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Sunday, September 8, 2024

Kentucky highway shooter still loose as cops find SUV, ‘AR rifle’; 7 people injured

 A  whoman shot motorists on a rural Kentucky highway was on the loose Sunday as cops said they recovered an SUV and an “AR rifle” — one day after he blasted five people and caused a crash that injured two others, cops said.

Multiple law enforcement agencies were searching for the shooter after he fired at a stretch of Interstate 75 in the small city of London, Kentucky on Saturday.

All of the victims were in stable condition early Sunday, though some had “very serious” injuries, including one person who was shot in the face, deputy Gilbert Acciardo, a spokesperson for the Laurel County Sheriff’s Office, said.

Joseph A. Couch has been named as a person of interest in the shooting.Laurel County Sheriff's Office/Facebook
Deputy Gilbert Acciardo, Public information Officer with the Laurel County Sheriff’s Office, gives details on the progress of the investigation of the shooting along I-75 in London, Ky., Sunday, Sept. 8, 2024.AP
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Cops identified Joseph A. Couch, 32, as a person of interest, warning locals that he should be considered “armed and dangerous.” Couch is described as a white male approximately 5’10 and weighing 154 pounds.

A silver SUV registered to Couch was found off a US Forest Service Road Saturday night with a rifle case inside, the sheriff’s office said in a Facebook post. Authorities also found “an AR rifle” near I-75 near to the car, the post added.

Police had arrived at a chaotic scene and saw several cars pulled off at the exit as well as nine vehicles with bullet holes.

Authorities continued their search for the gunman responsible for the shooting on Sunday.via REUTERS

“When our first two units got to the scene there, they said it was a madhouse: people on the sides of the road, emergency flashers going, bullet holes, windows shot out, nine vehicles shot. Can you imagine that? Just chaotic,” Acciardo said during a Sunday news conference.

Officers searched the remote, wooded area but the search was temporarily suspended due to darkness. The search started up again early Sunday morning as authorities also worked to determine where the gunman fired from.

Acciardo said authorities did not believe the shooting was a result of road rage.

People in the area were urged to remain home as the manhunt for the gunman continues.Rich Brimer via REUTERS

Local lawmakers are urging residents in the area to stay home as police continue to search for the gunman.

The Interstate was closed 9 miles north of London but reopened three hours later, officials said.

The FBI, the US Marshal’s Service and the federal Bureau of Alcohol, Tobacco, Firearms and Explosives are assisting local authorities in the investigation, officials said.

https://nypost.com/2024/09/08/us-news/sicko-who-shot-at-drivers-on-highway-still-on-the-loose-after-7-people-injured-it-was-a-madhouse/

Normalization of gambling is fueling addiction

 Let’s not call gambling the “hidden addiction” anymore.  

The medical, personal and financial wreckage of this condition is right in front of us as we watch the betting line scroll across the screen of sports broadcasts. Those of us who treat patients with problem gambling, as the condition is known, can feel it happening as our phones turn into portable casinos. We can hear it coming as we’re told stories about teens amassing gambling debt.  

It’s a race against the clock to offer treatment for problem gambling as a primary addiction in the U.S., because it has become prevalent, accessible and normalized. My colleagues and I are bracing for a public health challenge akin to the opioid epidemic. 

We’re seeing individuals face foreclosure and tremendous debt because they’re using mortgage, rent and grocery money to place bets. They feel fearful and without hope as their relationships splinter — not only from financial wreckage, but from the accompanying conditions from which problem gamblers also often suffer: anxietydepression, and substance use disorders. Nearly 40 percent of people with a gambling disorder will consider suicide.  

The demographics of the condition are startling, too. Young adults, particularly young men between the ages of 18 and 24, are more likely to engage in “risky” gambling behavior; teens don’t necessarily view gambling as an activity that can lead to problems. Age, cultural background and socioeconomic status also may contribute to an increased likelihood of developing a gambling problem.  

Problem gambling is exploding nationally, to the tune of about 7 million U.S. adults. Some of the same states that have legalized sports gambling have been overwhelmed by increases in calls to their gambling addiction hotlines.  

That legalization has helped normalize gambling culture. It’s legal in casinos or at racetracks in 38 states and Washington, D.C., and six states have measures pending to authorize it. Televised sports shows have done their part, too, because we barely notice the “betting line” on our screens. Some sports shows are dedicated entirely to gambling. About $23 billion was spent legally gambling on the last Super Bowl alone.  

Of course, gambling goes beyond sports. We visit casinos, buy scratch-off or lottery tickets, bet on horse races, play bingo, and participate in office raffles. Online gambling opportunities are endless. 

Many people can treat gambling as a form of entertainment without developing an addiction. But for others, it’s not so simple. People with problem gambling are chasing that dopamine rush — the high associated with every other type of addiction. And, like other addictions, gambling is a societal problem, not just an individual one. 

The national annual social cost of this addiction is around $14 billion. That includes gambling-related criminal justice, healthcare spending, job loss and bankruptcy. I’d like to see states weigh that against the relatively modest revenue increases they’ve seen from legalization.  

In the meantime, there is nothing modest about how my colleagues and I are preparing for the fallout.

We’re screening more patients for problem gambling, creating starter support groups and applying for state certification to treat gambling as a primary addiction. The federal government, states and individual families have roles to play, too. Lawmakers can take a close look at the Gambling Addiction Recovery, Investment and Treatment Act. If passed, this legislation would dedicate federal funds for programs to prevent, treat and study gambling addiction; support state health agencies and nonprofits that address gambling problems; and invest in best practices, comprehensive research into the condition, and early education about the risks of gambling. 

The healthcare workforce needs to know this problem is right on the horizon. Let’s prepare to understand the impact of problem gambling and expand screening across a variety of healthcare settings, so we can identify the condition and intervene early.    

When educators and parents discuss the responsible use of phones and social media with young people, they can add problem gambling, and how to obtain help for it, to the conversation. There are numerous apps and other gambling opportunities to track, and we need to keep underage kids from sidestepping age restrictions and parental permission to gamble. The hard truths about social media platforms collecting personal data also apply to gambling apps, as is the reality that gambling apps, like casinos, are specifically designed to keep us betting. 

We can all send the message that enjoying sports doesn’t have to include placing bets. Maybe one form of entertainment at a time is enough. Do we need our smartphones beside us as we spectate? Perhaps we can watch games without the betting line. 

Gambling now is in plain sight. Labeling it as entertainment doesn’t allow us to help our overwhelmed — and overmatched — patients. There are too many facets of this problem to heal, from accompanying conditions and addictions to financial counseling and relationships. We can’t do that until we’re honest about how normalizing and expanding gambling has contributed this burgeoning addiction. 

Heather Hugelmeyer, LCSW, is senior director of behavioral health at Northwell Health, overseeing addiction services at Zucker Hillside Hospital and South Oaks Hospital. 

https://thehill.com/opinion/healthcare/4866361-problem-gambling-addiction-treatment/

Is Artificial Intelligence The Next Easy-Money Bust?

 by Justin Murray via The Mises Institute,

Since early 2022, the big buzz in the tech industry, and among laymen in the general public, has been “artificial intelligence.” While the concept isn’t new - AI has been the term used to describe how computers play games since at least the 1980s - it’s once again captured the public’s imagination.

Before getting into the meat of the article, a brief primer is necessary. When talking about AI, it’s important to understand what is meant. AI can be broken down into seven broad categories. Most of the seven are, at best, hypothetical and do not exist. The type of AI everyone is interested in falls under the category of Limited Memory AI. These are where large language models (LLMs) reside. Since this isn’t a paper on the details, think of LLMs as complex statistical guessing machines. You type in a sentence and it will output something based on the loaded training data that statistically lines up with what you requested.

Based on this technology, LLMs can produce (at least on the surface) impressive results. For example, ask ChatGPT 4.0 (the latest version at the time of writing) the following logic puzzle:

This is a party: {}

This is a jumping bean: B

The jumping bean wants to go to the party.

It will output, with some word flair, {B}. Impressive, right? It can do this same thing no matter what two characters you use in the party and whatever character you desire to go to the party. This has been used as a demonstration of the power of artificial intelligence.

However, do this:

This is a party: B

This is a jumping bean: {}

The jumping bean wants to go to the party.

When I asked this, I was expecting the system to, at minimum, give me a similar answer as above, however, what I got was two answers: B{} and {}B. This is not the correct answer since the logic puzzle is unsolvable, at least in terms of how computers operate. The correct answer, to a human, would be I{}3.

To understand what’s going on under the hood, here’s the next example:

Dis be ah pahtah: []

Messa wanna boogie woogie: M

Meesa be da boom chicka boom.

This silly Jar Jar Binks-phrased statement, if given to a human, makes no sense since the three statements aren’t related and there isn’t a logic puzzle present. Yet, GPT4 went through the motions and said that I’m now the party. This is because—for all its complexity—the system is still algorithmically driven. It sees the phrasing, looks in its database, sees what a ton of people previously typed with similar phrasing (because OpenAI prompted a ton of people to try), and pumps out the same format. It’s a similar result that a first year programming student could produce.

Major Limitations

The above silly example proves there are tremendous limitations in the AI industry space. It works great if you ask it something simple and predictable, while it falls apart when you ask for something only slightly more complex, like trying to get an image generator to give you the image you wanted out of a simple four-sentence paragraph. There is, as the industry admits, a lot of work to be done while advancements are being made.

The problem? The whole AI experiment is ludicrously expensive and the cost accelerates well beyond the advancements in utility. OpenAI—the current leader in LLMs—is on track to lose $5 billion this year, representing half of its total capital investment. The losses only expand with the more customers the company signs up and the better their model gets.

There is a surprising lack of viable applications for which this technology can be used. Attempts to implement this technology in substantive ways have backfired badly. Air Canada’s AI assisted customer service and gave away discounted airfare. The Canadian court stated the company is liable for anything an AI assistant provides to a customer. The legal profession is—piecemeal—being forbidden from using AI in court cases across the U.S. after a string of high-profile events of AI programs fabricating documents. Major demonstrations were later to be discovered as heavily faked. Google’s new AI summary at the top of the search page takes roughly 10 times more energy to produce than the search itself and has near zero end-user utility. Revenues in the AI space are almost exclusively concentrated in hardware, with little end-user money in sight. There’s also the shocking energy requirements needed to operate it all.

To make matters worse, further development will likely only get more expensive, not cheaper. The hardware industry is at the tail-end of its advancement potential. Processor designers ran out of the clock speed lever to pull nearly two decades ago while single thread performance peaked in 2015. Processor design has been mostly getting by on increasing logic core count via shrinking transistors. Though this particular lever is expected to be exhausted next year when the 2nm process comes online. What this means is that, starting as early as next year, AI can’t rely on hardware efficiency gains to close the cost gap since we’re already close to the maximum theoretical limit without radically redesigning how processors work. New customers require new capacity, so every time another business signs on, the costs go up, making it questionable if there will ever be a volume inflection point.

With these revelations, a prudent businessman would cut his losses in the AI space. The rapidly expanding costs, along with the questionable utility, of the technology makes it look like a major money-losing enterprise.

Yet AI investments have only expanded. What is going on?

Big Tech Easy Money

What we’re seeing is a significant repercussion of the long easy-money era, which, despite the formal Fed interest rate hikes, is still ongoing. The tech industry in particular has been a major beneficiary of the easy-money phenomenon. Easy money has been going on for so long that entire industries, tech in particular, are built and designed around it. This is how food delivery apps, which have never posted a profit and are on track to lose an eye-watering $20 billion just in 2024, keep going. The tech industry will pile in billions to invest in questionable business plans just because it has the veneer of software somewhere in the background.

I’m seeing a lot of the same patterns in the AI boom as I saw years ago with the WeWork fiascoBoth are attempting to address mundane solutions. Neither of them scale well to the customer base. Both, despite being formally capital-driven, are highly subject to variable costs of operation that can’t be easily unwound. Both apply an extra layer of expense to do little more than the exact same thing as done before.

Despite this, companies like Google and Microsoft are willing to pour tremendous amounts of resources into the project. The main reason is because, to them, the resources are relatively trivial. The major tech firms—flushed with decades of cheap money—have enough cash on hand to outright buy the entire global AI industry. A $5 billion loss is a drop in the bucket for a company like Microsoft. The fear of missing out is greater than the cost of a few dollars in the war chest.

However, easy money has its limits. Estimates put the 2025 investment at $200 billion which—even for juggernauts like Alphabet—isn’t chump change. Even this pales in comparison to some of the more ludicrous estimates like global AI revenues reaching $1.3 trillion by 2032. The easy money today doesn’t care about where that revenue is supposed to manifest from. The easy money will, however, give out when the realities hit and the revenues don’t show up. How much is the market willing to pay for what AI does? The recent wave of AI phones hasn’t exactly arrested the long-run decline in smartphones, for example.

At some point, investors will start asking why these major tech firms are blowing giant wads of cash on dead-end projects and not giving it back as dividends. Losses can’t be sustained indefinitely.

The big difference in the current easy-money wave is who feels the pain when the bust happens won’t be the usual suspects. Big players like Microsoft and Nvidia will still be around, but they’ll show lower profits as the AI hype dies down. They siphoned up the easy money, spent it on a prestige project, and will not face the repercussions of the failure. There likely won’t be a spectacular company collapse like we saw in the 2009 era, however, what we will see are substantial layoffs in the previously prestigious tech space, and the bust will litter the landscape with small startups. In fact, the layoffs have already started.

Of course, I could always be wrong on this. Maybe AI really is legitimate and there will be $1.3 trillion in consumer dollars chasing AI products and services in the next five years. Maybe AI will end up succeeding where 3D televisions, home delivery meal kits, and AR glasses have failed.

I am, however, not terribly optimistic. The tech industry is in the midst of an easy-money-fueled party. My proof? The last truly big piece of disruptive technology the world experienced—the iPhone—turned 17 not all that long ago. The tech industry has been chasing that next disruptive product ever since and has turned up nothing. Without the easy money, it wouldn’t have been able to keep it up for this long.

https://www.zerohedge.com/technology/artificial-intelligence-next-easy-money-bust

Knowing What The F** Is Going On In Markets

  

It's amazing how our trading psychology improves when we take the time to step back, review macro markets, and understand what is going on in the heads of large money managers.

Consider the recent stock market:

*  Growth-related sectors have been particularly weak.  Check out the XLK (technology) and XLY (consumer discretionary) ETFs.

*  Value-related sectors have been relatively strong, especially the ones that benefit from lower interest rates.  Check out the XLRE (real estate); XLU (utilities); and XLP (consumer staples) ETFs.

*  The bond market has been strong, which means interest rates are falling.  Check out the BND (bond) ETF.

*  The US dollar has been weak.  Check out the DXY (dollar index).

*  Commodities have been falling.  Check out the DBC (commodities) ETF and oil prices.

Macro markets do not always trade thematically.  When they do, smart traders pay attention.  You can work on your psychology 24 hours and, if you don't understand market themes, you'll eventually get run over and lose money.

Going forward, a key question to ask is whether the theme of growth slowdown and potential recession is expanding or whether there are signs that the market's "theme-ness" is reversing.  Aligning shorter-term trading with the market's bigger picture helps ensure that you're swimming with the tide, not against it.

Further Reading:

The Importance of Understanding Global Macro Themes

.    D

https://traderfeed.blogspot.com/2024/09/knowing-what-f-is-going-on-in-markets.html

'Old, Frail Patients: Study More, Intervene Less?' Again

 The ability to save cardiac muscle during an acute coronary syndrome with percutaneous coronary intervention (PCI) made cardiology one of the most popular fields in medicine.

But acute coronary syndromes come in different categories. While rapid PCI clearly benefits patients with ST-segment elevation myocardial infarction (STEMI), the best use of angiography and PCI for patients with non–ST-segment elevation myocardial infarction (NSTEMI) is more complex.

The evidence for early invasive vs conservative strategies in patients with NSTEMI is mixed. There have been many trials and meta-analyses, and generally, outcomes are similar with either approach. Perhaps if one looks with enough optimism, there is a benefit for the more aggressive approach in higher-risk patients.

Despite the similar outcomes with the two strategies, most patients are treated with the early invasive approach. Early and invasive fit the spirit of modern cardiology.

Yet, older patients with acute coronary syndromes present a different challenge. NSTEMI trials, like most trials, enrolled mostly younger adults. 

Whether evidence obtained in young people applies to older patients is one of the most common and important questions in all of medical practice. Older patients may be at higher risk for a primary outcome, but they also have greater risks for harm from therapy as well as more competing causes of morbidity and mortality. 

Only a handful of smaller trials have enrolled older patients with NSTEMI. These trials have produced little evidence that an early invasive approach should be preferred. 

The SENIOR-RITA Trial 

At ESC, Vijay Kunadian, MD, from Newcastle, United Kingdom, presented results of SENIOR-RITA, a large trial comparing an invasive vs conservative strategy in NSTEMI patients 75 years of age or older. 

In the conservative arm, coronary angiography was allowed if the patient deteriorated and the procedure was clinically indicated in the judgment of the treating physicians.

Slightly more than 1500 patients with NSTEMI were randomly assigned to either strategy in 48 centers in the UK. Their mean age was 82 years, nearly half were women, and about a third were frail. 

Over 4 years of follow-up, the primary outcome of cardiovascular (CV) death or MI occurred at a similar rate in both arms: 25.6% vs 26.3% for invasive vs conservative, respectively (HR, 0.94; 95% CI, 0.77-1.14; P =.53). 

Rates of CV death were also not significantly different (15.8% vs 14.2%; HR, 1.11; 95% CI, 0.86-1.44). 

The rate of nonfatal MI was slightly lower in the invasive arm (11.7% vs 15.0%; HR, 0.75; 95% CI, 0.57-0.99)

Some other notable findings: Less than half of patients in the invasive arm underwent revascularization. Coronary angiography was done in about a quarter of patients in the conservative arm, and revascularization in only 14%. 

Comments

Because medicine has improved and patients live longer, cardiologists increasingly see older adults with frailty. It's important to study these patients. 

The authors tell us that 1 in 5 patients screened were enrolled, and those not enrolled were similar in age and were treated nearly equally with either strategy. Not all trials offer this information; it's important because knowing that patients in a trial are representative helps us translate evidence to our actual patients. 

Another positive was the investigators' smart choice of cardiovascular death and MI as their primary outcome. Strategy trials are usually open label. If they had included an outcome that requires a decision from a clinician, such as unplanned revascularization, then bias becomes a possibility when patients and clinicians are aware of the treatment assignment. (I wrote about poor endpoint choice in the ABYSS trial.) 

The most notable finding in SENIOR-RITA was that approximately 76% of patients in the conservative arm did not have a coronary angiogram and 86% were not revascularized. 

Yet, the rate of CV death and MI were similar during 4 years of follow-up. This observation is nearly identical to the findings in chronic stable disease, seen in the ISCHEMIA trial. (See Figure 6a in the paper's supplement.) 

I take two messages from this consistent observation: One is that medical therapy is quite good at treating coronary artery disease not associated with acute vessel closure in STEMI. 

The other is that using coronary angiography and revascularization as a bailout, in only a fraction of cases, achieves the same result, so the conservative strategy should be preferred.

I am not sure that the SENIOR RITA researchers see it this way. They write in their discussion that "clinicians are often reluctant to offer an invasive strategy to frail older adults." They then remind readers that modern PCI techniques (radial approach) have low rates of adverse events. 

Perhaps I misread their message, but that paragraph seemed like it was reinforcing our tendency to offer invasive approaches to patients with NSTEMI. 

I feel differently. When a trial reports similar outcomes with two strategies, I think we should favor the one with less intervention. I feel even more strongly about this philosophy in older patients with frailty.

Are we not in the business of helping people with the least amount of intervention?

The greatest challenge for the cardiologist of today is not a lack of treatment options, but whether we should use all options in older, frailer adults. 

Good on the SENIOR-RITA investigators, for they have shown that we can avoid intervention in the vast majority of older adults presenting with NSTEMI. 

John Mandrola practices cardiac electrophysiology in Louisville, Kentucky, and is a writer and podcaster for Medscape. He espouses a conservative approach to medical practice. He participates in clinical research and writes often about the state of medical evidence. 

https://www.medscape.com/viewarticle/old-frail-patients-study-more-intervene-less-2024a1000fzp

Clinical Approach to Post-acute Sequelae After COVID-19 Infection and Vaccination

 Monitoring Editor: Alexander Muacevic and John R Adler



The spike protein of SARS-CoV-2 has been found to exhibit pathogenic characteristics and be a possible cause of post-acute sequelae after SARS-CoV-2 infection or COVID-19 vaccination. COVID-19 vaccines utilize a modified, stabilized prefusion spike protein that may share similar toxic effects with its viral counterpart. The aim of this study is to investigate possible mechanisms of harm to biological systems from SARS-CoV-2 spike protein and vaccine-encoded spike protein and to propose possible mitigation strategies. We searched PubMed, Google Scholar, and ‘grey literature’ to find studies that (1) investigated the effects of the spike protein on biological systems, (2) helped differentiate between viral and vaccine-generated spike proteins, and (3) identified possible spike protein detoxification protocols and compounds that had signals of benefit and acceptable safety profiles. We found abundant evidence that SARS-CoV-2 spike protein may cause damage in the cardiovascular, hematological, neurological, respiratory, gastrointestinal, and immunological systems. Viral and vaccine-encoded spike proteins have been shown to play a direct role in cardiovascular and thrombotic injuries from both SARS-CoV-2 and vaccination. Detection of spike protein for at least 6-15 months after vaccination and infection in those with post-acute sequelae indicates spike protein as a possible primary contributing factor to long COVID. We rationalized that these findings give support to the potential benefit of spike protein detoxification protocols in those with long-term post-infection and/or vaccine-induced complications. We propose a base spike detoxification protocol, composed of oral nattokinase, bromelain, and curcumin. This approach holds immense promise as a base of clinical care, upon which additional therapeutic agents are applied with the goal of aiding in the resolution of post-acute sequelae after SARS-CoV-2 infection and COVID-19 vaccination. Large-scale, prospective, randomized, double-blind, placebo-controlled trials are warranted in order to determine the relative risks and benefits of the base spike detoxification protocol.

New Atrial Fibrillation Guidelines Confront Underlying Illness

 Updated guidelines for the management of atrial fibrillation released by the European Society of Cardiology are revamping the approach to care for this complex, multifactorial disease.

The identification and treatment of comorbidities and risk factors are the initial and central components of patient management, and are crucial for all other aspects of care for patients with atrial fibrillation (AF), Isabelle Van Gelder, MD, PhD, professor of cardiology at the University Medical Center in Groningen, the Netherlands, explained at the European Society of Cardiology (ESC) Congress.

It is not just appropriate to place the same emphasis on the control of comorbidities as on the rhythm disturbance, it is critical, said Van Gelder, who served as chair of the ESC-AF guidelines task force.

Comorbidities are the drivers of both the onset and recurrence of atrial fibrillation, and a dynamic approach to comorbidities is "central for the success of AF management."

Class I Recommendation

In fact, on the basis of overwhelming evidence, a class I recommendation has been issued for a large number of goals in the comorbidity and risk factor management step of atrial fibrillation management, including those for hypertension, components of heart failureobesity, diabetes, alcohol consumption, and exercise.

Sodium-glucose cotransporter-2 (SGLT2) inhibitors "should be offered to all patients with AF," according to Van Gelder, who identified this as a new class I recommendation.

Patients who are not managed aggressively for the listed comorbidities ultimately face "treatment failure, poor patient outcomes, and a waste of healthcare resources," she said.

Control of sleep apnea is also noted as a key target, although Van Gelder acknowledged that the supporting evidence only allows for a class IIb recommendation.

Control of comorbidities is not a new idea. In the 2023 joint guideline, led by a consortium of professional groups, including the American Heart Association (AHA) and the American College of Cardiology (ACC), the control of comorbidities, including most of those identified in the new ESC guidelines, was second in a list of 10 key take-home messages.

However, the new ESC guidelines have prioritized comorbidity management by listing it first in each of the specific patient-care pathways developed to define optimized care. 

These pathways, defined in algorithms for newly diagnosed AF, paroxysmal AF, and persistent AF, always start with the assessment of comorbidities, followed by step A — avoiding stroke — largely with anticoagulation.

Direct oral anticoagulants should be used, "except in those with a mechanical valve or mitral stenosis," Van Gelder said. This includes, essentially, all patients with a CHA2DS2-VASc score of 2 or greater, and it should be "considered" in those with a score of 1. 

The ESC framework has been identified with the acronym AF-CARE, in which the C stands for comorbidities.

In the A step of the framework, identifying and treating all modifiable bleeding risk factors in AF patients is a class I recommendation. On the basis of a class III recommendation, she cautioned against withholding anticoagulants because of CHA2DS2-VASc risk factors alone. Rather, Van Gelder called the decision to administer or withhold anticoagulation — like all decisions — one that should be individualized in consultation with the patient.

For reducing AF symptoms and rhythm control, the specific pathways diverge for newly diagnosed AF, paroxysmal AF, and persistent AF. Like all of the guidelines, the specific options for symptom management and AF ablation are color coded, with green signifying level 1 evidence.

The evaluation and dynamic reassessment step refers to the need to periodically assess patients for new modifiable risk factors related to comorbidities, risk for stroke, risk for bleeding, and risk for AF. 

The management of risk factors for AF has long been emphasized in guidelines, but a previous focus on AF with attention to comorbidities has been replaced by a focus on comorbidities with an expectation of more durable AF control. The success of this pivot is based on multidisciplinary care, chosen in collaboration with the patient, to reduce or eliminate the triggers of AF and the risks of its complications.

Pathways Are Appropriate for All Patients

A very important recommendation — and this is new — is "to treat all our patients with atrial fibrillation, whether they are young or old, men or women, Black or White, or at high or low risk, according to our patient-centered integrated AF-CARE approach," Van Gelder said.

The changes reflect a shared appreciation for the tight relation between the control of comorbidities and the control of AF, according to José A. Joglar, MD, professor of cardiac electrophysiologic research at the University of Texas Southwestern Medical Center in Dallas. Joglar was chair of the writing committee for the joint 2023 AF guidelines released by the AHA, ACC, the American College of Clinical Pharmacy, and the Heart Rhythm Society.

"It is increasingly clear that AF in many cases is the consequence of underlying risk factors and comorbidities, which cannot be separated from AF alone," Joglar explained in an interview.

This was placed first "to emphasize the importance of viewing AFib as a complex disease that requires a holistic, multidisciplinary approach to care, as opposed to being viewed just as a rhythm abnormality," he said.

https://www.medscape.com/viewarticle/new-atrial-fibrillation-guidelines-confront-underlying-2024a1000fvd