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In this episode of The EP Edit podcast, Rod Passman, MD, talks with Jodie Hurwitz, MD, President of the Heart Rhythm Society (HRS), about the selection of authors for HRS clinical guidelines, how atrial fibrillation (AF) guidelines will change practice, the impact of pulsed field ablation, and the role of HRS in maintaining high-quality care in interventional AF therapies. 

This podcast episode is also available on Spotify and Apple Podcasts!

Rod Passman, MD: Hello, I am Dr Rod Passman, and we are talking today from the Western AF Symposium. It is my pleasure to have the opportunity to speak with Dr Jodie Hurwitz, President of the Heart Rhythm Society. Jodie, welcome. 

Jodie Hurwitz, MD: Thank you. It is nice to be here.

Passman: So, this is a really interesting time in our field. There is a lot of great technology coming out and guidelines were recently released on AF. I think a lot of people want to know about the process of choosing people for HRS guidelines, how people become involved, and how we deal with the fact that we are individuals often tied to industry and that that is how we move this field forward. Tell me the HRS position on how you choose these people and how you strike those balances.

Hurwitz: Thank you for this very important question. When there are guidelines that are decided to be published and researched, this goes through the Scientific and Clinical Documents Committee (SCDC). There is an advertisement, if you will, that goes out to all the HRS members about becoming involved in these guidelines. There is a nominations group, and people submit their names. They fill out an extensive amount of information about what their interest is, why they should be involved in this, and any kind of relationships with industry. Those names go back to the SCDC committee and are reviewed. They are also reviewed through the ethics committee. Then, there is a selection, and those names go to the executive committee and the board of trustees, who review the selections, and then they go back to the SCDC. The important thing is that the chair and at least one of the cochairs of these committees need to have no involvement with industry, and the recommendation is at least 50% of each of the working committees have no involvement with industry. Obviously, this is a real sticking point. It is one of the big things that I comment on all the time. Our field is inherently and importantly involved with industry, so to have these committees include people who 100% have no relationships with industry I think would be a detriment.  

Passman: Yes, I think that the pendulum has a swung a bit, because I do think there was a year where no one on the writing committee had contact, but as you mentioned, our field moves forward from those interactions. I think they are very important. So, it sounds like a balance has been struck and I think that balance is fair. 

Hurwitz: So far it looks great. 

Passman: So, I think the guidelines have some really interesting things as some have pointed out. It is over 400 pages. Is that true? 

Hurwitz: It is not quite that long, but it is very long. As people have said, it takes a good weekend to go through everything. 

Passman: What stands out to you as being outstanding in terms of how this is going to change the way we practice medicine and how we care for patients with AF? What were the most remarkable changes?

Hurwitz: This is also a great question. I think that one of the most important things that the guideline has now done is include a class I indication for AF ablation for the treatment of patients with AF. It is also a class I indication now for ablation for patients who have heart failure. I think this really supports our discussion with patients. It enables us to give them data. It is no surprise that it helps with payers as well, so that we can work forward and push the envelope in an appropriate direction. I think one of the most important things that these guidelines also offered us is a staging of AF and the notion that AF is a continuum. This is so that we all, not only electrophysiologists, but cardiology and internal medicine physicians, can start looking for patients earlier so that we can get involved with their care earlier and change things going forward. There are also very specific recommendations for treating some of the steps, not only generally treating the hypertension or the obesity, but really give concrete suggestions about how to do this. The other thing that we have heard a lot about over the last several years, and I am delighted to see in the guidelines, is the fact that early treatment for AF is really paramount to helping our patients.  

Passman: I think those are huge changes and it sort of gets into something that someone said here yesterday. AF is an incredibly complicated disease. When we see patients referred to us, it may be different than being treated for something like high blood pressure or high cholesterol, where maybe primary care doctors feel pretty comfortable in their care. Has AF gotten so complex that this is clearly the domain of not even a cardiologist, but an electrophysiologist to deal with most patients, or are we just not communicating the ABCs to our primary care colleagues? 

Hurwitz: This is obviously something that you are passionate about. It is definitely not the purview of only electrophysiologists. I really think that it behooves us to better educate those people who essentially refer to us, but I think it is really important. Again, this is a personal opinion, as I think you have an opinion about this too. We need to get our health care providers involved in helping to prevent AF much earlier than we have been doing. Obviously, ablation procedures are the purview of electrophysiologists, but in the beginning treatment, we need all health care providers to help us with this.  

Passman: I think we need to expend a lot of energy sort of undoing the damage that trials like AFFIRM did, right? Because there are a lot of people who are not electrophysiologists who are not going to read our guidelines and not recognize how important early intervention is, and perhaps offer ablation even as first-line therapy. So, I think a lot of these patients may be cared for and not getting state-of-the-art care. Communicating that to our cardiology and internal medicine referrals is really important. 

Hurwitz: Right, and that can go to some of the derivatives of the guidelines and how we can get the message out, not only to our peers in electrophysiology (EP), but again, all the health care providers who ultimately will refer these patients to us. We need a little better ability to educate them. 

Passman: So obviously, there is so much excitement about PFA. This technology has just been approved in the United States with 2 companies. How do you foresee this changing the practice of EP? You and I have been doing this long enough to see AF ablation go from a multi-hour procedure to maybe one that is safer, that we could offer to patients who otherwise would not even consider, and certainly reduce the time that it takes to decrease radiation exposure and the risks involved. What do you foresee as the future? Is this going to be done more as a result? Are we going to offer it to sicker patients or frail patients who maybe we would be more concerned about collateral damage? Where do you think it is going to fall? 

Hurwitz: I probably can talk about this for quite a while, so I will just highlight a few things. I think what I would really like to enforce is what seems to be the safety data with PFA. I think that in comparison to the thermal ablation energies that we have been using for AF ablation, the notion that we can do this quicker, and therefore, that makes it better, is probably not the right way to approach this. Procedures using PFA as an energy source really still need to be done by an electrophysiologist. This is an EP issue. It will be interesting to see the widespread adoption of PFA. Unfortunately, right now some of the payers do not see the benefits of PFA the same way that we do, so there are some hurdles there that we need to overcome. I think that as we drive this field forward, we do better for our patients, which is fantastic. I really do think that PFA is going to be, for the time being, the energy source that we will all be using for ablations. n 

Passman: Do you have any concerns about how HRS maintains quality? Now that we have a better tool, the threshold for recommending it and the expertise that may be needed may change over time. So, how do we ensure that we maintain the quality that HRS is known for as this procedure maybe grows in number? 

Hurwitz: One worries that when something new is coming down the pike that everybody will want to jump on the bandwagon without really getting an appropriate sense of education on how to use these tools. I think that that is exactly where HRS can help with education. Competition among companies, I think, is actually very healthy. It drives the field forward. I think that we make sure that studies done are appropriate, that they include the right patients, that we get the right information from that. We have a very robust health policy committee that really looks at all of this in detail, and I think that supporting them and getting the data out from them is going to be very helpful.  

Passman: That is good to know. So, I have one last question for you. What is the best part about being HRS president? 

Hurwitz: Well, other people have said this before. I think it is the people. It is just amazing to me how many people all over the world I wind up getting to meet. You are involved in absolutely everything and that is really wonderful. You get to learn an awful lot about a lot of different things. The HRS staff is incredible. I have been in EP for a long time, and I still find the field absolutely fantastic and interesting. We are moving forward. This is a really fun time to be in EP again and I think HRS really supports that. So, as president, it is really fun to be able to be out there in front helping move this field forward.

Passman: That is a great answer. I want to thank you very much for taking your time to speak with us today. I really appreciate it.

Hurwitz: Thank you. 

The transcripts have been edited for clarity and length.