The Future of AF Management in ICD Patients

September is Atrial Fibrillation Awareness Month, a time to share information and help raise awareness about this complex condition.

Detection of atrial fibrillation (AF) is crucial for timely, adequate management, but it still poses a challenge for clinicians due to the frequently asymptomatic nature of AF.¹ This is even more true for patients with standard single-chamber implantable cardioverter-defibrillators (ICDs), since these lack atrial sensing.² 

It is undisputed that early AF detection matters, and in a previous blog post, electrophysiologist Dr. Mate Vamos talks about how to select ICDs and foster early AF detection. However, Prof. Dr. Reza Wakili, Division Head of the Electrophysiology and Arrhythmia Service at Essen University Hospital in Germany, is convinced that the future of AF management is in the reduction of AF burden and monitoring disease progression. On the occasion of this year’s AF Awareness Month, he takes the opportunity to outline the key pillars for successful AF management and discusses why digital patient treatment is here to stay.

“We know that atrial fibrillation is a widespread, often silent problem with an annual incidence of 21 percent – and is difficult, if not impossible, to detect with a standard, single-chamber ICD. In the long term, such undetected and untreated AF could lead to worsening of the patient’s clinical condition as well as rehospitalization,” says Prof. Dr. Reza Wakili. “Therefore, timely detection of AF in those patients is clinically important.” As AF affects prognosis, quality of life and morbidity, the current ESC Guidelines for the Diagnosis and Management of AF give a clear recommendation to screen high-risk patients, such as patients ≥65 years of age, as well as those with risk factors like arterial hypertension, diabetes or heart diseases.³

Besides the usual screening measures such as electrocardiograms (ECGs), there’s also another possibility for selected patients. “If physicians think about equipping their patient with a single-chamber ICD, it’s worth also considering DX systems – single-lead ICDs with atrial sensing capabilities. Several studies^4,5,6 have shown that DX technology, these systems are equipped with, can reliably detect AF,” the cardiac rhythm expert says. He adds, “If physicians are able to detect AF in time, it gives them a chance to be preemptive with respect to the treatment strategy, such as stroke prevention, rhythm control, rate control or other approaches.”

Although early AF detection is paramount for timely intervention and patient outcome, Prof. Dr. Reza Wakili also identifies a new trend in AF management, which is to comprehensively characterize AF beyond merely checking whether it is present or not. “I see a new strategy in AF management to move away from simply detecting AF towards the quantification and characterization of AF and the determination of the AF burden. Whether the chosen therapy can reduce the AF burden for the patient is becoming a central question in assessing any kind of therapeutic success or failure. We can observe that current clinical trials are already focusing strongly on the evaluation and the dynamics of AF burden,” Prof. Dr. Reza Wakili says, concluding that in the years to come, AF burden will emerge as the key criterion in AF diagnostics and therapy.

This is where DX systems can play a significant role. Thanks to their unique atrial sensing capabilities and diagnostics, DX ICDs correctly quantify the arrhythmic burden and reliably classify AF episodes, which has been demonstrated in the MATRIX trial presented at this year´s EHRA Congress.⁵ DX systems thereby enable clinicians to monitor AF burden and subsequent disease progression over time. 

Such monitoring is becoming more and more important since AF burden seems to be emerging as a better predictor of prognosis and stroke risk than a single measure of AF.⁷ “However, the question whether or not a threshold value for AF burden exists is very much debated in the community,” adds Prof. Dr. Reza Wakili. So for now, it remains unclear whether a discrete threshold can be determined that results in an increased stroke risk and therefore warrants anticoagulation therapy.

As advances are being made in holistic integrated approaches to manage AF, Prof. Dr. Reza Wakili also underlines the opportunities digital tools pose for better patient care in the future. “Digital patient treatment is a trend that has come to stay. Modern cardiac tools and data management systems provide us with great possibilities, from remote cardiac monitoring to interdisciplinary patient data management and active patient involvement. 

We know about the clinical benefits of remote monitoring and the positive effects of patient involvement, especially in AF management,” says the AF specialist, who predicts that digital solutions will become even more important in the future. “I see a lot of potential when it comes to digital tools for patient involvement such as apps, but also in terms of treatment optimization.”

One example of such digital patient involvement tools is the BIOTRONIK Patient App. It is designed to allow patients to engage in their own care and brings symptom recording together with rhythm recording in one platform for clinicians. In ICD patients, the Patient App is the perfect complement to BIOTRONIK Home Monitoring^®, a remote patient monitoring platform that provides up-to-date and complete device data sets. This way, enabling complete diagnostic assessment and earlier action responding to changes in patients’ condition might allow clinicians make well-informed decisions and potentially improve patient outcomes.

Learn more about the BIOTRONIK integrated AF Management Solution for ICD patients combining DX technology, Home Monitoring and the Patient App here.

References:

1. Lüscher TF. Challenges in atrial fibrillation: detection, alert systems, fibrosis, and infection, Eur Heart J. 2020;41(10):1063–1066.

2. Reinhold T, Belke R, Hauser T et al. Cost Saving Potential of an Early Detection of Atrial Fibrillation in Patients after ICD Implantation. Biomed Res Int. 2018;2018:3417643.

3. Hindricks G, Potpara T, Dagres N et al. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS): The Task Force for the diagnosis and management of atrial fibrillation of the European Society of Cardiology (ESC) Developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC. Eur Heart J. 2021;42(5):373–498.

4. Gwag HB, Lee SH, Kim JS et al. Long-term evaluation of sensing variability of a floating atrial dipole in a single‑lead defibrillator: The mechanistic basis of long-term stability of amplified atrial electrogram. Int J Cardiol. 2021;336:67–72.

5. Maglia G, Hindricks G, Theuns DA et al. Capability of guideline-conform remote atrial high rate episode monitoring with a single-chamber implantable defibrillator with atrial sensing. Europace. 2022;24(Suppl.1):euac053.515.

6. Biffi M, Iori M, De Maria E et al. The role of atrial sensing for new-onset atrial arrhythmias diagnosis and management in single-chamber implantable cardioverter-defibrillator recipients: Results from the THINGS registry. J Cardiovasc Electrophysiol. 2020;31:846–853.

7. Sánchez-Somonte, P, Gul Enes Elvin, Verma Atul. The Importance of Arrhythmia Burden for Outcomes and Management Related to Catheter Ablation of Atrial Fibrillation; Korean Circ J. 2021;51(6):477–486.