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EP LAB DIGEST. 2025;25(6):11,24.

Interview by Jodie Elrod
 

In this interview, EP Lab Digest talks with T. Jared Bunch, MD, FACC, FHRS, Associate Chief of Cardiology at the University of Utah, about the new criteria for establishing an Atrial Fibrillation (AF) Center of Excellence, including key operational standards to provide multidisciplinary care for AF patients.¹ Dr Bunch is an active participant in the Heart Rhythm Society (HRS).¹ 

HRS recently released a comprehensive framework for establishing AF Centers of Excellence. Can you walk us through the key pillars of this model and explain how they aim to improve outcomes for patients with AF?

Five years ago, HRS put together this idolized concept of what it means to provide excellent AF care; it was published under the leadership of Jonathan Piccini.² The second step was to ask the stakeholders, patients, providers, and institutions what was needed. The final step, which is the document that was published by HRS this year, was the actual criteria and mechanistic approach to creating AF Centers of Excellence. It is really based upon the challenging dilemma we face with AF, which is very prevalent in the United States. Anywhere from 7% to 8% of people have it, and that number is increasing. AF is disproportionately experienced by the elderly. Our way of managing it, not only through treatment and available tools, but also the risk factor modification that is required, continues to be more complex. So, making sure that we have guideline-congruent care is central to this document. 

The pillars are what is known. We need to be timely—patients need to have early access. We need to focus on stroke reduction, minimization of heart failure, and things that can have an early impact on mortality risk. We must look at known risk factors at the earliest visit of AF and then look back throughout the care of AF. We must have ways to provide early rhythm control, which can impact all the other needs. Patients must have access. 

So, those became the pillars, and they were really founded upon the new guidelines presented both from the American societies as well as the European societies that were published last year. 

One of the unique aspects of the new framework is the inclusion of AF Cooperatives and a Tiers for Accountability model. How do these features support scalability and collaboration across diverse health care settings, including rural or nonacademic centers?

One of the challenges when we put together the concept of an AF Center of Excellence or what it means to provide idolized care was that in the United States, we have diversity issues where we need to get all populations in early. We also have rural scarcity where we care for large geographic areas. So, one of the things that we had to tackle was how to do this. It is easy to quickly embrace these principles in a big city where you have a large institution that is already well established. But, for example, if you are in Utah, where I am from, specifically central or southern Utah, where there are a lot of rural care issues, it is not as easy to gain those tools. 

So, in talking about AF Centers of Excellence, if you do not have the ability to do that, we recommend joining an AF Cooperative, which means where institutions come together to pool resources but still adhere to the basic principles. Within those cooperatives, we must have rapid pathways to access. So, if you need an early cardioversion or ablation, the rural center has a rapid way to facilitate the patient entering that pathway. 

But at the same time, we also recognize that we are not starting from the same spot. Some centers are very mature and have had AF champions who have already matured their center, while others are just starting the process. So, we created a tiered approach to get there. At the bottom tier, which is bronze, that has the fundamental basic concepts that every person with AF needs immediately. The next step is silver, where you can build upon those blocks. Ultimately, the next tier is gold, where you are able to provide multispecialty care access, do quality improvement initiatives to continue to improve your outcomes and refine your approach, and help your patients long term. We think people can get there, but we did not want to say that this is what you must do all at once—we wanted to give them an approach to do it. We also recognize that an academic center is different than a big health care system, which is different from a multispecialty practice, which is different from a health care provider that may be completely independent. But we think across that spectrum, everybody can participate in this if done in an organized manner. That is what the document does—it outlines an organized way to proceed and provides a checklist to do that. 

With AF affecting over 10 million adults in the US and continuing to rise, what do you see as the most urgent next steps for institutions hoping to implement this framework and begin the process of becoming an AF Center of Excellence?

It is an enormous issue, and I think most people know somebody who has AF. If you are wanting to begin the process, the first step is to identify a champion—somebody who is going to help lead the effort. Everything goes better when there is somebody that really believes in this need and approach, and knows that their energy, motivation, and passion can make a meaningful difference in people’s lives. So, identify a champion and then begin the fundamental concepts of providing early access, identifying patients with AF, providing core needs, and growing in a stepwise manner. 

One of the things that we advocated is this concept of “right place, right person, right time.” We know that everything we do is better in the first year. We can change people’s lifespan. We can change people’s quality of life. We can minimize dependency on drugs. We can minimize dependency on repeated procedures if we act early in a comprehensive manner. So, we believe that is important—this “3 R” principle of getting people in early. I think we are blessed with technology now, because 15 years ago, if a patient told us they felt their heart race, we would order a monitor to diagnose AF. But now, a lot of our patients come in with a newly purchased smartwatch or smartphone that shows AF, and we must now be able to handle that burden in an organized manner. We recognize that the document speaks to that, but I think we have now the opportunity to treat things even earlier because of technology that identifies the rhythm even earlier.

The transcripts were edited for clarity and length.

References

1. Bunch TJ, Antman E, Catanzaro JN, et al. Criteria for the establishment of an atrial fibrillation center of excellence and key operational standards. Heart Rhythm. 2025:S1547-5271(25)02303-3. doi:10.1016/j.hrthm.2025.04.001

2. Piccini JP Sr, Allred J, Bunch TJ, et al. Rationale, considerations, and goals for atrial fibrillation centers of excellence: a Heart Rhythm Society perspective. Heart Rhythm. 2020;17(10):1804-1832. doi:10.1016/j.hrthm.2020.04.033