this program is brought to you by Emory University good morning everybody happy Friday morning welcome to Friday morning fellows conference our speaker this morning is Dr Quenton Lloyd one of our first year clinical track fellows quen did his undergraduate studies here in Atlanta at Clark Atlanta University uh did medical school of Mahi uh then University of Miami for residency where he did a year as as the chief resident and as you can see today he's going to discuss the updated guidelines for the diagnosis and management of atrial fibrillation take it away Dr Lloyd thanks Dr Williams uh good morning everyone um it's a pleasure to be here and to discuss these new guidelines with you guys um so let's get started so first of all no disclosures um and then of course like the objectives are here so we're going to essentially identify the updates from the 2 14 um apib guidelines and there was a 2019 like uh focused update so a little bit of updates from that um in regards to classification risk uh Factor management diagnosis and management of apib so jumping right into it so essentially one of the biggest things for like the new um guidelines is looking at the way we kind of like classify apib and so one of the biggest things that came about was that the previous classifications kind of focused on the duration um of the arhythmia and the new classification kind of um focuses focuses on it as in terms of like a Continuum noting that Atri fibrillation is essentially a disease a disease of progression rather than just based on its duration and so some of the ways they kind of classifi this are wait let me see so it kind of like now focuses on the uh stage of aib and so the stages kind of go from one through four with stage three kind of being like subdivided into four different stages 3A through 3D and so when it comes to stage one it's kind of more so now focusing on like Risk stratification and man management of risk uh factors and so both the modifiable and non-modifiable risk factors um so with stage one you look at the Patients overall risk of um in terms of like their obes OB their exercise tolerance if they have comorbidity such as hypertension renal disease um if they use alcohol diabetes if they have diabetes and then you also look at like the the genetics uh the sex and the age generally the a population historically in the US at least has been generally older uh white men and so those are generally like the non non-modifiable risk factors that we kind of F that we kind of look into but also kind of placing emphasis on the modifiable risk factors that I mentioned um stage two kind of focuses on patients that have uh preal fibrillation so these are patients that have evidence of structural disease or um electrical abnormalities but they don't yet have evidence um of atrial fibrillation they're just at higher risk of having it um so these are patients that have atrial enlargement on like their echos patients that have frequent like atrial ectopy E ectopy when we um like do like routine uh Clinic EKGs and then patients that have like the short burst of atrial activity which we'll talk about a little bit more um and then patients that have other um super ventricular arrhythmias like atrial flutter um and so that's kind of like where you consider doing like higher surveillance in these in this particular patient population um and then stage three is kind of like what we kind of think of when we think of apib like the parisal the persistent the longstanding persistent and then now there's been like this kind of like new uh category in terms of like abl which has been a big update um in terms of like the newer guidelines and so stage three like I said so that's kind of what we already know so 3A is kind of like your parisal apib less than seven days of onset persistent aib being greater than seven days but less than 12 months then your long-standing persistent being um less than seven days to greater than 12 greater than 12 months sorry and then now this new category like I said being um having had a successful oblation put you in in the category three um in the stage 3D um staging and then of course like stage four being peral at fibrillation and then the thing about this is that like throughout all of these like the biggest thing is that focusing on risk factor modification um should be done from stage one through stage four um and then kind of how we like manage uh stage three which um used to be like the what we considered the classification of H APB um has changed a little bit in up updated guidelines as well and this is just another pictograph that kind of explains that as well so the next kind of like take-home Point um from the new guidelines was that the in terms of like risk factor modification and prevention the guidelines kind of focus on this like pillar um that kind of focuses initially on the risk factor modification but then also focuses on the the exact management that we kind of focus on so like uh risk factors stroke risk looking at rate control versus Rhythm control optimizing the modifiable risk factors and then kind of working on symptom management and kind of assessing a patients like atop pilation burden so in terms of like uh primary prevention so it's a class one indication uh in the new guidelines so patients at increased risk of apib should receive comprehensive guideline um directed uh life lifestyle and risk factor modification for AP Trion obesity physical inactivity unhealthy and unhealthy alcohol consumption smoking diabetes and hypertension and then this is kind of that pillar that I was talking about where they kind of focus on the the modifiable risk factors and then kind of work their way up and so they have like these pneumonics that they kind of use so Head to Toes kind of like looking at the mod modifiable um risk factors um and behavioral changes that patients can make to reduce their AA burden so heart failure exercise focusing on treating arterial hypertension um optimizing glucose control in terms of diabetes uh tobacco cation increased physical activity in terms of obesity uh reducing uh alcohol consumption and then sleep in general and then also they kind of place a focus on having like shared decision- making between patients in terms of like the newer um kind of recommended therapies when it comes to treatment of atrial fibrillation and then again like I said you always want to make sure that you're assessing like the patient Str risk opt optimizing their modifiable risk factors like I said and then again um focusing on the patient overall quality of life with their symptom management and this can come in the form of rate control or Rhythm control which originally used to be that rate control was the preferred go-to method um but that's kind of changed a little bit with recent studies as well so the Third Kind of tih Home point so flexibility and using uh clinical risk scores and spanding Beyond the Chast for the uh prediction of um of systemic embolism or stroke so chlas is probably like the most um studied most validated uh risk score um clinical risk score for assessing like a patient's uh risk of stroke essentially but like in the newer guidelines it kind of focuses on maybe going Beyond just what Chaz Bas provides in terms of like RIS stratification and kind of focusing on some newer um RIS stratification in terms of stroke prevention um so essentially the guidelines say that for class one uh patients with a atrial fibrillation should be evaluated for their annual risk of Thro em embolic events using a validated clinical risk or such as Chaz 2 um patients with apib should be evaluated for factors that specifically indicate a higher risk of bleeding such as previous bleeding and use of drugs that increase bleeding risk in order to identify patients uh possible interventions to prevent bleeding on culation um most notably the whenever we think of like atal fibrillation in like stroke provision we always like try to take into account the patients like bleeding risk um which there are like validated scores for like U looking at a patient's risk of bleeding I think has bled being like probably the most common one that use but one thing that they say that's a class three that provides no benefit is that in patients who areed deemed high risk for stroke bleeding risk score should not be used in uh isolation to determine eligibility for oral an coration but only to supplement and to essentially be a essentially focus on modifying those risk factors of bleeding rather than saying oh this patient has a hasb of such and such we shouldn't an calulate this patient for such and such reason especially in highrisk patients and so these are some of the other scores that are um used so the like I said the Chaz bask is probably like the most validated one but then the Atria and the garos so these are kind of like these newer um risk factor um clinical assessment tools that kind of assess the patients risk of stroke um and they include a few more things than the ch's vas score does um so they include age um sorry they include renal function protura are probably like two of the biggest ones but the thing that one of the reasons that these some of the the uh like bleeding risk scores um are maybe not the best um is the fact that they use a lot of things that can also promote embolism but also promote bleeding as well um like a patient's age hypertension renal dysfunction um so it that's one of the reasons why they say to not use um has bled and like the bleeding RIS stratification scores um in isolation to determine if a patient is eligible for anti- coagulation and so some of the additional risk factors that aren't in included in the childb score that so that we should uh be mindful to keep in mind when we're thinking about patients that are candidates for oral anarul so patients that have higher AP burden longer duration which there have been like recent studies that kind of like focus on this kind of like picture uh persistent permanent uh apib versus parisal um apib is another thing to think about um if the patient is obese if they have history of HCM um if their hypertension is poorly controlled they have low renal function poor renal function function protura or like I talked about earlier if they have like this enlarged LIF atrial volume those are um things that you may also want to consider but that are not included necessarily in the tadb score so next so in the newer guidelines the there's been like emerging evidence that kind of focuses on um early Rhythm control rather than rate control um in this specific uh patient population and so one of the things that's in the newer guidelines kind of focuses on is like it focuses on looking at a patient's overall um symptom burden and kind of seeing that and comorbidities that the patient has to kind of look and see what they have going on in terms of like their their underlying comorbidities and so one of the things that the newer guidelines kind of focuses on is earlier um risk factor modific earlier uh Rhythm control and so essentially this kind of comes from one of the newer trials the East uh AF uh net for trial which essentially was a trial that had about 2700 patients that were randomized um that were recently identified as having atop fibrillation um that were randomized to Rhythm versus rate control um and then basically basically in this trial initially patients were randomized to patients that were randomized to the Rhythm control arm um 87% were treated with anti-ar rithmic drugs and 8% with agrial fibrillation but two years um 35% were not on anti- rythmic drugs that have received the atrial um atrial fibrillation oblations um and then there's also data from like L from this trial and large res Registries that have consistently shown the importance of monitoring for agulation uh burdens which I kind of talked about and so essentially once aib is identified um it's better to focus on early Rhythm control in these particular patients and they're um more likely to be more likely to be successful um in terms of preventing apib recurrence when the strategies implemented early um so similarly in the caban which kind of like looked at um catheter ablation catheter ablation based Rhythm um control um and it was essentially in that study it was the catheter ablation Rhythm control was associated with a 40% 40 46% reduction in mortality rate in patients with HF compared with medical therapy Alone um but we'll discuss that a little bit more later in detail um so essentially for the uh this particular group of patients um so which kind of patients do we usually kind of want to focus on when it comes to Rhythm control versus rate control and so this kind of table kind of like summarizes a little bit um when we think about which patient should go to which category or which one we should focus on with which Patient Group so generally like patients for like that favor rate control it kind of breaks it down into the patient factors and then also the um physical examination or the anatomy of the patient and so in terms of fa um characteristics that kind of favor patient characteristics that kind of favor rate control you kind of look at um if the patient what the patient prefers so kind of looking at the patient's um uh using like that shared decision M decision making that the guidelines kind of focus on um the patients overall age so older patients you kind of want to focus on uh rate control versus like Rhythm control because sometimes the the Rhythm control Strate IES may not be the best in those particular patient populations so how long the patient has had atal fibrillation is another big thing um so like the longer the patient has had atrial filation you get more of that remodeling of the left atrium and then that can kind of um tell you whether or not the patient is more likely a candidate for rate or Rhythm control um and then overall like the symptom burden for the patient so if they're having fewer symptoms you're less likely to use a rhythm control Rhythm control strategy more likely to just control the patients rate if they're having P symptoms versus um the the the vice versa for the patients that are having more symptoms um then kind of like like we talked about the physical examination in the anatomy of the patient so patients that are having like difficult to control heart rate they have like these smaller lift atriums more lb dysfunction and more AV um atrial ventricular um AV regurgitation um you're more likely to use Rhythm control in these particular patient populations and so so this particular table kind of essentially talks about the it's a essentially a summarization of this table so kind of like a decision tree when it comes to the treatment um required to decrease a patient's aphid um burden and so in patients that that do have heart failure we'll talk about a little bit um but patients that don't necessarily have heart failure you kind of use like a decision-making approach to kind of determine if the patient is a candidate for drug drug uh medical therapy uh cath rehabilation or surgery and so patients that are not hard failure and discussing with the patient um in who in which anti- rythmic drugs are not effective one of the first line therapies um would be cath ablation for this uh patient population um outside of that um anti- arthic drug therapies receive a 2-way recommendation um in this particular patient population um and then also same thing for surgery in this particular patient population but the biggest thing is that in this specific patient population cath ablation has a a 1A recommendation for these patients and then in terms of like the treatment algorithm for conversion of patients um to agrial fibrillation so normal LV uh function you kind of want to use our ivone and ibutilide as like a 2A and then procainamide as like a 2B um in patients that have reduced heart failure um IV IV otone is the the 2A Rec has a 2-a recommendation for treatment in this patient population and then if you have a patient that has atal fibrillation that's occurring outside of the hospital um in patients with a normal LV function uh you can use this so-called pill inth pocket approach um with fid propanone but again this these are generally reserved for patients that don't have underlying structural heart dysfunction um and then in terms of like maintaining a patient in sinus rhythm once they achieve sinus rhythm um so these are kind of like the medical medications that are um given like 2 a 2B and then three recommendations which are kind of similar to the ones we know um so again in patients that have like the normal elv elv LV function with no history of Mi or structural heart disease you can use defal jerone foni propanone um as a 2A and also amone um and then if patients do have the LV dysfunction prior Mi or significant atrial um structural or um structural heart disease amone and defal are going to be the the biggest two that you'll use most notably though the one of the things of course that we know is that in patients that have reduced um EF and they are either uh Niha stage three uh Clash 30 or4 um or like a recently decompensated harder then Jone should not be using this particular patient population uh let's see and then so the next one kind of focuses on one of the bigger things that have come about the guidelines from the recent uh 2014 and 2019 focused update so cathic reation in these guidelines receives a class 1a indication whereas before I think it was 2B I'm in Prior recommendations and this comes from a number of trials that have been um done since then um or that were actually published around the time of um the prior um guidelines being released release so essentially for a atrial fibrillation cath rebolation class one in patients with symptomatic AF when anti-ar rythmic drugs have been ineffective CRA indicated or tolerated and not tolerated not preferred um and continued Rhythm control is desired cath relation is a useful uh to improve symptoms um and then also in select patient patients generally younger like we talked about with fewer fewer uh comorbidities uh with symptomatic parisal a in whom Rhythm control is desired cation is usual as a first line therapy to improve symptoms and reduce reduce progression U to persistent apib and then in patients with symptomatic or clinically significant atal um flutter cath oblation is useful improving symptoms as well or like the the main class one indications so outside of that in terms of like patients that have atrial fibrillation and heart failure um uh thought to be due to arhythmia induced copy should be in which C arhythmia induced cardiopathy is suspected um and an early aggressive approach to apab Rhythm control is recommended uh specifically using cath ablation this in this particular patient population and so in terms of like the class one indication so in patients with Who present with a new diagnosis of heft ref and fibrillation arhythmia induced cardiopathy should be suspected and like I said you want to consider early and aggressive uh Rhythm control strategies in these patients um and especially in patients with who are on gdmt um with reasonable expectation of procedural benefit cath oblation should be recommended in these patients um to improve not only their symptoms but their Quality quality of life and tricular function and then their overall cardiovascular outcomes um and then in terms of like the 2A recommendations that we have now and it's in appropriate patients um with symptomatic AF and hepf with reasonable expectations of benefit um cath ablation can be useful in this particular patient population uh to improve their symptoms and quality of life U that receives a 2A recommendation and then a little bit in terms of like the uh medical therapy so in patients with AF and heart failure dection is reasonable for rate control in combination with other rate controlling agents as or as monotherapy um if those other agents aren't tolerated well and then in patients with agal fibrillation he ref um and refractory rvr um who are not candidates for any type of Rhythm uh or who are not candidates for or in whom Rhythm control has failed um AV node ablation and BV pacing uh therapy can be used uh to improve symptoms quality of life and EF in these particular patients so those last three all get two-way recommendations in the newerk guidelines and then this is kind of like like a table that kind of summarizes those um and so number seven so in terms of the uh um atrial High rate episodes um that's another thing that's kind of been looked at uh in the newer guidelines as well um so these atrial high high atrial High rate episodes um are essentially defined as these atrial events um exceeding the program detection rate Limited by limited set by the device like in patients that have like pacemakers or defibrillators um these are essentially recorded by implanted devices but require visual inspection to confirm ail and exclude other atrial arrhythmias artifact or over sensing and then also this kind of like talks about the subclinical AF um which refers to arhythmia identified individuals who do not have symptom symptomatic um symptoms attributable to atrial fibrillation but uh in in whom there's no previous AKG documented um um at fibrillation but the patient has some type of wearable such as like a face um some type of device implantable device or wearable um that shows uh evidence of atrial fibrillation they just haven't been symptomatic from it and so in terms of this newer um kind of discussion when it comes to these atrial High rate episodes so in terms of like 2A uh recommendations so for patients with Device detected atrial High rate episodes lasting greater than 24 hours and with a Chaz vas of two or more um or equivalent stroke risk using either that atrial or the Garfield score um it's reasonable to initiate anti-coagulation um with a shared decision-making framework for uh patients for this duration and this table kind of like summarizes essentially um that recommendation and so essentially what this says is it kind of looks at the patients overall risk um using that Chads Basque risk assessment clinical tool and then kind of looks at the overall duration of those subclinical AF and uh atrial High rate episodes and then kind of determines if the patient is is a candidate for uh atrial fibr is a candidate for anti-coagulation and so Circle A essentially are patients with short and like these infrequent um atal High rate episodes these patients don't necessarily and that that are low risis these patients don't necessarily require um ant regulation um B uh for Circle B uh these are essentially like patients with intermediate risk um that also have these atal high rate episodes lasting greater than six minutes um but less than 24 hours it's not really clear necessarily in this patient population um but there on whether patients should get anti culation but there are studies underway and then uh Circle C is kind of like the patients that are at high risk um with like these longer grest than 24hour um High atrial episodes High atrial um rate episodes um so these patients should get uh anti culation um and so for the highrisk population with uh the ahre and the scaff buried in between 6 to 24 minutes um at the time these guidelines were made there was kind of like lacking evidence to know if patients were candidates for anti-coagulation however there were like two studies that were published um um that well the results came out not uh recently um that kind of suggests maybe not doing anti-coagulation this particular patient population uh one was the aresia and the other one was Noah and essentially uh in the Aria trial it was looking at among patients with subclinical apib um and a paban essentially resulted in a lower risk of stroke or systemic embolism than aspirin but resulted in a higher risk of major bleeding in those particular patients and then the Noah trial essentially showed that among patients with these atrial High rate episodes detected by uh devices imparable devices uh anti-coagulation with ad doxan didn't really reduce the incidence of um it was a composite of cardiovascular death uh stroke and systemic embolism um as compared to Placebo but it resulted in higher incidents um of major bleeding um but the incidence of stroke was relatively low in both groups um so essentially in that particular patient population anation might may not be the best um for those patients but definitely in the patients that have the high- risk and then these uh HOH High rate episodes lasting greater than uh 24 hours so um patients without a prior diagnosis of AF so again like in terms of 2B and three uh recommendations so there is a 2B recommendations for patients with um device detected uh atrial High rate episodes currently between 5 minutes and 24 hours that if they have a high um risk with the tras or whatever other clinical risk assessment tool you want to use um it may be reasonable to anti uh patients um in this particular patient population I think this was public this was essentially in the guidelines before we had the data from the um aresia and the Noah trial and then again of course there's really no benefit in patients that have these atrial High rate episodes with uh duration lasting less than five minutes to Anto culate them and so again another thing I know like uh at least for me I've been on Echo and like we have like a lot of Neurology uh colleagues that prefer getting te's and loop records in patients that um have stroke of unknown ideology um so there is a 2A recommendation um for that in patients with stroke or Tia of undetermined cause um for doing in initial cardiac monitoring and if needed extended monitoring with um an implantable Loop um a reasonable to improve detection of apib um in these particular patients in which you don't know the ideology of the stroke so number eight so left atrial appendage occlusion devices um actually receive a higher level um recommendation um I think before it was a 2B to but now it's a 2A and so in patients with aib a moderate to high risk of stroke um based on like the trazas or whatever clinical risk assessment score you use and a contra indication to long-term anti-coagulation um it's reasonable to um with a non-reversible cause it's reasonable to use these percutaneous um left atrial appendage occlusion devices uh namely like the Watchmen is probably like the most common one that we that we'll see used and so in terms of like those longterm anti-coagulation uh contraindications so severe bleeding due to non-reversible cause involving the GI track pulmonary area pulmonary um system GI system um spontaneous uh brain bleeds um or intraspinal bleeds and then any serious bleeding related to recurring Falls when it um when the cause of the Fall cannot be is not is not felt to be uh treatable um so I know those are like some things we think about when we think about starting ulation in our patients as well uh number nine so recommendations are made for patients with atal fibrillation identified during um medical illness or surgery so there's emphasis made on the risk of recurrent aib after aib is discovered during non-cardiac illness or other precipitant such as surgery um so essentially what this is saying that in our patients uh population that has that there's oftentimes where we have patients and they're acutely ill and we get consulted for these patients that develop this like new atal new uh quote unquote atrial fibrillation um so in terms of the guidelines they defined precipitance as either an acute infection cardiac surgery or non-cardiac surgery um and essentially in two studies this came about because in two studies um they looked at the recurrence of aib um in patients that atop fibrillation was first discovered during their acute illness or non-cardiac surgery and the recurrence was 42 to 68% in the acute um medical illness group and about 39% in the non-cardiac surgery group during a 5-year followup and then what they saw was that regardless of the initial precipitant through uh through these studies they've shown that recurrent apib was associated with increased risk of heart failure um and then there was also a retrospective study looking at about 3800 patients with apib um in Subs admitted to us hospitals that kind of used the Chaz bass score and showed that the Chaz bass score was a poor predictive acute stroke risk and that parent uh parental anti coagulation did not really reduce the risk of stroke um in these particular patients um and then also that the risk of stroke did not differ whether patients had pre-existing apib or Nuance at a a and so essentially for the prevention um of aib after cardiac surgery so in terms of like the 2-a recommendations in patients undergoing cardiac surgery um who are higher risk for postoperative apib it's reasonable to administer short-term uh prophylactic beta blockers or amator on to reduce the incidence of post postoperative apib um and the impatient undergoing cabbage atic valve or sending atic anism um operations it's reasonable it's reasonable to perform a concominant posterior left pericardiotomy to reduce the incidence of post-operative um atrial fibrillation in these particular patients um and essentially for for me like I didn't know but like I guess like the pericardiotomy um is an option for prevention of AP and essentially allows for the drainage of the dependent blood and pericardial fluid um into the left plal space which is theen where that it's thought to be that what's irritating the left atrium to leading to the postop a so th those both receive a 2A recommendation um and then in terms of treatment after um cardiac surgery so in postoperative cardiac surgery patients oh it's kind of like what we talked about yeah so that's that and and then that kind of talks about it also so in terms of like acute medical illness and including apib in the critical care setting um so these one the class one indication for this specific patient population is that patients with apib who are identified in the setting of acute medical illness or surgery should be consulted uh counseled about the significant risk of recurrent apib after acute illness is resolved um and then at least like 2A recommendation in patients with apip who are identified in the setting of acute medical illness or surgery our patient follow up for thrombolic um risk ratification decision making on oax or on Oak initiation or continuation as well as apib surveillance um can be beneficial um given a high risk of apib recurrence in these particular patient populations and then in terms of like acute Medical in terms of uh kind of management in patients that have acute medical illness or surgical illness um this kind of like kind of summarizes that uh uh what we were talking about just now so in terms of patients that have an acute precipitant uh which was earlier defined um in patients that have risk factors and comorbidities for agal fibrillation so patients that have acute AF so you want to focus on treatment of the acute uh precipitating uh F uh factors or triggers um and then in terms of like the the symptom burden and kind of managing the patients from an atrial pration standpoint you want to focus on a rate or Rhythm control strategy of course and you want to focus on uh stroke prevention in this uh patient population in the acute setting when it comes to care transition um you also want to counsel the patients regarding their risk of uh a recurrence and then to continuously follow these patients uh outpatient um to assess their risk of uh a uh burden and then kind of focusing on a rhythm monitoring um strategy whether that be with the um a wearable or implantable loop recorder um and then F kind of like essentially focusing on the lifestyle and risk factor modifications you can uh mitigate with this particular patient population and then lastly kind of focusing on a spec on the guidelines focus on specific patient populations that weren't necessarily um talked about in Prior uh guidelines so specifically in patients with hyperthyroidism in ag of fibrillation who have an elevated risk of stroke uh based on a standard clinical risk score anti-coagulation does have a one there is a onea recommendation for anti coralation um in this particular patient population until the thyroid uh dysfunction um is resolved essentially and so that kind of stems from the fact that oftentimes we'll have patients that we're consulted on that have uh hyperthyroidism and we often tell our colleagues to hey control their hyperthyroidism first and then the atrial prolation essentially should get better um and most trials have shown that at about a median of one to three weeks after thyroid hormone levels have returned to normal um usually patients have a spontaneous reversion back to sinus rhythm um but in this particular patient population it is reasonable um to give them anti-coagulation um especially like it's been shown in like laboratory findings that patients that have hyperthyroid hyperthyroidism also have laboratory studies that Focus that suggest a higher coagulable state as well also in athletes is another um so in this particular po patient population um it kind of focuses on pvi ablation for these patients so there's a 2A recommendation for impatient PTI with in athletes that develop Agri fibrillation culation with PV is a reasonable um strategy for rhythm control because of its Effectiveness um and low risk of detrimental effect on Exercise capacity so essentially where this came about was that there it's been shown that with moderate levels of exercise has been associated with lower incidents of AF but these high volume endurance um athletes um which essentially is defined as greater than 45 metabolic equivalent hours per week has been actually been associated with higher prevalence of AA particularly in young a athletes um it's not really fully known like the mechanism why this does happen um it's thought to be maybe related to like atal myopathies from like exercise and do stretch or like inflammation but there um have essentially been no Studies have really looked at the exercise Mo moderation um but sometimes that's proposed um and then generally athletes will often choose to continue their high-intensity Sports um and not really want to take medications because usually these patients are like younger so that's kind of how this cath ablation like young athletes um um came about um with the 2A recommendation um let's see and then lastly um in terms of like the pregnant population so this wasn't really mentioned in there was no really mention of uh pregnancy and Atri fibrillation in the prior guidelines but at least in like the newer guidelines um in pregnant patients with aib uh direct current cardiov version is safe in patients is safe to the patient and fetus um and should be performing in the manner that you would do any other patient um in patients that in pregnant patients that require um cardiov version um and then in terms of like the medical therapy of course the biggest thing is that you want to avoid um medications like amone in these particular patient population when you're considering medications to give them for um Rhythm management um but usually like sodal and fide um without any other underlying structureal heart disease is safe in this uh patient population these are the references and that's it all right well thank you qu important topic and a lot to digest there um you know for me I guess you know the the sort of making cath ablation class one is sort of the headline and and I think it's good they address this sort of uh officially address this sort of very low burden aib group you know now that we have wearables and more implantable monitoring devices you know what do you do with these folks that have like you know just a few seconds or a couple minutes of apib here and there and and I'm glad they address that one thing I just sort of a smaller thing but something that caught my eye and I hope I read this right this back this goes this is back towards the beginning your slide about any arhythmic therapy um it's interesting I I saw am for patients with a normal heart they had amiodarone as a 2A and sodol as a 2B uh yeah they're on the left um yeah I think I read that right anyway I that just caught my eyes like that's interesting that they would prefer am odone over sodol in a patient with you know a normal heart um I guess maybe just because it's more efficacious uh you know I don't know if you uh they commented on that or if you remember anything about that uh not necessarily that's the way it's always been I've just never known that that they would because I you know I just thinking I don't know just probably not not what I would do uh in practice uh for for this group but anyway just any any thoughts you had there yeah I think at least like when I've been on um my rotations during my brief stance as a fellow U I think like patients that have like um like some type of uh structural like heart dysfunction like we usually like shy away from using soda LA but I could be wrong if someone else wanted to comment uh Robbie uh that catches my too and uh we really don't do that I mean maybe he's an but I'm sure say maybe antient but for long-term Outpatient Therapy that would be a little that would I'm sure uh Europe they do that though so uh yeah s like the Europeans were voting here and you know again maybe for short-term therapy you know per procedural or after a blade you know like again I could see short-term amone use but in terms of like long chronic an chronic drug therapy for someone with a normal heart I don't know just otone we just we just don't do it very often uh for long-term maintenance of scius Rhythm and patient with normal LV function no prior Mi or no prior structural heart disease not not really done uh in in practice so Robbie Stan you know it's it's they're both twos it may just be that there's more data on am odone than there is data on sodol but I'm with you you know uh and I think we're with all the EP guys that am odone is not the person thing pull out over so law um I've got a question for Quenton what what about mitro valve disease I didn't see it at all in here uh I so they kind of did talk about it in terms of like the inter culation but I didn't like focus on it um for this particular presentation though yeah there was that part where they talked about AV disease I think they meant you know I don't think that was that was an aortic Val right Quenton I think you said that I think it was h ventricular valve as a sort of risk factor for recurrence or or consideration uh there you go like down at the bottom there I think that that refers to mital or tricuspid valve regurgitation and when you're favoring rate control versus Rhythm control but you're right they didn't they didn't go into it much Quinton this is mahm Abdu um back to that anti- arhythmic slide uh one thing that also caught my eye is the indication for suol uh in patients who have a reduced EF um if I remember correctly Su was a class three recommendation uh based on the sword trial however now they have it as a class 2B in those patients who have reduced CF so that's another thing to highlight um so uh so yeah anecdotally and in practice sometimes in conjunction with EP we sometimes use toal in patients with with heart failure however it was kind of outside of the guidelines but now you have a class 2B recommendation so right all right well um thank you everybody for tuning in this morning thank you Quin for an excellent review and um hope everybody has a great uh rest of their day and we'll see everybody uh next 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