Presentado en XXVIII Congreso Dominicano de Cardiología, Punta Cana, junio 2021

1. ¿Qué hay de nuevo en las
guías de fibrilación
auricular?
Sergio L. Pinski, MD, FHRS
Cleveland Clinic Florida
Weston, Florida, USA
@SergioPinski

2. La epidemia de FA en el siglo XXI

3. Guías clínicas de fibrilación auricular
• AHA/ACC/HRS, 2014, actualización en 2019
• European Society of Cardiology (ESC), 2020 (versión en español en
Revista Española de Cardiología 2021)
• Plétora de guías de otros países y organizaciones y de aspectos
focalizados de la FA (por ejemplo tratamiento antitrombótico,
ablación, medidas de calidad)
• Muchos estudios recientes destinados a cambiar las guías clínicas

4. Clases de recomendaciones
ACC/AHA
ESC

5. Niveles de evidencia
AHA/ACC
ESC

6. Manejo integral de la FA: Estragegia CC to ABC

7. Manejo integral de la FA: Estragegia CC to ABC

8. Meta-análisis de terapia antitrombótica doble vs triple en
pacientes con FA y stent coronario
Gargiulo et al. Eur Heart J Cardiovasc Pharmacother 2021;7:f50

9. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation
www.escardio.org/guidelines
©ESC
Figure 20 (1) Post-procedural management of patients with AF and ACS/PCI (full-
outlined arrows represent a default strategy; graded/dashed arrows show treatment
modifications depending on individual patient’s ischaemic and bleeding risks)
©ESC

10. No hay necesidad de antiplaquetarios en pacientes
anticoagulados con FA y enfermedad coronaria estable
Yasuda et al. N Engl J Med 2019;381:1103

11. Recomendación para exclusión de la orejuela de la AI
durante cirugía cardíaca en pacientes con FA

12. Endocardial LAA suture

13. Residual leak post LAA endocardial ligation

14. Post LAA endocardial ligation

15. Whitlock et al. N Engl J Med 2021; (in press)

16. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation
www.escardio.org/guidelines
©ESC
Recommendations for rhythm control
Recommendations Class Level
Rhythm control therapy is recommended for symptom and QoL
improvement in symptomatic patients with AF.
I A
Recomendación para control del ritmo

17. Kirchhof P et al. N Engl J Med 2020;383:1305-1316
Kirchhof et al. N Engl J Med 2020;383:1305
EAST-AFNET 4. El control de ritmo temprano en la FA
mejora el pronóstico y reduce complicaciones

18. Ablación en pacientes con insuficiencia cardíaca: CASTLE-AF
Marrouche et al. N Engl J Med 2018;378:417

19. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation
(European Heart Journal 2020-doi/10.1093/eurheartj/ehaa612)
www.escardio.org/guidelines
©ESC
Recommendations for rhythm control/catheter ablation
of AF (2)
Recommendations Class Level
AF catheter ablation after failure of drug therapy
AF catheter ablation for PVI is recommended for rhythm control after one
failed or intolerant class I or III AAD, to improve symptoms of AF recurrences
in patients with
I
• Paroxysmal AF, or A
• Persistent AF without major risk factors for AF recurrence, or A
• Persistent AF with major risk factors for AF recurrence B
AF catheter ablation for PVI should be considered for rhythm control after
one failed or intolerant to beta-blocker treatment to improve symptoms of
AF recurrences in patients with paroxysmal and persistent AF.
IIa B
Recommendations for rhythm control/catheter ablation
of AF (2)
Recomendaciones para ablación por catéter

20. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation
(European Heart Journal 2020-doi/10.1093/eurheartj/ehaa612)
www.escardio.org/guidelines
©ESC
Recommendations Class Level
First-line therapy
AF catheter ablation for PVI should/may be considered as first-line rhythm
control therapy to improve symptoms in selected patients with symptomatic:
• Paroxysmal AF episodes, or IIa B
• Persistent AF without major risk factors for AF recurrence. IIb C
as an alternative to AAD class I or III, considering patient choice, benefit,
and risk.
C
Recommendations for rhythm control/catheter ablation
of AF (4)
Recommendations Class Level
First-line therapy (continued)
AF catheter ablation:
• Is recommended to reverse LV dysfunction in AF patients when
tachycardia-induced cardiomyopathy is highly probable, independent of
their symptom status.
I B
• Should be considered in selected AF patients with HF with reduced LVEF to
improve survival and reduce HF hospitalization.
IIa B
AF catheter ablation for PVI should be considered as a strategy to avoid
pacemaker implantation in patients with AF-related bradycardia or
symptomatic pre-automaticity pause after AF conversion considering the
IIa C

21. CABANA: ablación vs drogas antiarrítmicas
Packer et al. JAMA 2019;321:1261

22. Crioablación vs droga antiarrítmica en FA paroxística
Andrade et al. N Engl J Med 2021;384:305

23. Wazni et al. N Engl J Med 2021;384:316
Crioablación vs droga antiarrítmica FA paroxística

24. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation
(European Heart Journal 2020-doi/10.1093/eurheartj/ehaa612)
www.escardio.org/guidelines
©ESC
of risk factors and concomitant diseases in patients with AF (1)
Recommendations Class Level
Identification and management of risk factors and concomitant diseases is
recommended as an integral part of treatment in AF patients.
I B
Modification of unhealthy lifestyle and targeted therapy of intercurrent
conditions is recommended to reduce AF burden and symptom severity.
I B
Opportunistic screening for AF is recommended in hypertensive patients. I B
Attention to good BP control is recommended in AF patients with
hypertension to reduce AF recurrences and risk of stroke and bleeding.
I B
In obese patients with AF, weight loss together with management of other
risk factors should be considered to reduce AF incidence, AF progression, AF
recurrences, and symptoms.
IIa B
2020 ESC Guidelines for the diagnosis and management of atrial fibrillation
(European Heart Journal 2020-doi/10.1093/eurheartj/ehaa612)
www.escardio.org/guidelines
©ESC
Recommendations Class Level
Identification and management of risk factors and concomitant diseases is
recommended as an integral part of treatment in AF patients.
I B
Modification of unhealthy lifestyle and targeted therapy of intercurrent
conditions is recommended to reduce AF burden and symptom severity.
I B
Opportunistic screening for AF is recommended in hypertensive patients. I B
Attention to good BP control is recommended in AF patients with
hypertension to reduce AF recurrences and risk of stroke and bleeding.
I B
In obese patients with AF, weight loss together with management of other
risk factors should be considered to reduce AF incidence, AF progression, AF
recurrences, and symptoms.
IIa B
Recommendations for lifestyle interventions and management
of risk factors and concomitant diseases in patients with AF (2)
Recommendations Class Level
Advice and management to avoid alcohol excess should be considered for AF
prevention and in AF patients considered for OAC therapy
IIa B
Physical activity should be considered to help prevent AF incidence or
recurrence, with the exception of excessive endurance exercise, which may
promote AF.
IIa C
Opportunistic screening for AF should be considered in patients with OSA. IIa C
Optimal management of OSA may be considered, to reduce AF incidence, AF
IIb C
Recommendations for lifestyle interventions and management
of risk factors and concomitant diseases in patients with AF (2)
Recommendations Class Level
Advice and management to avoid alcohol excess should be considered for AF
prevention and in AF patients considered for OAC therapy
IIa B
Physical activity should be considered to help prevent AF incidence or
recurrence, with the exception of excessive endurance exercise, which may
promote AF.
IIa C
Opportunistic screening for AF should be considered in patients with OSA. IIa C
Optimal management of OSA may be considered, to reduce AF incidence, AF
progression, AF recurrences, and symptoms.
IIb C

25. Obesidad y FA
Mahajan et al. JACC Clin Electrophysiol 2018;4:1529

26. Pérdida de peso, mejoría metabólica y
functional reducen la FA
• LEGACY – weight loss leads to reduced AF burden w/o ablation
• ARREST-AF – improved control of multiple risk factors reduces AF burden after AF
ablation (HTN, DM, weight)
• CARDIO-FIT – improved CV fitness leads to decreased AF burden after AF ablation
Lau et al. Circulation 2017;136;583

27. Ejercicio físico y FA
Exercise Burden
AF Incidence
Estes & Madias. JACC Clin Electrophysiol 2017;3:921
Mohanty et al. J Cardiovasc Electrophysiol 2016;27:1021

28. Consumo de alcohol e incidencia de FA: no hace falta mucho
Csengeri et al. Eur Heart J 2021;42:1170

29. Estudio controlado: Abstinencia del alcohol reduce la FA
Voscoboinik et al. N Engl J Med 2020;382:20

30. Sensibilidad exquisita al alcohol en la FA
• Estudio presentado en ACC, Mayo 2021; Gregory Marcus, MD, UCSF
• 100 pacientes con FA paroxística bebedores moderados. Holter
continuo de 4 semanas, marcando la ingesta de alcohol.
• Sensor transcutáneo de alcohol y medición periódica de metabolitos
para corroborar
• Un trago duplicó el riesgo de FA en las 4 horas subsiguientes (OR
2.26); 2 ó más tragos más que lo triplicaron (OR 3.58)
• Un aumento del 0.1% en la concentración en sangre de alcohol
(inferido por el sensor) resultó en un 38% mayor riesgo de FA

31. Los ácidos grasos omega 3 aumentan la FA en
forma dosis-dependiente