that that more goes along the lines of people who have you know very specific signs of high risk of aib so you get these all the time when you order the ECG patch monitors you see people with a high burden of pac's or high burden of these bursts of atrial teoc cardia uh those people are at very high risk of of having a subsequent Atri fibrillation you're not going to see a lot of the recommendations here and the guidelines around this these concepts of prea FIB but what we're hoping is that this will sort of open up uh in the research Community for us to study this and to to really learn whether or not you know things like heighten surveillance uh make sense in this in this population so hopefully more to come on in the next guidelines I want to start with the definition of apib if you go back historically you know very old set of guidelines um you see this 30 second rule it just pops up it's kind of out of nowhere it's a bit arbitrary there's no data sort of to back it up uh but the concept used to be that if you had 30 seconds of a fib on a 24-hour halter that was enough to make a diagnosis of Atri fibrillation uh the problem of course is that now we monitor people for much much longer than 24 hours and so 30 seconds of aib just doesn't make sense anymore so actually in the last set of guidelines the 30 second rule was removed um but you know in this set of guidelines what we what we did want to introduce into the definition was this idea of being able to make a diagnosis using things other than a surface ECG um so U you know wearables are a lot more commonly used now and you know I often get the question can I use this ECG from the wearable to make a diagnosis and make management decisions and the short answer is yes I mean you do have to look at it you do have to um assure yourself that it's high enough quality and if you're confident about the quality um and and the Rhythm then sure you can make you can use that for in your clinical practice um same thing with intracardiac uh uh egms from these devices uh as long as you look at it um and you agree uh that that it looks PS fibrillation then uh you can make a diagnosis the other Concepts that were introduced in these guidelines are this idea of AF burden um that's going to come into play as we talk about how you think about risk stratifying uh patients and then there's this concept of subclinical a fib now the concept's been around for a while but there's a lot more data around this this idea that there are people who have age fibrillation are just asymptomatic for one reason or another maybe they have an implantable device maybe they were wearing a wearable device um they were they were found to have AG tribulation and what do you do with them do you anti coagulate them or not so we'll address that in a second um so when we're thinking about uh you know screening for Atri fibrillation uh there's been a lot of data over the last 10 years uh around around the idea that if you screen people uh who are at risk for Atri fibrillation you will find people who are who have Atri fibrillation in fact the more you screen the more of them that you find and the longer you screen the longer uh the higher the chance that you will find people and there multiple modalities that have been looked at spot checking uh multiple times or just the ECG patch monitors or even planable monitors I mean clearly the more you screen the more you will find so the question then becomes do you start screening the general population do we recommend screening I mean if we know we can find these patients with atal fibrillation out there we're asymptomatic should we start screening the US uh uh task force uh and and ultimately the guidelines here we we decided not to make that recommendation primarily because we just don't know yet if uh if we screen these asymptomatic uh patients uh and find a fib is there a benefit to anticoagulating there there's not yet a um uh a u a definitive answer in in that uh in in that realm um the the Europeans have decided that in their guidelines they were going to recommend uh um essentially opportunistic screening so if if you see somebody in the office they're over 65 maybe they have some risk factors check their pulse maybe check a a strip ECG strip and and maybe you'll find a fib and manage it that way all right the exception to this is those who have had a stroke or a systemic embolis um and uh this study came out you know 10 years ago the crystal AF study um you know people who have had Strokes had implantable loop recorder and very clearly there was a much higher rate of Atri fibrillation we know that that that's the case uh with these other studies um but um because there's what we you know we thought that that because they they are at such a high risk of having another stroke that it would be reasonable without randomized Control Data to support this but we thought it would be reasonable uh to recommend um anticoagulation in that population so so there's now a class 2A recommendation uh to screen those uh those patients who've had a stroke and and screen with an implantable loop recorder this is this is more recent data um is uh more advantageous than screening with just say an ECG patch monitor so you will again the more you screen the more you will find just as a reminder uh when we talk about these these guidelines is that uh you know we we give these these recommendations a class so class is based on this risk benefit uh so not so much the science behind it but but rather whether or not we overall think that the Ben uh does or does not outweigh the risk so class one is a clear great benefit over over risk all right and then the level of evidence is based on the science you know are there randomized trials are there multiple Rand they good randomized trials do we have good metaanalyses or is it just based on observational data okay so we're going to talk about prevention so in the older guidelines in you know 10 from 10 years ago really the focus was on stroke risk management and symptom management um but there's a whole new section now in this set of guidelines on uh sort of optimizing uh risk factors so if you if you have a patient with Atri fibrillation many of them will have comor comorbid conditions you know risk factors for apib uh that need to be managed so things like hypertension diabetes but then they also have sort of habits and other environmental exposures that that should be addressed and uh part of the reason this was added in this set of guidelines is that now there's a lot more data around around these recommendations to support um support them in the guidelines um one of the one of the big studies that that that came out um you know several years ago was this uh randomized trial of of weight loss intervention and this is from uh press Sanders in Australia it wasn't a very big study but in that study they were very very strict about uh you know restrictions and and they were they was very Hands-On and they achieved a a very successful weight loss in in their in their cohort and they found you know for the first time that an inter you know a randomized trial showed that intervening and and and U on on weight loss actually improved uh burden and symptoms in these patients um so that was sort of a first study of its of its kind again not very big but but but but very impactful this is a study that we refer to a lot and part based on that um there's now a class one recommendation that uh if you've got a patient with a BMI over over 27 who has aib you really should recommend uh that they they lose they lose weight similarly for exercise exercise is a little bit complicated aib very high levels of exercise endurance training uh things like that do lead to a greater degree of of Atri fibrillation uh but a moderate exercise at least in in um in uh observational studies um a little bit of a debate on this but has shown some reduction in in atal fibrillation U but it wasn't until this this study that we had sort of a again it was a small study but it was a very Hands-On Interventional study on uh exercise and uh those who did go through the program compared to controls uh had less recurrence of age fibrillation so now exercise gets a class one recommendation so if you have a patient with aib we are supposed to now recommend that they at least exercise for about 210 minutes uh per week it's about half an hour a day all right what about some of the habits um so smoking again no randomized trial here uh but we feel that smoking is so important that we gave it a Class A Class one for many reasons um there is some data saying if you smoke retrospective data saying if you smoke less you'll get less aib um but despite that uh the fact that there's no randomized trial this this gets a class one um alcohol is a little bit different there's there's a little bit of a um back and forth in the retrospective literature about whether or not alcohol is associated with Mor FIB um but uh this study that was done not too long ago um uh again small study about 140 patients randomized uh to abstinence versus just control uh did show a reduction so if you are able to successfully get your patients off alcohol then they will have less AIT and that's that's now class one recommendation all right so for all you coffee drinkers this is this is good news um so caffeine again back and forth in the retrospective literature um no clear uh no clear um uh answer there uh but we felt that there was there was not enough data to support um recommending that patients stop uh stop you know enjoying their their cup of coffee every morning all right so we talk a lot about uh Sleep Disorders in in nature fibrillation it's very very clear that if you have sleep apnea or another sleep disorder you are at higher risk of Atri fibrillation that's very very clear um what isn't so clear is whether or not intervening in other words putting these patients on CPAP actually helps reduce the rate to fibrillation a couple of very small uh randomized trials looked at this question did not could not conclude that that it was beneficial um but there's a class 2B recommendation in patients with aib only because it is so common about 20% of patients uh with apib also have uh undiagnosed sleep apnea um and so the recommendation there is more so because they may have other benefits uh to getting sleep studies and and potentially put on cab um so not not necessarily for a fib reduction all right so how are we going to do this because you know this is a lot to do in the EP clinic and in the Cardiology clinic um and now there's a class one recommendation here that you should do it you know you really should be talking to your patients about all of these risk factors and one suggestion of course is to have um extra help you know there are you know nurse uh nurse-led clinics for example uh where uh it may be beneficial to have patients um with these risk factors with aib sent and in fact this is a plug for Linda's clinic so Linda aabani U has a clinic specifically designed to do this so if you have a patient with Atri fibrillation and you and and multiple risk factors don't really have time to talk to them about diet and exercise and so forth this is the perfect uh patient to refer to to Linda and she will spend the time and and discuss all of these modifiable risk factors all right so checking in on Mark oh Mark is here Mark has joined us all right so Mark it's good to see you can you can you hear us okay yeah I can I'm looking a lot better on your slides than I am in real life so I you know we used a little bit of generative AI to uh to picture what you were doing over there in Spain and uh you know generative I thinks that you know you've been exercising a lot trying to prevent aib uh but uh but um so Mark we uh we wanted to just take a a break between some of these sections uh to to see if you could go through the chat and see and see if PE you know anybody's asked any questions and try to address some of them so anything anything burning in the uh in the chat discussion great I'll uh I'll take a look and and I am happy to serve in the role of sidekick here and uh and just add some context from time to time uh you know these guideline committees uh go do this uh in the same kind of way as as before and they're getting uh they're getting very good at it I've been on quite a few of them and and so but you're the real expert here so I'll I'm looking forward to hearing your summary and uh this is uh I'm beginning to like generative AI I don't know you you do look quite tone in this uh in this in this picture all right so we'll uh we'll jump ahead and then uh we'll take another break and and see if you you you see any burning questions there on the chat all right well let's uh let's talk about stroke prophylaxis this is a big component of of the guidelines and a lot of what we end up doing so as Mark will probably tell you we had a really long discussion in fact this debate kind of extended I think to two different sessions because there was a lot of um controversy here um so so in the older set of guidelines the recommendation was that everybody used Chad's vask I would say most of us do um most of the clinical trials use chadz vasque it's well validated um and it's pretty simple we all most of us have memorized what the Chads vas is by now we calculate that as as we see these patients in clinic but you know several members in the committee said you know wait a second Chas vas isn't perfect it doesn't take into account a lot of the other risk factors what do we do with people like with renal what do we do with people who are in this intermediate uh risk category um you know this chadv doesn't take into account things like burden and so forth so ultimately the vote was that we would recommend that a system be used such as um Chad's vasque but if you want to use Atria Garfield anything else like that it would be reasonable to do so and so we we tried to write the guidelines and there were a few a few lapses here but we tried the guidelines in such a way that when we when we're talking about say a Chaz score of two well most populations that translates into about a 2% uh risk of stroke per year so whatever that that equivalent is in whatever uh guideline or whatever uh risk ratification tool you're using uh that's what you should refer to we also talked a lot about um the uh things like has bled you know things these these bleeding risk factors and in the community what's happening is that people are using Chad vasque but then they're using things like has bled to to to say no this patient is at high risk of of bleeding so we we shouldn't anticoagulate them um the problem of course is that um the more risk factors you have for aib and higher in stroke the higher your Chaz vath score is also the higher your has bled score is um and so ultimately uh we we we we thought there was no benefit in using uh something like these these bleeding risk scores in as adjunctive to a to to to a stroke restratification system um that doesn't mean that you shouldn't address the bleeding uh risk if if your patient has a GI bleeding that's recurrent well you address that but you don't necessarily stop them if they have a from an coagulation if they have a high score on one of these other tools so what about intermediate risk and this is this is where we also sort of discuss these these Concepts and we talked a little bit about the introduction of of AF burden there a few different ways of defining it um so um but if you have a patient and we're saying this with a class 2A without a lot of evidence so limited data here to support this but if you've got an intermediate risk patient you can use these other things to help you further rest stratify and burden is just uh one of the things so if you have very high burden patient with a Chaz Vass score of zero or one uh you might consider anticoagulating in a patient like that right can I make a comment about pleas Marco this is an area that that I I worked on lot and and one of the the issues is that you know just like in the old days we had the Framingham risk score for coronary disease and people are developing better scores and they're using new markers and everything else and we're improving the scores and the idea that we didn't want to enshrine Chad's vas as the as the only way to do it by making that part of the guideline we want to keep the door open to let people develop better scores and maybe now if we have wearables and other things will uh we'll have a lot better idea about what people's risks are after we use U you know more modern data so that that's part of the thing the focus is on the risk rather than the method so if you get you know you have a high risk that that that means some means something different than if you have a low risk but you know you can you can probably improve your risk assessments so I'll just stop there yeah thanks Mark yeah that's very very good point all right so uh the choice of a Doak over warrin was introduced in the focused update in 2019 um essentially you know that remains the recommendation now it's a class one recommendation unless a patient has something like uh Rheumatic mitro stenosis or or a mechanical valve um because know these all of these DOA are non-inferior and some of them might even be superior to warrin and the bleeding risk uh at least in terms of in cranial bleeding is is better with uh with the dox maybe not so much with GI bleeding except for uh apixaban but for the most part overall the the bleeding profile is is a little bit better uh with with the DOA so there's a class one now um indication for for using the dog that's not new that's that was present in the 201 19 focused update um what is introduced here though is is this idea that uh aspirin um there is no benefit to using aspirin in a lowrisk population so you know I very very commonly see patients with aib with a chadsvasc of zero or one come into my office with on aspirin um we know there's more bleeding with Aspirin there doesn't appear to be any any benefit um so the the advice now is to uh to just take them off of that aspirin unless there's another indication for it a very common problem too in our field is this idea that well I feel like my patient has a higher bleeding risk maybe if I underdose them a little bit maybe cut the dose in half they'll do better um no randomized TRW here but there's a lot of good retrospective data nice met analyses showing that's that's not that's not the case if you underdose them if they meet indications and you underdose them they have a higher risk of of of stroke um and importantly they do not have a lower risk of of bleeding so you're really not helping them very much um so so now there's a class three here um indication here uh indicating harm if so you have to be really careful when you're underdosing somebody that you document exactly why and and that you understand and the patient understands the risk and so forth all right so to illustrate the next uh concept I just wanted to present this case this is this is the kind of patient we see almost every day in in our clinic so 65 year old gentleman has myotonic distrophy um and an EF of 35% so you know good candidate for anticoagulation If he if he develop develops Atri fibrillation he had an ICD placed and six months later sure enough he has a a 4-Hour long episode of Atri fibrillation um question is do you an to coagulate them all right so asymptomatic incidentally detected a fib does that Merit anticoagulation so a lot of debate in this in this in this area um but a very common clinical problem um so a lot of a lot of data around this this question comes from this study called assert uh seever this is an older study um you done um several years ago where uh patients who are in this higher risk profile who had recently implanted pacemakers or icds were followed prospectively and um in in within a sort of a three-month time period if they had at least six minutes of Atri fibrillation then they were at higher risk of stroke um so that was one one of the first clues that hey maybe we should be paying attention to uh to this patient uh population uh the same group did a follow-up study uh this time they followed the patients on average about two and a half years and they found sure enough you know you follow them out a little bit longer you're going to find a lot more patients with uh with aib and several patients now are are having longer and longer episodes of aib many even you know greater than 24 hours um what they found on long-term follow-up was that if you had only if you had a f for more than 24 hours were you at higher risk of a stroke but these shorter episodes were not associated you think well why is that the case you know in part I think that's because with a very short monitoring period if you have a a you know an hourong episode that probably means that you have a high burden of apid but if you extend the monitoring period to years and years a one hour long episode during a three plus year monitoring period means you probably have less burden than that patient who was was found to have an hour of aib you know within the first month or two so it's all about burden you know so greater the burden the greater the risk so ultimately in the guideline that's that's you know we there were a lot of retrospective uh studies not just the assert uh that suggest this and so based on all this uh we thought that well for greater than 24 hours um it was you know more recommended so class 2A recommendation if you have that Chad's askas of two or more uh that you be on on anticor regulation um if it was less than five minutes then there's probably no benefit um so that got a class three but then there's this gray area this this these are five minutes to 24 hours what did we do with that and ultimately we decided that um you know if he had a greater risk of stroke uh so Chad ask of three or greater um and then you had some intermediate length uh aib episode then uh then then you may benefit again not that was based that decision was based not on randomized trial data sure enough as soon as the guidelines came out we got two you know potentially helpful randomized trials so Noah afnet was um randomizing uh these patients this patient population with the device detected aib um to um to doxan or or Placebo Chad vascor of two and uh and essentially that trial was stopped early because um there was no clear benefit and and the and the um the patient population was having a greater of bleeding so that the the trial was stopped a little bit early um almost you know just a about a month or just a little bit after that uh this other study similar design but there's some important differences they used a pixan instead of AD oxan they had a greater risk in their patient population so Chad that score of three or more and uh and then they limited their their duration from six uh six minutes to 24 hours so it's that that sort of gray area and um you know I think this was kind of in in I think in step with the ultimate guideline which is that in this in this intermediate risk group um yes there is a benefit to uh stroke reduction here uh but there's also a greater risk of bleeding so you have to balance that out so ultimately you know I think as a clinician when you see a patient like this you just have to weigh the risk and the benefits if they have a if they have if they appear to have a very high stroke risk and and a reasonable bleeding risk you might decide to antiquate them and uh and vice versa so um so there's there's still a lot of room here for clinical judgment um and I think it'll be a long time before we know exactly how long for exactly what tro stroke risk in a randomized trial we we need to anticoagulate people but in the meantime there's a lot of uh a lot of leeway yes yes yes so there there is a lot in growing literature on on burden and burden defined in different ways there's these Concepts like density there's this concept of duration uh longest episode and so on a lot of good retrospective data but we just don't have the prospective data to say okay after this cut off of Burden whatever you want to use there's a benefit to stroke R that's what we kind of need but we don't don't quite have yet what about Smartwatch detected aib well there's there's there's an ongoing and I I think they they they already finished the enrolling and hopefully we'll hear results um maybe even this year at HRS um on on whether or not those at risk for stroke detected a fib on their smartwatch randomized to anticoagulation versus not whether or not they have any benefit so hopefully we'll get a little bit of clarity there so we're all pretty excited to hear about that all right a few other stroke prevention so if you if you're you know if you have if you're looking for alternatives to stroke permission there there are these these uh left atrial appendage Fusion devices the way to think about this is there two different populations one population that has um an irreversible U contraindication uh to an regulation and there is I think you know again not not good prospective randomized stud uh trials supporting this but a lot of good retrospective data and some prospective clinical trials that are not randomized uh compared to Historic data that show that yes you do have a reduction and stroke so so in these patients who just can't take anticor regulation a closure device is uh better than nothing um there is however for the for the other group of patients uh who uh may just have a preference you know for whatever reason personal decisions or maybe they've got a minor bleed or something where they just prefer not to be on an anticoagulant um there is randomized data showing non-inferiority first we saw it for for war for now more recently for doax there is non inferiority to uh to um uh to these to these Therapeutics so um compared to uh to the to the closure devices so um so I so uh ultimately we gave this a class 2B recommendation um despite the fact that there's this non-inferiority randomized data uh these closure devices do carry some risk um and so remember when we're thinking about um class of recommendation there's that risk benefit balance that we make and so ultimately this received a class that group of patients received a class 2B indication about sort of opportunistic uh closure so if somebody's going for cabbage or valve surgery um in the last set of guidelines there was a 2B recommendation for uh for just doing opportunistic um uh atrial left atrial appendage occlusion surgically um but now we have very nice randomized data actually this allows three uh data randomized uh that showed a very clear benefit now you have to remember a few things though these patients who underwent closure surgical closure they remained on anticoagulation so it's not that you're doing it to get rid of the anticoagulation but you do it so that you have a further reduction of of stroke stroke risk um but everybody remains or should remain on anticoagulation um if you look down there there's a 2B indication for taking them off of anticoagulation we just don't have a lot of really good data and certainly no randomized data to support um to support that so so that gets a Class 2 be but there's class one indication now if they're going for surgery they really should be getting that that um atrial appendage uded um I included this in in our discussion today because uh even though there hasn't been a lot of uh uh supportive data recently or randomized data you know we we struggle a lot with thinking about what to do with intcal Hemorrhage and inra fibrillation and I think uh this was an opportunity to just lay out some some guidelines that people can refer to when when you get that patient because it's always a challenge uh and and the summary here is that if if they're very high risk of stroke you know they've got a mechanical valve or romatic mital stenosis um then you should probably start within one or two weeks uh re start the anticoagulation after intracranial hemorrhage if there's sort of normal risk of stroke but a low risk of recurrent intracranial hemorage so if they have like a traumatic event or something like that that cause the brain bleed then it's reasonable to to to restart their anticoagulation four to eight weeks after their their bleeding event but if there are a high risk of rebleeding in the brain uh then you really should be thinking about these atrial appendage collusion devices so so again not a lot a ton of data here but um uh but some guidelines for us to to use as clinicians all right uh this is another area that I think uh was helpful um this this question of you know after PCI uh do you do you you know in patients who need you know a aspirin in a P2 y12 inhibitor uh do you do you add that on top of their an an coagulation if they uh they have Atri fibrillation and then the last set of guidelines um there was some data but not a lot so that there was a 2A indication for dual uh uh anti-thrombotic therapy over triple but now there's been a little bit more data some nice met analyses and so now it's a class one so unless your patient is a very high risk for instant thrombosis so if they've had IST before and and and you're worried that they're going to have another one um then uh then dual antitha therapy is is recommended here and that's a class one for our stable patients know one year post their PCI or cabbage um who need to be or or who who preferably would would normally be on aspirin long term um if if they have Atri fibrillation now the recommendation is take them on off the aspirin and just leave them on monotherapy so just just their anti-coagulant therapy and some uh some nice uh nice supportive data there all right well we'll check in with Mark here so this is a this is AI what AI thinks Mark is doing uh or or doing that you should not do if you're on an anticoagulation so I don't know if you did the running of the bulls Mark but uh uh but here here the AI thinks you did I I stayed safely on the balcony Marco all right very good very good all right so Mark any burning questions that have come up in the chat uh no just a comment from Ken about a nice guidance some videos that he had and mentioned in the in the chat on how much AF is too much so there's some back and forth no major questions but interesting chat okay a great job has has a question maybe you can address this one yeah I was wondering a little bit about the what we in the hospital which isop and guid around yeah Mark did you hear that so the question was what do we do with post ope FIB uh does does buron play a role there what what do you remember what we did in the guidelines no I don't remember exactly how we treated that uh it's been a while sorry yeah so so burden really didn't wasn't addressed in in the in the posttop period but um there we did we did address it in the sense that if if you do see it um not not burden but if it is present then you should just think about monitoring more because those patients are at higher risk again not Based on randomized data or anything like that but but burden you're right though I mean I think burden should play a bigger role in these kinds of questions but it's just not something that we uh uh we we we have enough data to to make a a recommendation around I think there was a question from Dr fr um about is there a role of evaluating left agal size or stroke prevention any of the stroke prevention scores yeah so um yes there are uh there are some scores um that that do take into account left atal size um but um uh but uh but but again that that I think yeah there are a couple there are few scores that do and we do we do address them in in the guideline um and and and also in that sort of idea of that intermediate risk patient where you you're you're thinking of things to add to to help you further stratify so burden was one of them but left atrial size is is another one and any any any addition there mark anything else about left atrial size no I I I do think that's you know another example of of additional information it's sort of in that additional information category to help you do the stratification if you if you know that but you know I I I think that uh that you know it's when you're on the fence yeah yes yeah it's not yeah um I mean I think in part because there's just so much good data on on stroke risk in patients with HCM and it's very very clear that their stroke risk is just through the roof if they have a fib and HCM um I think you're right that there are these other cardiomyopathies where where uh you we are going to see this much higher stroke risk we just don't have the data to support that and the guidelines make specific comments around HCM and how you shouldn't use the Chads vas or these other uh you know forms of stratification um but we didn't address these other other cardiopathies like approach early on they're also en for yeah yeah so so we do and and I'll get to this a little bit more at the end but we we do pretty extensive uh evaluation in those with early on today FIB including you know genetic testing and imaging uh we MRI all of our early onday is specifically looking for these these these kinds of structural abnormalities um but I do not an coagulate them unless they have uh manifest myopathy yeah one more question in the chat on on anti-coagulation questions from Dr Alex derson is there guidance on anti-coagulation after successful with no yeah Mark do you want to take this one so the idea of anti-coagulation after ablation I I uh I don't I I think the idea of that you know the risk is so low that you don't have to do it is is uh is hard I think people were were shying away from from saying that it had to be you know you have to wait a while to make sure it really worked especially given the any risk of recurrence later so you know I I don't think it was anything immediate uh for ablation yeah and and I I'll just add that there's ongoing there are ongoing studies to address this question but in the guideline I think we ultimately said that um it there's not enough data to support taking them off yeah yes Dr Mar still regarding antiag yes um any comments or discussion among the writing group about PRN antiag something address so not in the guideline um but um we have now this react study just uh looking at sort of pill in the pocket PRN uh use of anticoagulation um so you know we have a large you know we just started just a few months ago this large study called react aib uh where we're uh taking people who have low burden aib um and are already on a doac and randomizing to using the Smartwatch uh for pillin the pocket approach of anti coagul versus control so um maybe in the next set of guidelines we'll we'll have we'll have the the results of that but it's going to be a few years um but that is a plug for that study so if you any of you have a low burden aib patient with a chadz vasque uh for below um then uh let us know because uh they may be candidates for this uh for this study and we will give them watches if they're randomized to uh intervention yeah yes AJ no we couldn't we couldn't I mean the guidelines had had been yeah yeah but but but yeah I mean for that particular Cas when we ended up anti coagulating even before that was that happened even before the guideline discussions um uh but yes we ended up anticoagulating that patient I I sort of value or or factor in myopathy a little bit more than some of the other risk factors he had an EF of 35% I I thought he was at high enough risk and and I knew that he likely have progression of a yeah that's a good you know and I've thought about that I think I think the guidelines kind of reflect ultimately what was found in in those uh in those studies so I I probably would not have changed the the guideline yeah based on that it could have gone differently though depending on the findings yeah yes Jack yes that is another argument so so you know in the in the Noah trial there was a there was a much bigger bleeding risk in the in the uh pixelan study the control was aspirin so there was a greater bleeding risk but you can imagine if those patients had been randomized to to Placebo that bleeding risk might have been even bigger so you're right I mean there there's no question here there's I think that it's not very clear yet um um but that again leaves a lot of room for uh clinical judgment Dr Mary yeah yeah a lot of pati with coronary dise mention indication to use antiag yes yes Bas trial yes so let me bring that up yes so so the the a fire trial so they randomize patients River oxan versus R River plus aspirin and they had um it was non- inferiority study uh but uh so the so so so Riv River oxan alone was not inferior um and there was lower bleeding risk so it's basic really I I mean the class one comes essentially from this from this study it generalizes any uh we think so yes I mean the river was studied here but we we think so yeah yeah okay let's go on to rhythm control all right so um I think a lot of us trained with a firm you know with the thought that hey if your patient not that symptomatic rate control is probably just as fine as as as Rhythm control um there you know a few retrospective studies that kind of challenged that question especially you know as as Rhythm control itself evolved you know in particular with the with the um the rise of of of the use of ablation and uh and this study was very flal this East AF net4 study it was a very large study uh that randomized patients to um to Rhythm control uh primarily with the intent that you know this was done in Europe so the intent was going to be that you know these these patients would mostly be on anti- rythmic medications versus usual care and that's what happened when they randomized patients to Rhythm control most of them got medications um so anti- rythmic drugs uh for rhythm control eventually though over time up to about 20% of patent in that arm ended up getting an ablation done so just keep that in mind also this is a higher risk group so uh so also also keep that in mind uh but the idea here was that well maybe if we get to them early within the first year of their diagnosis um that Rhythm control might be uh better than than uh uh than usual care and and that ended up being the case so this trial was actually stopped early as well but this time for efficacy so uh there was good evidence that early Rhythm control in this patient population uh was beneficial um so um so why is this different from uh from you know firm and so on you know a big part of this is probably because you know the idea here was to act early so if if you get to these patients early before they Remodel and so forth uh you might get better better um better benefit U but also you know again we're entering this ablation area 20% of these patients were getting a bladed so maybe there's something to that and um now if even if your patient doesn't fall into this category of early detection um there's still this concept that well maybe maybe Rhythm control is better anyway uh than than rate just rate control even in asymptomatic patients um uh and and so uh based on retrospective data we know that with rhythm control you get less dementia a less likelihood of of progression to to persistent uh and longstanding persistent aib um so you have something to point to if you really want to Rhythm control your patients um you have that discussion with them and say if you you know if you're worried about developing Dimensions so forth then then Rhythm control might make sense even in those asymptomatic patients who've had aib for more than a year so there is some leeway here as well um the question that has come up in our field uh and this is sort of the one of the burning questions is whether or not uh if if you choose Rhythm control whether or not ablation is firstline therapy is is better and there were several randomized studies uh that showed that yes if you if you do an ablation early as a first line you get less aib you get less burden of aib less progression to persistent aib so that's pretty clear um so if if you've got a symptomatic patient uh and you're thinking about um Rhythm control uh then then you can tell them that yes if you do an ablation first line chances are greater that you'll have success than than just medications but what about hard end points um so things like mortality and Cabana was really designed to address this um this would have been I think groundbreaking if they had shown in the general population that if you do a an ablation is first first line therapy that you get a mortality reduction then I think we'd be in a slightly different world but what they found was that um their primary Endo which was Deathstroke major bleed cardiac arrest so they were kind of going for these really hard in points uh they did not they did not see an improvement in in uh first line therapy with ablation versus medical care now you ask you know 20 different EPS their interpretation of the study you get 20 different answers uh many of the EPS will point to well well what about the on treatment analyses those who actually got an ablation did better but um obviously there are a lot of you know flaws to that kind of thinking um you know in theory maybe there is something there but uh but the study didn't wasn't n designed to to to show that so um so at least what we can say is in Cabana there was there was less aib there were there were fewer aib hospitalizations those were all secondary endpoints consistent with all the other randomized trials uh but not a mortality benefit so um there is a Class one indication now if if you um if you've got you know a younger patient um with uh um a few comorbidities then you know first line therapy is useful and notice the wording there is useful um you know we didn't say should be done um but is useful uh so that's a class one with with the you based on the data that we talked about in the slightly older patients um maybe with more comorbidities there still a class 2A indication here and we said you know first line with ablation can be useful so look at the wording uh and you know use your clinical judgment but um but you've got you've got some leeway there as well now this very different for heart failure patients so I I I have to say I think this is this study I think surprised most of us in a field uh when this study first came out you know taking patients with heart failure and randomizing them to um to ablation as first line versus uh medical therapy uh because in the older guidelines it was all about rate control you know we didn't even think that Rhythm control was was that that important in um in in in heart failure patients and all the guidelines were were all about how to Rak control these patients uh but um but this study kind of changed our mentality we used to avoid bringing these patients to Cath Lab because they had you know we gave them a lot of fluids in the lab and they always had heart failure afterwards and so we didn't like doing it but now we see that there is mortality benefit and that wasn't in just Castle a fib but a few other um randomized studies and Men analyses show a clear a clear benefit um and so now there's a class one indication um uh for uh for for using uh you know ablation as a as a first line approach in this in this population all right so when I think about Mark learning about Rhythm control this is well when the AI thinks about it this is what they what it sees so any any good flamco shows in in Spain Mark that you've been to oh yeah uh gotta go to flco the hard thing is uh is going out to dinner at 10 o'clock uhuh but that but that's okay if you take your Siesta right there there you go exactly a good a good tradition okay so we're getting here to the home stretch I just wanted to point this out because just because you know we see a lot of these patients uh patients with early ondate defibrillation um so we know that there are many inherited cardiopathies related to um Atri fibrillation um in the older guidelines the recommendation was well unless there's a very strong family history uh we shouldn't be doing genetic testing on these patients and and we and others have have have looked at these uh early onset atrial fibrillation patients and are finding that many of them do have pathogenic or likely pathogenic variants associated with their early onset Atri fibrillation and now in the guidelines what we say is if they're below the age of 45 please send them over uh for uh genetic testing and counseling the other thing that we added here in the guidelines was that if they're really really young you know less than 30 years old uh then we should also be doing EP studies because it turns out a lot of them have avnrt or avrt as the reason for their agulation and and that it goes apib goes away when when you blade them appropriately um so that's that's another new there's a lot more in the guidelines we don't have time to go through everything a lot of special populations um this is a plug for our inherited clinic so if you've got an early onset a fib below the age of 45 send them our way we'll do genetic testing counseling we usually do cardiac MRI um as well all right so that will close