ACC/AHA/ACCP/HRS Guideline Updates in the Management of Atrial Fibrillation

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Dr. Thomas: 
Hello, I'm Kevin Thomas, and I'm the vice dean for equity, diversity, and inclusion, and professor of medicine at Duke University Medical Center. It is really a pleasure to be here with you today to talk about the impact of social determinants of health on management of atrial fibrillation and how social determinants of health was an important addition to the newly released guidelines on the management of patients with atrial fibrillation from the American Heart Association, the American College of Cardiology, and the Heart Rhythm Society.

We are becoming increasingly aware of the importance of considering social determinants of health in the management of many cardiovascular conditions. For years now we began to understand how this may impact individuals who are receiving care for acute myocardial infarction, and more recently looking at the effect of social determinants of health on individuals with heart failure.

Recently, we've seen an emergence in publications recognizing and elevating the importance of social determinants of health as we consider the management of patients with atrial fibrillation. Social determinants of health, just as a reminder, really pushes us to consider the conditions in which patients live, age, work, and also the areas in which healthcare is delivered. And we know that adverse social determinants of health can lead to untoward outcomes in patients who have A-fib: an increased risk of stroke, an increase in all-cause mortality, as well as an increase in hospitalizations. And so it was really important that we considered the social determinants of health as we thought about this emergent and refresh in caring for patients with atrial fibrillation.

We know that when you look at certain individuals, social determinants of health typically have an adverse impact on health. When we think about individuals who live in rural locations, individuals who are from certain underrepresented racial and ethnic groups, and individuals who identify as their gender as being female, are individuals who disproportionately have untoward social determinants of health that lead to adverse outcomes. We want to really consider this as we think about some of the new guidelines that were recently released.

So the recommendation to address health inequities and barriers to A-fib management really reference issues of social determinants of health. So the recommendation is for patients who have atrial fibrillation, regardless of sex and gender, diversity, race and ethnicity, or adverse social determinants of health, should be equitably offered guideline-directed stroke risk reduction therapies, as well as rate or rhythm control strategies and lifestyle and risk factor modification, as indicated, to improve the quality of life and to prevent adverse outcomes. And this received a strong recommendation from the committee with a recommendation of a Class 1 indication, and then the level of evidence that really summarizes the strength of the recommendation and the data that's available rose to a level of evidence of b for non-randomized control trials. And so this usually is more than one trial that is high quality in evidence. And it usually is non-randomized and may be observational in nature or consists of a meta-analysis.

And so we thought it was really important to emphasize the strength of this recommendation from the committee and to really get clinicians to think about the patients that they care for and how, again, their social determinants of health may influence their ability to access healthcare, as well as how treatment is delivered for individuals, and ultimately, what their outcomes are. And so when I think about, again, social determinants of health, I like to focus on certain populations that historically have been undertreated, have had disparities in treatment, and have had untoward outcomes. And we've talked about, again, sex and gender diversity. Women tend to present later in their stage of disease when they have atrial fibrillation, are less likely to be treated with oral anticoagulants, and less likely to be treated and managed with rhythm control strategies.

Now we know that there is increasing evidence that early rhythm control is important. And so these populations, including those individuals who are Black or Hispanic and Latin-A in their racial and ethnic identities are at risk for untoward outcomes.

So as we think about our treatment and our recommendations and management of patients with atrial fibrillation, I implore you to really consider an individual's social determinants of health as you think about approaching their treatment goals and their management strategies.

Thank you so much for joining us today. And thank you for your engagement. We really hope that you found this information valuable, and will be able to use this when you think about your own clinical practice.

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