Advertisement

Management of Atrial Fibrillation: 2014 Guidelines

Guideline Watch |
May 19, 2014

Management of Atrial Fibrillation: 2014 Guidelines

  1. Mark S. Link, MD

New guidelines for AF should increase the number of patients who receive anticoagulants and who are advised to undergo catheter ablation.

  1. Mark S. Link, MD

Sponsoring Organizations: American College of Cardiology, American Heart Association, Heart Rhythm Society

Target Population: Cardiologists, internal medicine practitioners, emergency medicine personnel

Background and Objective

This document is a thorough revision intended to replace the previous guidelines from the sponsoring organizations (published in 2006 and updated in 2011).

Key Points

—The selection of long-term antithrombotic therapy should be guided by the patient's risk for thromboembolism, regardless of (1) whether the pattern of atrial fibrillation (AF) is paroxysmal, persistent, or permanent; or (2) the duration of AF (Class I).

Table 1: Dose Selection of Oral Anticoagulant Options for Patient with Nonvalvular AF and CKD (Based on Prescribing Information for the United States)*
*Renal function should be evaluated prior to initiation of direct thrombin or factor Xa inhibitors and should be reevaluated when clinically indicated and at least annually. CrCl should be measured using the Crockoft-Gault method. †The concomitant use of P-glycoprotein inducers or inhibitors with dabigatran, or the concomitant use of dual P-glycoprotein and strong CYP3A4 inducers or inhibitors with either rivaroxaban or apixaban, particularly in the setting of CKD, may require dosing adjustment or avoidance of concomitant drug use (see the FDA drug label; Section 8.6). ‡Use apixaban 2.5 mg BID if any 2 patient characteristics present: Cr ≥1.5 mg/dL, ≥80 years of age, body weight ≤60 kg (172). Apixaban is not recommended in patients with severe hepatic impairment. §Modeling studies suggest that dabigatran 75 mg BID might be safe for patients with CrCl 15–30mL/min, but this has not been validated in a prospective cohort. Some countries outside the United States use 110 mg BID (170). ║Dose-adjusted warfarin has been used, but observational data regarding safety and efficacy are conflicting. ¶No published studies support a dose for this level of renal function. #In patients with end-stage CKD on stable hemodialysis, prescribing information indicates the use of apixaban 5 mg BID with dose reduction to 2.5 mg BID if the patient is either ≥80 years of age or body weight ≤60 kg.

Reprinted with permission from January CT et al. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation. Circulation 2014 Mar 28; [e-pub ahead of print].
Table 1: Dose Selection of Oral Anticoagulant Options for Patient with Nonvalvular AF and CKD (Based on Prescribing Information for the United States)*

*Renal function should be evaluated prior to initiation of direct thrombin or factor Xa inhibitors and should be reevaluated when clinically indicated and at least annually. CrCl should be measured using the Crockoft-Gault method. The concomitant use of P-glycoprotein inducers or inhibitors with dabigatran, or the concomitant use of dual P-glycoprotein and strong CYP3A4 inducers or inhibitors with either rivaroxaban or apixaban, particularly in the setting of CKD, may require dosing adjustment or avoidance of concomitant drug use (see the FDA drug label; Section 8.6). Use apixaban 2.5 mg BID if any 2 patient characteristics present: Cr ≥1.5 mg/dL, ≥80 years of age, body weight ≤60 kg (172). Apixaban is not recommended in patients with severe hepatic impairment. §Modeling studies suggest that dabigatran 75 mg BID might be safe for patients with CrCl 15–30mL/min, but this has not been validated in a prospective cohort. Some countries outside the United States use 110 mg BID (170). Dose-adjusted warfarin has been used, but observational data regarding safety and efficacy are conflicting. No published studies support a dose for this level of renal function. #In patients with end-stage CKD on stable hemodialysis, prescribing information indicates the use of apixaban 5 mg BID with dose reduction to 2.5 mg BID if the patient is either ≥80 years of age or body weight ≤60 kg.

Reprinted with permission from January CT et al. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation. Circulation 2014 Mar 28; [e-pub ahead of print].

—Patients with nonvalvular AF and a CHA2DS2-VASc score ≥2 should receive oral anticoagulation with warfarin, dabigatran, rivaroxaban, or apixaban (Class I). Modified dosages of some of the newer anticoagulants can be considered in patients with non–end-stage chronic kidney disease, depending on the severity of renal dysfunction (Class IIb; Table 1).

—In patients with nonvalvular AF and a CHA2DS2-VASc score ≥2 who undergo coronary revascularization (percutaneous or surgical), antiplatelet therapy with clopidogrel (75 mg once daily) but without aspirin may be a reasonable adjunct to oral anticoagulation (Class IIb).

—The following drugs are recommended to maintain sinus rhythm in patients with AF:

  • Dofetilide

  • Dronedarone

  • Flecainide

  • Propafenone

  • Sotalol

  • Amiodarone

Table 2: Recommended Drug Doses for Pharmacological Cardioversion of AF Recommended given in conjunction with a beta blocker or nondihydropyridine calcium channel antagonist administered ≥30 minutes before administering the Vaughan Williams Class IC agent

AF indicates atrial fibrillation; AV, atrioventricular; BID, twice a day; CAD, coronary artery disease; CrCl, creatinine clearance; GI, gastrointestinal; INR, international normalized ratio; IV, intravenous; and QD, once daily.

Reprinted with permission from January CT et al. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation. Circulation 2014 Mar 28; [e-pub ahead of print].

Drug selection should depend on underlying heart disease and comorbidities (Table 2); however, owing to its potential toxicities, amiodarone should be used only when other agents have failed or are contraindicated and after thorough risk assessment (Class I).

—Catheter ablation is recommended in patients with symptomatic paroxysmal AF who are unresponsive or intolerant to ≥1 class I or III antiarrhythmic medication (Class I) and may be considered as an initial rhythm-control strategy in those with recurrent AF who have undergone a thorough assessment of the risks and outcomes of drug and ablation therapy (Class IIa).

—Catheter ablation is reasonable in selected patients with symptomatic persistent AF who are unresponsive or intolerant to ≥1 class I or III antiarrhythmic medication (Class IIa).

—AF catheter ablation to restore sinus rhythm should not be performed solely to obviate the need for anticoagulation (Class III).

What's Changed

The following are important additions, changes, and shifts in emphasis from previous guidelines:

  • Anticoagulation based on thrombotic risk, irrespective of AF pattern

  • Failure to support the common practice of allowing 48 hours of AF before considering long-term anticoagulation.

  • Move from CHADS2 to CHA2DS2-VASc for risk assessment

  • New oral anticoagulants placed on at least an equal footing with warfarin (The authors comment that “all 3 new oral anticoagulants represent important advances over warfarin because they have more predictable pharmacological profiles, fewer drug–drug interactions, an absence of major dietary effects, and less risk of intracranial bleeding than warfarin.”)

  • Consideration of clopidogrel and an anticoagulant without aspirin after coronary reperfusion

  • Stronger recommendations for — and cautions about — AF catheter ablation

Comment

These new guidelines represent an intensified management approach to reduce or prevent morbidity associated with atrial fibrillation. They are likely to increase the use of anticoagulation — and of the new oral anticoagulants — in individuals with AF, and they provide stronger and more specific recommendations for the use of catheter ablation. I agree with a more aggressive approach to anticoagulation; however, I believe the decision to undergo ablation is more personal and should be made only after a thorough discussion of the risks and benefits.

Note to readers: At the time NEJM Journal Watch reviewed this paper, its publisher noted that it was not in final form and that subsequent changes might be made.

  • Disclosures for Mark S. Link, MD at time of publication Grant / Research support Unequal Technologies Editorial boards UpToDate

Citation(s):

Reader Comments (11)

A LEE ANNEBERG Physician, Geriatrics, long-term care facilities

Very important information for our physicians who care for residents in long term care facilities who all have declining renal function, impaired functional status and limited life expectancy. Another instance of where "less is more" in geriatric prescribing.

Nataniel

Is very importante, this guidelines for manage AF

GEORGE MATHEW Cardiology, Leesburg ,Fl

Patients who are high risk for vascular thrombosis, such as Smokers,Dibetes, certain Cancers etc may need low dose Aspirin in addition. Need to clarify - May be we should individualise each Patient

EUGENE SILVA Physician, Cardiology

Need to see the data on 1st time episode of A fib lasting < 48 hrs and need for long term anticoagulation. Data to show risk of stroke higher than cost and risk of bleeding in all comers.

JEFFREY ANDERSEN Physician, Family Medicine/General Practice

I'm in more agreement with ESC guidelines than ACC regarding stented AF patients.
TOAT for 1m for bare metal stents, 3-6m for DES
THEN OAC + Plavix to one year post stent
After this indefinite ASA +OAC

Manuel Campos-Monteiro Physician, Internal Medicine, Portugal

I Think that Guidelines are very useful, but they are only guidelines!

RAMAMURTHY BINGI

Guidelines allow for uniformity of scientific practice they also raise issues like do these apply to rheumatic heart disease? Do they apply to children? And do this mean to that I should keep all score cards and look at them repeatedly avoiding patient eye contact? Each individual is a variable in biology and drug handing tempered by local economic mileu should I play strictly by book rules

ramzi nassif Physician, Cardiology

simple case scenario: Plavix and rivaroxaban were used following elective PCI(stent placement), and the 43 year old working single mother of 2 children, who was a smoker and has history of HTN, drops dead 2 months later, and autopsy shows subacute stent thrombosis.
Does the(Class IIb) dual therapy that MAY be reasonably used STAND in COURT!! when recommendation to follow an algorithm for stenting and anticoagulation in patients with Atria Fibrillation has been previously published?

Kalyani Ballapuram Physician, Internal Medicine

I'm excited to know that i got some clarification about whether to place patients with Afib and ACS after coronary perfusion on dual antiplatelet therapy with an anticoagulant, Its great they mentioned that clopidogrel + anti caogulation may be enough without aspirin, can anyone clarify why they worded it as " may" and if there are any exclusions to this concept.

Juan Silva Physician, Internal Medicine, Hospital

I need to know all the new information about cardiology diseases. Thanks for this help. I thing It will be very important to de treatment to my patients.

Shailaja Chavan DNB med. IDCCM Physician, Critical Care Medicine, India

Guidelines are definitively helpful to manage AF. provides usefull guide for anticoagulation during coronary perfusion

Your Comment

(will not be published)

Filtered HTML

  • Allowed HTML tags: <a> <em> <strong> <cite> <blockquote> <code> <ul> <ol> <li> <dl> <dt> <dd>
  • Web page addresses and e-mail addresses turn into links automatically.
  • Lines and paragraphs break automatically.

Plain text

  • No HTML tags allowed.
  • Web page addresses and e-mail addresses turn into links automatically.
  • Lines and paragraphs break automatically.
Do you have any conflict of interest to disclose?
CAPTCHA
This question is for testing whether you are a human visitor and to prevent automated spam submissions.
Image CAPTCHA
Enter the characters shown in the image.

Vertical Tabs

* Required

Reader comments are intended to encourage lively discussion of clinical topics with your peers in the medical community. We ask that you keep your remarks to a reasonable length, and we reserve the right to withhold publication of remarks that do not meet this standard.

PRIVACY: We will not use your email address, submitted for a comment, for any other purpose nor sell, rent, or share your e-mail address with any third parties. Please see our Privacy Policy.

Advertisement
Advertisement
Advertisement