CCS Atrial Fibrillation Guidelines:
Management Of AF In 2014: Putting
The New Guidelines Into Practice
October 2014
About this Slide Set
This slide set is a quick-reference tool that features essential diagnostic and treatment
recommendations based on the 2010 CCS Atrial Fibrillation Guidelines, the 2012 CCS Atrial
Fibrillation Guidelines Update and the 2014 Focused Update of the CCS guidelines for the
management of AF.
These recommendations are aimed to provide a reasonable and practical approach to care for
specialists and allied health professionals obliged with the duty of bestowing optimal care to
patients and families, and can be subject to change as scientific knowledge and technology
advance and as practice patterns evolve. The guideline is not intended to be a substitute for
physicians using their individual judgment in managing clinical care in consultation with the
patient, with appropriate regard to all the individual circumstances of the patient, diagnostic and
treatment options available and available resources. Adherence to these recommendations will
not necessarily produce successful outcomes in every case.
For the complete CCS Atrial Fibrillation Guidelines, or for additional resources, please visit our
guidelines website at www.ccs.ca.
www.ccs.ca
Atrial Fibrillation Guidelines
The 2014 Focused Update of the Canadian Cardiovascular
Society
Guidelines for the Management of Atrial Fibrillation
Co-chairs and Authors
Jeff S. Healey and Atul Verma
Authors
John A. Cairns, Stuart Connolly, Jafna L. Cox, Paul Dorian, David Gladstone,
Gordon J. Gubitz, Noah Ivers, Kori Leblanc, Laurent Macle, Michael Sean McMurtry,
L. Brent Mitchell, Stanley Nattel, Pierre Pagé, Ratika Parkash, P. Timothy Pollak,
Allan C. Skanes, Ian G. Stiell, Mario Talajic, Teresa S. M. Tsang and Carl Van Walraven.
Publication date: October 2014
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Atrial Fibrillation Guidelines
Faculty
Atul Verma, MD FRCPC FHRS
Director of Electrophysiology Research & Labs
Southlake Regional Health Centre
Assistant Professor, University of Toronto
Adjunct Professor, McGill University
John A Cairns, MD, FRCPC, FACC
Professor of Medicine
Division of Cardiology
University of British Columbia
Allan C. Skanes, MD FRCPC
Associate Professor, Department of Medicine,
Division of Cardiology Cardiologist, London
Health Sciences Centre Director,
Electrophysiology Lab
London Health Sciences Centre
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Atrial Fibrillation Guidelines
Jeff Healey, MD, FRCPC
McMaster University
Paul Dorian, MD, FRCPC
Department Director, Division of Cardiology
University of Toronto
Staff Cardiac Electrophysiologist
St. Michael's Hospital
Professor of Medicine
Division of Cardiology and Clinical Pharmacology
University of Toronto
Staff Scientist at the Li Ka Shing Knowledge
Institute.
L. Brent Mitchell, MD, FRCPC
Professor of Medicine and Cardiac Sciences
Libin Cardiovascular Institute of Alberta
Alberta Health Services and University of Calgary
Overview of the 2014 Update
• 2014 publication is meant as an update to prior update in 2012 and
original major guideline re-write in 2010
• Includes an executive summary of ALL guidelines from 2010 onwards
(updated) which can be downloaded online at the CJC website
www.ccs.ca
Atrial Fibrillation Guidelines
Overview of the 2014 Update
Key new elements of the 2014 Update:
•New, simplified stroke risk stratification scheme: “The CCS Algorithm”
•Detection of AF in patients with stroke
•Investigation and management of subclinical AF
•Commentary on left atrial appendage closure
•Re-write on cardioversion guidelines in ED
•New section on peri-procedural management of oral anticoagulation
•New rate/rhythm control algorithm
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Atrial Fibrillation Guidelines
New CCS Algorithm
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Atrial Fibrillation Guidelines
Detection of AF in Stroke Patients
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Atrial Fibrillation Guidelines
Management of SCAF
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Atrial Fibrillation Guidelines
Perioperative Management of OAC
• What constitutes low, intermediate and high risk procedures for
perioperative bleeding
• When interruption of OAC is required and when it is not
• How to stop new direct oral anticoagulants around the time of surgery
• When and how to bridge for cessation of warfarin therapy
• When to restart OAC after surgery
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Atrial Fibrillation Guidelines
New Rate/Rhythm Algorithm
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Atrial Fibrillation Guidelines
Case 1 : Dr. YD
AF in Emergency Department
by John A. Cairns, MD FRCPC FACC
October 2014
Disclosures
• DSMBs
Chair:
AVERROES (apixaban), SHIELD-2 (azimilide), ARTESIA (apixaban)
Member:
ACTIVE Trials (aspirin, clopidogrel, warfarin), PALLAS (dronedarone),
COMPASS (rivaroxaban),
• Advisory Boards
Boehringer Ingelheim Canada (Since Nov 2010), St Jude Medical (since
Jan 2012), Bayer (intermittent), BMS (intermittent)
• Research trial funding
Medtronic, Sanofi Aventis, Astrazeneca, Bayer, Boston Scientific
• Speaker honoraria
Boehringer Ingelheim Canada, Lilly, Pfizer/BMS, Bayer
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Atrial Fibrillation Guidelines
Dr. YD, Age 42, Family Practitioner
• Last evening he was out celebrating the marriage of his receptionist and
consumed about 12 ounces of Johnny Walker Black label.
• He went home by taxi, slept poorly and realized this morning about 6:00 am
that his heart rate was rapid and pulse irregular.
• He has a mild bitemporal headache and is driven to the ED by his wife.
• He has been well, no known hypertension, DM, heart disease, TIA/stroke
and no known arrhythmias although he does have mild palpitations from time
to time. No COPD or asthma.
• In ED: no chest pain, mild SOB, slightly sweaty. HR 140, irregularly irregular,
BP 140/90, JVD 4 cm, Chest clear. ECG shows AF, rate 140.
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Atrial Fibrillation Guidelines
Overview of AF Management
AF Detected
Management of
Arrhythmia
Assessment of
Thromboembolic
Risk (CHADS2)
ASA
OAC
Rate
Control
No antithrombotic therapy may be appropriate in
selected young patients with no stroke risk factors
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Atrial Fibrillation Guidelines
Rhythm
Control
Dr. YD, Age 42, Family Practitioner
How will you manage his rhythm?
1. Electrical cardioversion (150-200 j) in ED as soon as it can be done.
2. IV metoprolol 5 mg, repeated Q 5 min up to 3 times if rate remains above
110. Home on po metoprolol 50-100 mg bid if AF persists.
3. IV metoprolol 5 mg, repeated Q 5 min up to 3 times if rate remains above
110. Add propofenone 450 mg po about 10-15 minutes after first dose of
metoprolol if AF persists.
4. IV metoprolol 5 mg, repeated Q 5 min up to 3 times if rate remains above
110. Electrical cardioversion if AF persists.
5. Digoxin 0.25 mg IV, repeat at 1 hour intervals up to 4 doses if AF persists.
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Atrial Fibrillation Guidelines
Dr. YD, Age 42, Family Practitioner
How will you manage his rhythm?
1.Electrical cardioversion (150-200 j) in ED as soon as it can be done.
2.IV metoprolol 5 mg, repeated Q 5 min up to 3 times if rate remains above
110. Home on po metoprolol 50-100 mg bid if AF persists.
3.IV metoprolol 5 mg, repeated Q 5 min up to 3 times if rate remains above
110. Add propofenone 450 mg po about 10-15 minutes after first dose of
metoprolol if AF persists.
4.IV metoprolol 5 mg, repeated Q 5 min up to 3 times if rate remains above
110. Electrical cardioversion if AF persists. Best answer! *
5.Digoxin 0.25 mg IV, repeat at 1 hour intervals up to 4 doses if AF persists.
*This is a young man with no stroke risk factors. His AF has been present for only a few hours. It is likely the AF was precipitated by
his alcohol indiscretion and he is likely to return to NSR with cardioversion and likely to remain in sinus rhythm. Accordingly, electrical
cardioversion is a good option. It makes sense to give IV metoprolol to slow his rate before cardioversion. The cardioversion may be
done without prior anticoagulation. He requires no ongoing OAC or ASA.
Hence, the best answer is #4. #3 would be acceptable if there is some reason not to do electrical cardioversion, or if there is any
expectation that he may have recurrent episodes of AF and might be suitable for a pill in the pocket regimen, but this does not appear
indicted in this first presentation of AF. #2 is OK, but in a young person with acute onset, electrical (or pharmacological) cardioversion
has a high likelihood of resolving the AF. #1 is not advised since there is no rush to cardiovert him and giving metoprolol will be likely
to decrease symptoms prior to cardioversion. #5 would not be a good choice.
www.ccs.ca
Atrial Fibrillation Guidelines
Dr. YD, Age 42, Family Practitioner
How will you reduce his risk of stroke if you decide to cardiovert him?
1. IV LMWH or a NOAC po about 1 hour prior to any cardioversion attempt.
2. IV LMWH or a NOAC po about 1 hour prior to electrical cardioversion, but
not required for pharmacologic cardioversion.
3. No anticoagulant required pre cardioversion attempt.
4. Start dabigatran 150 mg bid and have him return for cardioversion after 3
weeks of dabigatran.
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Atrial Fibrillation Guidelines
Dr. YD, Age 42, Family Practitioner
How will you reduce his risk of stroke if you decide to cardiovert him?
1. IV LMWH or a NOAC po about 1 hour prior to any cardioversion attempt.
2. IV LMWH or a NOAC po about 1 hour prior to electrical cardioversion, but
not required for pharmacologic cardioversion.
3. No anticoagulant required pre cardioversion attempt. Best answer! He is
young, has no risk factors for stroke, and the duration of AF has been short.
The risk of a stroke with cardioversion and no anticoagulation is very low.
He requires no anticoagulation pre cardioversion.
4. Start dabigatran 150 mg bid and have him return for cardioversion after 3
weeks of dabigatran.
www.ccs.ca
Atrial Fibrillation Guidelines
Management of AF in the ED – Recommendations
Is Patient Stable?
Immediate Risk for
Stroke?
Low Risk
1. Clear onset <48 hours, or
2. Therapeutic OAC ≥ 3 wks
Pharmacological or
electrical CV at 150-200
J
(Immediate anticoagulation in ED
before CV not required) *
Antithrombotic therapy
-Initiate OAC upon discharge from ED (or
continue current OAC) if age ≥ 65 or
CHADS2 ≥ 1
-Otherwise, initiate ASA if CAD or vascular
disease
-Early follow-up to review long-term OAC
YES
NO
High Risk**
No therapeutic OAC ≥ 3 weeks and one of:
1. Onset >48 hours or unknown, or
2. Stroke/TIA <6 months or
3. Mechanical or rheumatic valve disease.
Rate-control
Therapeutic OAC for 3
Trans-esophageal
weeks before
echocardiography (TEE)
outpatient CV
guided CV
Antithrombotic therapy
- Continue OAC for ≥4
weeks after CV
- Early follow-up to review
long-term OAC
Antithrombotic therapy
- Initiate immediate OAC* in ED
and continue for ≥4 weeks
- Early follow-up to review
long-term OAC
Unstable – AF causing:
1. Hypotension, or
2. Cardiac ischemia, or
3. Pulmonary edema
Consider urgent
electrical CV if rate
control not effective
Antithrombotic therapy
- Initiate immediate OAC* in ED and
continue for ≥4 weeks if any ‘high
risk’ ** features present
Early follow-up to review
long-term OAC
* Immediate OAC = a dose of OAC should be given just prior to cardioversion - either a novel direct oral anticoagulant (NOAC) or a dose of heparin or low molecular weight heparin
with bridging to warfarin if a NOAC is contraindicated.
Emergency Management of AF
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Atrial Fibrillation Guidelines
Supporting Data
• Post CV TE 0.8% vs 5.3% with oral anticoagulation. Prospective cohort
study (Bjerkelund et al 1969).
• 90% of TE occur within 10 d of CV. Meta-analysis (Berger 1998)
• TE < 1% for CV < 48 hrs with no OAC (case series 1997, 2002)
• CV > 48 hrs, TE occurs following CV even with OAC (< 1% by 30 days).
Rate with NOACs similar to with VKA (NOAC RCTs 2012-14)
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Atrial Fibrillation Guidelines
Supporting Data
• Finnish Study 2014 (Nuotio I et al. JAMA 2014;312:647)
Rates of TE with duration of AF:
<12 hrs: 0.3%; 12-24 hrs: 1.1%; 24-48 hrs: 1.1%
Multivariable Analysis of Risk Factors for TE (n= 5116)
OR(95% CI)
P Value
Time:12-24 vs <12 4.0 (1.7-9.1)
.001
24-48 vs <12 3.3 (1.3-8.9)
.02
Age, y (continuous) 1.06 (1.03-1.09) <.001
Female sex
2.1 (1.1-4.3)
.04
Heart failure
3.5 (1.4-8.6)
<.001
Diabetes
2.7 (1.3-5.8)
.01
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Atrial Fibrillation Guidelines
Dr. YD, Age 42, Family Practitioner
How will you reduce his risk of stroke if you decide to cardiovert him?
1. IV LMWH or a NOAC po about 1 hour prior to any cardioversion attempt.
2. IV LMWH or a NOAC po about 1 hour prior to electrical cardioversion, but
not required for pharmacologic cardioversion.
3. No anticoagulant required pre cardioversion attempt.
4. Start dabigatran 150 mg bid and have him return for cardioversion after 3
weeks of dabigatran.
www.ccs.ca
Atrial Fibrillation Guidelines
Dr. YD, Age 42, Family Practitioner
How will you reduce his risk of stroke if you decide to cardiovert him?
1. IV LMWH or a NOAC po about 1 hour prior to any cardioversion attempt.
2. IV LMWH or a NOAC po about 1 hour prior to electrical cardioversion, but
not required for pharmacologic cardioversion.
3. No anticoagulant required pre cardioversion attempt. Best answer! He is
young, has no risk factors for stroke, and the duration of AF has been short.
The risk of a stroke with cardioversion and no anticoagulation is very low.
He requires no anticoagulation pre cardioversion.
4. Start dabigatran 150 mg bid and have him return for cardioversion after 3
weeks of dabigatran.
www.ccs.ca
Atrial Fibrillation Guidelines
Dr. YD, Age 42, Family Practitioner
How will you reduce his risk of stroke post discharge from Ed?
1. If AF persists, he requires maintenance ASA 81 mg daily at least until
follow-up at 1 month.
2. Whether AF persists or resolves, he requires maintenance ASA 81 mg at
least until follow-up at 1 month.
3. If AF persists, he requires maintenance OAC at least until follow-up at 1
month.
4. Whether AF persists or resolves, he requires maintenance OAC at least
until follow-up at 1 month.
5. Whether AF persists or resolves, he requires no maintenance
antithrombotic therapy.
www.ccs.ca
Atrial Fibrillation Guidelines
Dr. YD, Age 42, Family Practitioner
How will you reduce his risk of stroke post discharge from Ed?
1. If AF persists, he requires maintenance ASA 81 mg daily at least until
follow-up at 1 month.
2. Whether AF persists or resolves, he requires maintenance ASA 81 mg at
least until follow-up at 1 month.
3. If AF persists, he requires maintenance OAC at least until follow-up at 1
month.
4. Whether AF persists or resolves, he requires maintenance OAC at least
until follow-up at 1 month.
5. Best Answer! Whether AF persists or resolves, he requires no
maintenance antithrombotic therapy. - He is young, has no risk factors for
stroke. He fits the CCS algorithm of no antithrombotic therapy for AF.
www.ccs.ca
Atrial Fibrillation Guidelines
Dr. YD, Age 42, Family Practitioner
Within the group of patients with CHADS2 = 0 (annual stroke risk 1.9%):
• Data from Danish epidemiological studies indicate the following annual
risks of stroke:
Age 65-74: 2.13%
Vascular disease: 1.40%
Age < 65, no vascular disease:0.7%
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Atrial Fibrillation Guidelines
The “CCS Algorithm” for OAC Therapy in AF
Age 65
OAC*
YES
NO
Prior Stroke/SE/TIA or
Hypertension
or
Heart failure
or
Diabetes Mellitus
OAC*
YES
(CHADS2 risk factors)
**may require lower dosing
NO
CAD or
Arterial vascular disease
Consider and modify (if possible)
all factors influencing risk of
bleeding on OAC (hypertension,
antiplatelet drugs, NSAIDs,
excessive alcohol, labile INRs)
and specifically bleeding risks for
NOACs (low eGFR, age ≥ 75, low
body weight)**
ASA
YES
(coronary, aortic, peripheral)
NO
No
Antithrombotic
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* We suggest that a NOAC be used in preference
to warfarin for non-valvular AF.
Atrial Fibrillation Guidelines
Dr. YD, Age 42, Family Practitioner
How will you reduce his risk of stroke post discharge from ED?
1. If AF persists, he requires maintenance ASA 81 mg daily at least until
follow-up at 1 month.
2. Whether AF persists or resolves, he requires maintenance ASA 81 mg at
least until follow-up at 1 month.
3. If AF persists, he requires maintenance OAC at least until follow-up at 1
month.
4. Whether AF persists or resolves, he requires maintenance OAC at least
until follow-up at 1 month.
5. Whether AF persists or resolves, he requires no maintenance
antithrombotic therapy.
www.ccs.ca
Atrial Fibrillation Guidelines
AF Management in the ED
Recommendation
For patients with no high-risk factors for stroke (recent stroke or TIA within 6
months; rheumatic heart disease; mechanical valve) and clear AF onset within
48 hours or therapeutic OAC therapy for 3 weeks, we recommend that they
may undergo cardioversion in the ED without immediate initiation of
anticoagulation. After attempted or successful cardioversion, antithrombotic
therapy should be initiated as per the CCS algorithm.
(Strong Recommendation, Moderate-Quality Evidence)
Atrial Fibrillation Guidelines
AF Management in the ED
Recommendation
For patients at high risk of stroke with cardioversion (not receiving therapeutic
OAC therapy for 3 weeks with any of the following: AF episode duration not
clearly < 48 hours, stroke or TIA within 6 months, rheumatic heart disease,
mechanical valve), we recommend optimized rate control and therapeutic OAC
for 3 weeks before and at least 4 weeks after cardioversion.
(Strong Recommendation, Moderate-Quality Evidence)
Atrial Fibrillation Guidelines
AF Management in the ED
Recommendation
We suggest that patients at high risk of stroke (not receiving therapeutic OAC
therapy for 3 weeks with any of the following: AF episode duration not clearly
< 48 hours, stroke or TIA within 6 months, rheumatic heart disease, mechanical
valve) may undergo cardioversion guided by transesophageal
echocardiography with immediate initiation of intravenous heparin or low
molecular weight heparin (LMWH) before cardioversion followed by therapeutic
OAC for at least 4 weeks after cardioversion.
(Conditional Recommendation, Moderate-Quality Evidence)
Atrial Fibrillation Guidelines
AF Management in the ED
Recommendation
For patients whose recent-onset AF/AFL is the direct cause of instability
with hypotension, acute coronary syndrome, or florid pulmonary edema, we
recommend that immediate electrical cardioversion be considered with
immediate initiation of intravenous or LMWH before cardioversion followed by
therapeutic OAC for 4 weeks afterward (unless AF onset was clearly within 48
hours or the patient has received therapeutic OAC for 3 weeks) followed by
therapeutic OAC for at least 4 weeks after cardioversion
(Strong Recommendation, Low-Quality Evidence)
Atrial Fibrillation Guidelines
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Atrial Fibrillation Guidelines
Case 2 : Mrs. BB
Rate and Rhythm Control
by Paul Dorian, MD FRCPC
October 2014
Disclosures
• Paul Dorian has received grant support and honoraria
from
Bayer, Boehringer-Ingleheim, BMS, Pfizer, Sanofi
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Atrial Fibrillation Guidelines
A guidelines based approach to AF
management
• Mrs. BB, a 77 year old lady has hypertension, otherwise well
• Lives alone, has a dog
• On Ramipril 10 mg and bisoprolol 5 mg a day for hypertension
• 5 ft 5 in, 190lbs.
• Comes to the office for routine BP follow-up
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Atrial Fibrillation Guidelines
• Pulse rate 85/min, irregular
• BP 145/95 , repeated X 3
• No murmurs , no signs CHF
• Says she feels well
• On closer questioning, she walks the dog around the block; she used to
walk to the park, 2-3 kms away, but “no longer feels like it”
• EKG shows AF, otherwise normal, rate 88/min
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Atrial Fibrillation Guidelines
What next?
Why does she have AF?
1.
Thyroid
2.
Hypertension
3.
Sleep apnea
4.
Ethanol
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Atrial Fibrillation Guidelines
What next?
What are the risks and benefits of rhythm control?
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Atrial Fibrillation Guidelines
History
Establish Severity (including impact on QOL)
Identify Etiology
Identify reversible causes (hyperthyroidism, ventricular pacing,
SVT, exercise)
Identify factors whose treatment could reduce recurrent AF or
improve overall prognosis (i.e. hypertension, sleep apnea, left
ventricular dysfunction)
Identify potential triggers (i.e. alcohol, intensive aerobic training)
Identify potentially heritable causes of AF (particularly in lone AF)
Determine thromboembolic risk (e.g. CHADS2 Score)
Determine bleeding risk to guide appropriate antithrombotic
therapy
Review prior pharmacologic therapy for AF, for efficacy and
adverse effects
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Atrial Fibrillation Guidelines
Establish AF Severity
Use to Guide Therapeutic Approach
CCS
SAF Score
Impact on QOL
0
Asymptomatic
1
Minimal effect on QOL
2
Minor effect of QOL
3
Moderate effect on QOL
4
Severe effect on QOL
Dorian et al Can J Cardiol 2006;22:383-386
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Atrial Fibrillation Guidelines
• SAF class 2-3 on detailed discussion
• Choices:
– increase beta blocker
– attempt to restore sinus rhythm
• CHADS = 2 (CHADSVaSC 4)
• OAC for 3-4 weeks
• Electrical Cardioversion
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Atrial Fibrillation Guidelines
Rhythm Management
Recommendations
• We recommend that an AV blocking agent should be used in patients
with AF or AFL being treated with a class I antiarrhythmic drug (eg,
propafenone or flecainide) in the absence of advanced AV node
disease (Strong Recommendation, Low Quality Evidence).
• We recommend electrical or pharmacologic cardioversion for
restoration of sinus rhythm in patients with AF or AFL who are selected
for rhythm-control therapy and are unlikely to convert spontaneously
(Strong Recommendation, Low Quality Evidence).
• We recommend pre-treatment with antiarrhythmic drugs prior to
electrical cardioversion in patients who have had AF recurrence post
cardioversion without antiarrhythmic drug pre-treatment (Strong
Recommendation, Moderate Quality Evidence).
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Atrial Fibrillation Guidelines
Rhythm Management
Recommendations
• We suggest that patients requiring pacing for the treatment of
symptomatic bradycardia secondary to sinus node dysfunction, atrial or
dual-chamber pacing be generally used for the prevention of AF
(Conditional Recommendation, High Quality Evidence).
• We suggest that, in patients with intact AV conduction, pacemakers be
programmed to minimize ventricular pacing for prevention of AF
(Conditional Recommendation, Moderate Quality Evidence).
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Atrial Fibrillation Guidelines
• How likely is cardioversion to be successful?
( distinguish “success” with IRAF from “failure”)
• If sinus rhythm restored , how likely is AF to recur?
• What can be done to prevent recurrence?
• HT control, ETOH reduction if excessive, sleep apnea
treatment if appropriate
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Atrial Fibrillation Guidelines
How do we tell if rhythm control is justified?
• Assess QOL without knowing the rhythm or doing an
EKG
• eg QOL improves post CV, and worsens again with
recurrence, vs
• No better, or better, but AF recurs without symptoms
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Atrial Fibrillation Guidelines
Major Goals of AF/AFL Arrhythmia Management
•Identify and treat underlying structural heart disease and other predisposing conditions
•Relieve symptoms
•Improve functional capacity/quality of life
• Reduce morbidity/mortality associated with AF/AFL
Prevent tachycardia-induced cardiomyopathy
Reduce/prevent emergency room visits or hospitalizations secondary to AF/AFL
• Prevent stroke or systemic thromboembolism
Recommendations
• We recommend that the goals of ventricular rate control should be to improve symptoms
and clinical outcomes which are attributable to excessive ventricular rates. (Strong
Recommendation, Low Quality Evidence)
• We recommend that the goals of rhythm control therapy should be to improve patient
symptoms and clinical outcomes, and that these do not necessarily imply the elimination of
all AF. (Strong Recommendation, Moderate Quality Evidence)
Atrial Fibrillation Guidelines
Rate vs Rhythm Control for Patients with Symptomatic AF
SYMPTOMATIC AF
ATTEMPT RATE CONTROL
Beta-blocker
Calcium channel blocker
Special circumstances in
which to consider early
rhythm control:
Highly symptomatic
Multiple recurrences
Extreme impairment in QOL
Arrhythmia-induced
cardiomyopathy
YES
SYMPTOMS RESOLVE
NO
CONTINUE RATE
CONTROL
MODIFY RATE CONTROL - CONSIDER RHYTHM CONTROL
Paroxysmal AF
Low burden
recurrence
Pill in pocket
antiarrhythmic therapy
Persistent AF
High burden recurrence
Maintenance
antiarrhythmic therapy
Catheter ablation
Consider cardioversion
Symptoms
Symptoms
improve,
improve,
and patient
but AF recurs maintains sinus
rhythm
Symptoms
don’t change
in sinus
rhythm and
AF recurs
Observe. If AF
recurs, determine if symptomatic
Atrial Fibrillation Guidelines
Overview of Rhythm Management
Rhythm Control Choices
Normal Systolic Function
No Hx of CHF
Dronedarone+
Flecainide*
Propafenone*
Sotalol#
Rhythm Control Choices
Hx of CHF or Left Ventricular
Systolic Dysfunction
EF > 35%
EF ≤ 35%
Amiodarone
Sotalol**
Amiodarone
Catheter
Ablation
Amiodarone
Catheter Ablation
Drugs are listed in alphabetical order
+ Dronedarone should be used with caution in combination with digoxin
• Class I agents should be AVOIDED in CAD and should be COMBINED
with AV-nodal blocking agents
# Sotalol should be used with caution in those at risk for torsades de
pointes VT (e.g. female, age > 65 yr, taking diuretics)
** Sotalol should be used with caution with EF 35-40% and those at risk
for torsades de pointes VT (e.g. female, age > 65 yr, taking diuretics)
Atrial Fibrillation Guidelines
When, if at all, should antiarrhythmic drugs
be used?
1. “Prophylactically “?
2. If AF recurs?
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Atrial Fibrillation Guidelines
If an antiarrhythmic is required, which one?
• If no CAD or LV dysfunction
• Consider flecainide, propafenone , dronedarone ( cost),
sotalol ( fatigue)
• Amiodarone usually second line, but in older patients
often effective at low doses note: efficacy assessed as:
• Patient feels better and has no adverse effects, NOT
“ A fib is completely suppressed”
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Atrial Fibrillation Guidelines
Established Patterns and Severity of Atrial Fibrillation
Patterns of Atrial Fibrillation
SAF Score*
SAF
Score
Newly
Diagnosed AF
Paroxysmal:
Self-terminating
<7d
Class 0
Persistent:
Sustained ≥7d
Permanent:
Decision to
continue
in AF
Impact on QOL**
Asymptomatic
1
Minimal effect on
QOL
2
Minor effect on QOL
3
Moderate effect on
QOL
4
Severe effect on
QOL
* Dorian P, Cvitkovic SS, Kerr CR; et al. Can J Cardiol. 2006; 22(5): 383-386
Atrial Fibrillation Guidelines
** QOL = quality of life
Overview of AF Management
AF Detected
Assessment of
Thromboembolic
Risk (CHADS2)
Appropriate
Antithrombotic
Therapy
Detection and
Treatment of
Precipitating Causes
Management of
Arrhythmia
Rate
Control
Atrial Fibrillation Guidelines
Rhythm
Control
Overview of Rate Management
Rate Control Drug Choices
Heart Failure
CAD
No Heart Failure
or CAD
β-blocker
± Digoxin
β-blocker*
Calcium Channel
Blocker#
Combination Rx
β-blocker*
Calcium Channel
Blocker#
Digoxin†
Combination Rx
Drugs are listed in alphabetical order
*β-blockers preferred in CAD
# Non-dihydropyridine calcium channel blockers (diltiazem, verapamil)
†Digoxin may be considered as monotherapy only in particularly sedentary
individuals
Atrial Fibrillation Guidelines
Managing Rate Control - Recommended Drugs
ß-Blockers
Drug
Dose
Adverse Effects
Atenolol
50 - 150 mg p.o. daily
bradycardia, hypotension, fatigue,
depression
Bisoprolol
2.5 - 10 mg p.o. daily
as per atenolol
Metoprolol
25 mg - 200 mg p.o. bid
as per atenolol
20 - 160 mg p.o daily - bid
as per atenolol
80 - 240 mg p.o. tid
as per atenolol
Nadolol
Propranolol
Calcium Channel Blockers and Digoxin
Drug
Dose
Adverse Effects
Verapamil
120 - 480 mg p.o. daily
120 - 240 mg p.o. bid
bradycardia, hypotension, constipation
Diltiazem
120 - 480 mg p.o. daily
120 - 240 mg p.o. bid
bradycardia, hypotension, ankle swelling
Digoxin
0.0625 mg - 0.25 mg p.o. daily
bradycardia, nausea, vomiting,visual
disturbance
Atrial Fibrillation Guidelines
Managing Rhythm Control - Recommended Drugs
Drug/Dose
Flecainide
50-150 mg
BID
Propafenone
150-300 mg
TID
Amiodarone
100-200 mg
OD (after 10g
loading)
Dronedarone
400 mg BID
Sotalol
80-160 mg
BID
Efficacy
Toxicity
Comments
30-50%
Ventricular tachycardia
Bradycardia
Rapid ventricular response to AF
or atrial flutter (1:1 conduction)
Contraindicated in patients with CAD or LV dysfunction
Should be combined with an AV nodal blocking agent
30-50%
Ventricular tachycardia
Bradycardia
Rapid ventricular response to AF
or atrial flutter (1:1 conduction)
Abnormal taste
Contraindicated in patients with CAD or LV dysfunction
Should be combined with an AV nodal blocking agent
60-70%
Photosensitivity, Bradycardia,
GI upset, Thyroid dysfunction,
Hepatic toxicity, Neuropathy,
Tremor, Pulmonary toxicity,
Torsades de pointes (rare)
Low risk of proarrhythmia
Limited by systemic side effects
Most side effects are dose & duration related
GI upset
Bradycardia
Hepatic toxicity
Should not be used for rate control or for rhythm control in
patients with a history of CHF or LV EF < 40%.
Should be used with caution when added to digoxin.
Liver enzyme monitoring required.
New agent – limited experience outside clinical trials.
Torsades de pointes
Bradycardia
Beta-blocker side effects
Should be avoided in patients at high risk of torsades de pointes
VT – especially women >65 years taking diuretics or those with
renal insufficiency
QT interval should be monitored 1 week after starting
Use cautiously when EF<40%
40%
30-50%
Atrial Fibrillation Guidelines
Rhythm Management
Recommendations
• We recommend the optimal treatment of precipitating or reversible predisposing conditions of AF prior
to attempts to restore or maintain sinus rhythm (Strong Recommendation, Low Quality Evidence).
• We recommend a rhythm-control strategy for patients with AF or AFL who remain symptomatic with
rate-control therapy or in whom rate-control therapy is unlikely to control symptoms (Strong
Recommendation, Moderate Quality Evidence).
• We recommend that the goal of rhythm-control therapy should be improvement in patient symptoms
and clinical outcomes, and not necessarily the elimination of all AF (Strong Recommendation,
Moderate Quality Evidence).
• We recommend use of maintenance oral antiarrhythmic therapy as first-line therapy for patients with
recurrent AF in whom long-term rhythm control is desired (see Figures) (Strong Recommendation,
Moderate Quality Evidence).
• We recommend intermittent antiarrhythmic drug therapy (“pill in the pocket”) in symptomatic patients
with infrequent, longer-lasting episodes of AF or AFL as an alternative to daily antiarrhythmic therapy
(Strong Recommendation, Moderate Quality Evidence).
• We recommend that oral antiarrhythmic drug therapy should be avoided in patients with AF or AFL
and advanced sinus or AV nodal disease unless the patient has a pacemaker or implantable
defibrillator (Strong Recommendation, Low Quality Evidence).
Atrial Fibrillation Guidelines
Rhythm Management – Recommendations and Practical Tip
Recommendations
• We recommend that dronedarone not be used in patients with permanent AF
nor for the sole purpose of rate control (Strong Recommendation, High Quality
Evidence).
• We recommend dronedarone not be used in patients with a history of heart
failure or a left ventricular ejection fraction <0.40 (Strong Recommendation,
Moderate Quality Evidence).
•We suggest dronedarone be used with caution in patients taking digoxin
(Conditional Recommendation, Moderate Quality Evidence).
Practical Tip: Dronedarone is a reasonable choice for rhythm control in
selected patients with AF. Typically, these would be patients with nonpermanent
(predominantly paroxysmal) AF with minimal structural heart disease.
Consideration should be given to monitoring for liver enzyme elevations within 6
months of initiating therapy with dronedarone.
Atrial Fibrillation Guidelines
Strategy of rhythm-control for recent-onset AF/AFL
Clear onset <48 h or
Therapeutic OAC2 x 3 weeks
High-risk patients1 or Onset >48 h
or unknown or Inadequate OAC2
Rate-control
Hemodynamically
unstable
Urgent electrical
CV at 150-200J
Hemodynamically
stable
Pharmacological
or electrical CV at
150-200J
Antithrombotic therapy
- No prior anticoagulation required
- Initiate OAC in ED if CHADS2 >1 or age >65
- Otherwise, initiate ASA if CAD or vascular d.
- Early follow-up to review long-term OAC
1 High
Therapeutic OAC
for 3 weeks
before CV
Trans-esophageal
echocardiography
(TEE) guided CV3
Antithrombotic therapy
- Initiate or continue OAC for >4 weeks
- Early expert follow-up to review long-term
OAC
risk of stroke (e.g. mechanical valve, rheumatic heart disease, recent stroke/TIA)
2 OAC = oral anticoagulant; N-OAC = Novel OAC (dabigatran, apixaban, rivaroxaban)
3 Immediate N-OAC preferred, but if N-OAC contraindicated use warfarin with heparin bridging
www.ccs.ca
Atrial Fibrillation Guidelines
Case 3 : Mr. MB
Stroke Prevention
by John A. Cairns, MD FRCPC FACC
October 2014
Dr. Fred Brown, a GP colleague,
asks for your advice about
Mr. MB, Age 67
Heart “skipping beats” and “racing”, especially on
exertion –2 weeks prior to GP visit
•
•
•
•
Previously well, active, no significant limitations
No hypertension, DM, CHF, no meds
HR 100 irreg, BP 135/85
HS normal, no murmurs or gallops, JVP just visible at
45°
www.ccs.ca
Atrial Fibrillation Guidelines
Dr. Fred Brown, a GP colleague,
asks for your advice about
Mr. MB, Age 67 (cont’d)
•
•
•
Hgb 145, Glucose 5.4, Cr 1.0 (eGFR 110)
EKG – AF 95/min
Echo – unremarkable (LA 4.0, LV 5.0, EF 55%, no LVH)
Dr. Brown started him on atenolol 50 mg qam and
symptoms are much improved
www.ccs.ca
Atrial Fibrillation Guidelines
Mr. MB, Age 67 yr, 1 week post atenolol 50 mg qam
How would you treat him to reduce his risk of
stroke?
1. No antithrombotic therapy ?
2. ASA 81 mg/day ?
3. OAC ?
www.ccs.ca
Atrial Fibrillation Guidelines
How would you treat him to reduce his risk of
stroke?
1. No antithrombotic therapy ?
2. ASA 81 mg/day ?
3. OAC ? Best answer! This 67 year old man fits the
CCS algorithm for use of OAC. The new algorithm
looks first at age and if the person is age ≥ 65 years,
OAC is indicated, provided the risk of major bleeding
is not excessive.
www.ccs.ca
Atrial Fibrillation Guidelines
What is Mr. MB’s CHADS2 score?
1. 1
2. 2
3. 0
4. 3
What is his annual risk of stroke?
1. 0.5% ?
2. 1.0% ?
3. 2.0% ?
4. 5.0% ?
www.ccs.ca
Atrial Fibrillation Guidelines
What is Mr. MB’s CHADS2 score?
1. 1
2. 2
3. 0 – Best answer! His CHADS2 score is 0. Note in
CHADS2 no points are given for age until the patient is
≥ 75 years.
4. 3
What is his annual risk of stroke?
1. 0.5% ?
2. 1.0% ?
3. 2.0% ? Best answer! His annual risk of stroke at age
67 is about 2.13 % (mean risk for CHADS2 score of 0 is
1.9%, but his risk at age 67 is higher than the mean in
this category).
4. 5.0% ?
www.ccs.ca
Atrial Fibrillation Guidelines
Stroke rate/ 100 patient yr
Risk Factor
Score
20
Congestive Heart
Failure
1
Hypertension
1
12
Age ≥ 75
1
8
Diabetes Mellitus
1
Stroke/TIA/
Thromboembolism
2
Maximum Score
6
www.ccs.ca
16
1.9%
4
0
Atrial Fibrillation Guidelines
0
1
2 3 4
CHADS2
5
6
Mr. MB, Age 67
BUT, within the group of patients with CHADS2 =
0 (annual stroke risk 1.9%):
• Data from Danish epidemiological studies indicate the
following annual risk of stroke:
Age 65-74: 2.13%
Vascular disease: 1.40%
Age < 65, no vascular disease:0.7%
www.ccs.ca
Atrial Fibrillation Guidelines
The “CCS Algorithm” for OAC Therapy in AF
Age 65
OAC*
YES
NO
Prior Stroke/SE/TIA or
Hypertension
or
Heart failure
or
Diabetes Mellitus
OAC*
YES
(CHADS2 risk factors)
**may require lower dosing
NO
CAD or
Arterial vascular disease
Consider and modify (if possible)
all factors influencing risk of
bleeding on OAC (hypertension,
antiplatelet drugs, NSAIDs,
excessive alcohol, labile INRs)
and specifically bleeding risks for
NOACs (low eGFR, age ≥ 75, low
body weight)**
ASA
YES
(coronary, aortic, peripheral)
NO
No
Antithrombotic
www.ccs.ca
* We suggest that a NOAC be used in preference
to warfarin for non-valvular AF.
Atrial Fibrillation Guidelines
How would you treat him to reduce his risk of
stroke?
1. No antithrombotic therapy ?
2. ASA 81 mg/day ?
3. OAC ?
www.ccs.ca
Atrial Fibrillation Guidelines
How would you treat him to reduce his risk of
stroke?
1. No antithrombotic therapy ? Incorrect. Given his 2.1%
annual risk of stroke it would be wise to prescribe
antithrombotic therapy.
1. ASA 81 mg/day ? Incorrect. Probably inadequate
protection. His stroke risk would be reduced by about 20%,
with an annual risk of major bleeding of about 0.5%.
1. OAC ? Correct! Best choice. OAC recommended by CCS
Guidelines.
www.ccs.ca
Atrial Fibrillation Guidelines
What about bleeding risk?
What would be his annual risk of bleeding on
OAC?
1. 0.5%?
2. 1%?
3. 3%
4. 5%
www.ccs.ca
Atrial Fibrillation Guidelines
What about bleeding risk?
What would be his annual risk of bleeding on
OAC?
1. 0.5%?
2. 1%? – Best answer! This comes from the HAS-BLED
score, which gives him 1 point for being over age 65.
3. 3%
4. 5%
www.ccs.ca
Atrial Fibrillation Guidelines
www.ccs.ca
Atrial Fibrillation Guidelines
The “CCS Algorithm” for OAC Therapy in AF
Age 65
OAC*
YES
NO
Prior Stroke/SE/TIA or
Hypertension
or
Heart failure
or
Diabetes Mellitus
OAC*
YES
(CHADS2 risk factors)
**may require lower dosing
NO
CAD or
Arterial vascular disease
Consider and modify (if possible)
all factors influencing risk of
bleeding on OAC (hypertension,
antiplatelet drugs, NSAIDs,
excessive alcohol, labile INRs)
and specifically bleeding risks for
NOACs (low eGFR, age ≥ 75, low
body weight)**
ASA
YES
(coronary, aortic, peripheral)
NO
No
Antithrombotic
www.ccs.ca
* We suggest that a NOAC be used in preference
to warfarin for non-valvular AF.
Atrial Fibrillation Guidelines
Prevention of Stroke in AF/AFL
Stratification of patients using a predictive index for stroke risk
Recommendation
We recommend that all patients with AF or AFL (paroxysmal, persistent or
permanent), should be stratified using a predictive index for stroke risk (for
example, the “CCS algorithm” based on the CHADS2 model).
(Strong Recommendation, High Quality Evidence)
Atrial Fibrillation Guidelines
Prevention of Stroke in AF/AFL
OAC therapy for patients ≥ 65 year or CHADS2 ≥ 1
Recommendation
We recommend that OAC therapy be prescribed for most patients with age ≥
65 years or CHADS2 ≥ 1 (the “CCS algorithm”)
(Strong Recommendation, Moderate Quality Evidence)
Atrial Fibrillation Guidelines
For Mr. MB, age 67, the GP is asking: “If I
prescribe an OAC, which should I choose?”
1. Warfarin to achieve INR 2-3 ?
2. Rivaroxaban 20 mg daily ?
3. Dabigatran 150 mg bid or Dabigatran 110 mg bid?
4. Apixaban 5 mg bid ?
5. Any of 2, 3 or 4, although not all are equivalent?
Atrial Fibrillation Guidelines
Stroke or systemic embolic events
in large NOAC trials, vs warfarin
Dabi 150 mg
Rivaroxaban
Apixaban
Edox 60 mg
Ruff et al., The Lancet, 2013
Major bleeding events in large
NOAC trials, vs warfarin
RE-LY
150 mg
60 mg
Ruff et al., The Lancet, 2013
Secondary efficacy and safety
outcomes in large NOAC trials,
vs. warfarin
RR(95%CI)
p
Efficacy
Efficacy
Ischaemic stroke
Haemorrhagic stroke
Myocardial infarction
All-cause mortality
0·92 (0·83–1·02) 0·10
0·49 (0·38–0·64) <0·0001
0·97 (0·78–1·20) 0·77
0·90 (0·85–0·95) 0·0003
Safety
Intracranial haemorrhage
Gastrointestinal bleeding
0·48 (0·39–0·59) <0·0001
1·25 (1·01–1·55)
0·043
0·2
0·5
FavoursNOAC
1
2
Favourswarfarin
Ruff et al., The Lancet, 2013
Prevention of Stroke in AF/AFL
Most patients should receive a NOAC
Recommendation
We recommend that when OAC-therapy is indicated for patients with nonvalvular AF, most patients should receive dabigatran, rivaroxaban, apixaban or
edoxaban (when approved) in preference to warfarin.
(Strong Recommendation, High Quality Evidence)
Atrial Fibrillation Guidelines
For Mr. MB, age 67, the GP is asking: “If I
prescribe an OAC, which should I choose?”
1. Warfarin to achieve INR 2-3 ? Correct! An acceptable therapy since
OAC is indicated. Warfarin will reduce risk by 2/3, but complex to use.
2. Rivaroxaban 20 mg daily ? Correct! A preferred therapy. Non-inferior
to warfarin and easier to use.
3. Dabigatran 150 mg bid or Dabigatran 110 mg bid? Correct! A
preferred therapy. Superior to warfarin and easier to use. Dabigatran
110 mg bid Correct! An acceptable therapy. Non-inferior to warfarin.
Easier to use.
4. Apixaban 5 mg bid ? Correct! A preferred therapy. Superior to
warfarin and easier to use.
5. Any of 2, 3 or 4, Best answer. All are acceptable therapies, but the
NOACs are preferred over warfarin, and the features of the individual
NOACs vary.
Atrial Fibrillation Guidelines
www.ccs.ca
Atrial Fibrillation Guidelines
Case 4: the pediatrician
and
Case 5 : the young patient
Catheter Ablation
by Allan C. Skanes, MD FRCPC
October 2014
Disclosures
Knowledge Translation work with:
• Boehringer-Ingelheim
• Bayer
• Pfizer
Research Grants with:
• Boehringer-Ingelheim
• Biosense Webster
Atrial Fibrillation Guidelines
Case 4
66 year-old pediatrician with intermittent palpitations for
last 6-8 months
• Strong palpitations, SOB, mild CP
• Long episodes he finds it hard to finish clinic
• To ED once where rapid AF documented
• Underwent DC cardioversion
• Put on Bisoprolol 2.5mg daily and titrated to 5mg
daily
Atrial Fibrillation Guidelines
Case 4
Has had high blood pressure readings recorded intermittently but
“is not hypertensive”
Agitated he had to wait.
PMHx: None
On ASA and Bisoprolol
Avid cyclist
Overweight but denies snoring / apneic breathing
States “I do not have sleep apnea”
HR 80bpm BP 165/90
Otherwise exam is normal
•Echo: essentially normal – LA slightly enlarged 42mm
– LV function normal, EF 60%, no WMA, no LVH
Atrial Fibrillation Guidelines
Case 4
Has read about ablation and wants “cryoballoon” ablation –
he has read that this is the newest breakthrough
Doesn’t want drugs because they will cloud his sensorium
and effect his ability to do clinic.
Atrial Fibrillation Guidelines
Your advice for Case 4?
1.
Discuss PV isolation in detail – refer for PVI
2.
Strongly suggest add flecainide to bisoprolol
3.
Refer him to EP for further discussion
4.
Suggest he take amiodarone and if fails - ablation
Atrial Fibrillation Guidelines
Your advice for Case 4?
1.
Discuss PV isolation in detail – refer for PVI
2.Strongly suggest add flecainide to bisoprolol – Best
answer! The latest CCS AF Guidelines suggest that anti-arrhythmic drugs be given an
opportunity for rhythm control prior to AF ablation. Although there is evidence that AF ablation as a
first line therapy is effective, the data are mixed and the complication rate is, in most operators
opinion too large to do this on a routine basis. There may be rare exceptions where AF ablation is
considered prior to trials of anti-arrhythmic drugs, but these should be rare and individualized with
full patient informed consent. The choice of anti-arrhythmic drugs as first line could be either
flecainide or amiodarone, although amiodarone is not usually first line. Flecainide would probably be
my choice over amiodarone, as long as there is no evidence of coronary disease and it would be
acceptable to the patient to take it as well as a AV node blocking agent such as a beta blocker or
diltiazem. Sotalol and amiodarone are reasonable monotherapies for AF.
3.Refer him to EP for further discussion – Probably, most
popular answer!
4.Suggest he take amiodarone and if fails - ablation
Atrial Fibrillation Guidelines
AF Ablation as first line therapy
MAANTRA PAF Study
N Eng J Med 2012;367:1587-95
N=294
Baseline
p=0.007
3 mths
6 mths
12 mths
Atrial Fibrillation Guidelines
18 mths
24 mths
RAAFT 2 Study: 1st line AF Ablation
Time to First recurrence of symptomatic/asymptomatic AF/AT/AFl
n=127
72.%
55%
HR: 0.56 (0.35 – 0.90) p= 0.02
Morillo C et al. JAMA. 2014 Feb 19;311(7):692-700
Atrial Fibrillation Guidelines
Worldwide AF Ablation (’03-’06)
Type of Complication (n=14,218)
Femoral pseudoaneurysm
AV fistulae
Pneumothorax
No of Pts
152
88
15
Rate%
0.93
0.54
0.09
Valve damage/requiring surgery
11/7
0.07
Tamponade
Transient ischaemic attack
PV stenosis requiring intervention
Stroke
Permanent diaphragmatic paralysis
Death
Atrium-esophageal fistulae
213
115
48
37
28
25
3
1.31
0.71
0.29
0.23
0.17
0.15
0.02
TOTAL
741
4.54%
Cappato R et al. Circ Arrhythm Electrophysiol. 2010;3:32-8
Atrial Fibrillation Guidelines
Ablation
Recommendations
• We recommend catheter ablation of AF in patients who remain symptomatic
following adequate trials of anti-arrhythmic drug therapy and in whom a
rhythm control strategy remains desired.
(Strong Recommendation, Moderate Quality Evidence)
• We suggest catheter ablation to maintain sinus rhythm as first-line therapy for
relief of symptoms in highly selected patients with symptomatic, paroxysmal
AF.
(Conditional Recommendation, Low Quality Evidence)
Values and Preferences:
These recommendations recognize that the balance of risk with ablation and
benefit in symptom relief and improvement in quality of life must be
individualized. They also recognize that patients may have relative or absolute
cardiac or non-cardiac contra-indications to specific medications.
Atrial Fibrillation Guidelines
Comparison of North American and European Guidelines
CCS Guidelines
ESC Guidelines
ACCF/AHA/HRS
Strength
Level of
Evidence
Class
Level of
Evidence
Class
Level of
Evidence
Paroxysmal*
Conditional
Moderate
IIa
(Conditional)
A (High)
I (Strong)¶
A (High)
Persistent*
Conditional
Moderate
IIa
(Conditional)
B (Moderate)
IIa
(Conditional)
A (High)
Failed 1 drug
Conditional
Moderate
--
--
I (Strong)¶
A (High)
Strong
Moderate
--
--
--
--
Conditional
Low
IIb
(Conditional)
B (Moderate)
--
--
--
--
--
--
IIb
(Conditional)
A (High)
Failed ≥ 2
drugs
1st Line
PAF / sign.
structural
heart disease
* Applies to patients with symptomatic AF and failed at least one anti-arrhythmic drug.
¶ Dictates ablation performed in experienced centre in patient with minimal heart disease
-- Not directly addressed. Often this group is incorporated into other recommendations
Atrial Fibrillation Guidelines
Case 4
• Agrees to add flecainide 50mg bid to bisoprolol
• Recurrent episodes of AF – but shorter
• Flecainide increased to 100mg bid
• Episodes on average 1 / month lasting 45-90
minutes
• “Very bothered by spells” although does not limit
work or personal activities
Atrial Fibrillation Guidelines
Thermacool study: Freedom from PAF
Wilber DJ et al JAMA 2010;303:333
Atrial Fibrillation Guidelines
Systematic Review of RCTs of
Ablation vs Rx
Systematic Review of RCTs of Ablation vs Rx
Ablation
28/32
Control
13/35
OR
11.85
95% CI
3.4-41.4
12/15
6/15
6.0
1.2-30.7
46/53
13/59
23.3
8.5-63.6
85/99
24/99
19.0
9.2-39.3
38/68
6/69
13.3
5.1-34.9
266/344
102/346
15.8
10.1-24.7
• 9 RCTs / 3 systematic reviews in 1274 patients who have failed ≥ 1 drug
• uniformly demonstrate large differences in recurrence of AF
• (OR 9.74 95% CI, 3.98 to 23.87) in favour of ablation vs AAD
Piccini JP et al. Circ Arrhythm 2009;2:626
Atrial Fibrillation Guidelines
Contact Force / Cryoablation
Technological Advances
Improved outcomes
Improved sustainability
Improved safety
Atrial Fibrillation Guidelines
Contact Force / Cryoablation
Technological Advances
Improved outcomes
Improved sustainability
Improved safety
Reddy VY et al. Heart Rhythm 2012; 9:1789 –1795
Atrial Fibrillation Guidelines
Posterior LA as source of
Triggering beats and Circular activity
Atrial Fibrillation Guidelines
Tachycardia in Right Veins
ECG Lead
II
Right Veins
CS
Atrial Fibrillation Guidelines
AF Ablation lesion set
Atrial Fibrillation Guidelines
Tachycardia in Right Veins: Behind
Fence
II
R
L
P
V
PV Tachycardia
CS
Atrial Fibrillation Guidelines
PV Isolation
Why do patient need a repeat procedure?
Atrial Fibrillation Guidelines
Case 4
• Doing well 3 months after ablation
– No recurrent symptoms
– Loop recorder shows occ. PACs but no AF
• 66 year old man with “hypertension” despite his
assurances (CHADS2=1)
Atrial Fibrillation Guidelines
What would you recommend for Case 4 at this
point?
1. Continue OAC (dabigatran 150mg bid)
2. Stop dabigatran
Atrial Fibrillation Guidelines
What would you recommend for Case 4 at this
point?
1. Continue OAC (dabigatran 150mg bid) Refer to practical
tips in next slide.
2. Stop dabigatran
This is an area of intense debate and there is no correct answer!
Studies of long-term monitoring have consistently shown asymptomatic episodes of AF both
prior to and following ablation. Symptoms are therefore not a good guide for the
presence or absence of AF. It is the standard of practice in many centers internationally
to stop the OAC at this stage. However, the need for OAC after a “successful” ablation
has not been rigourously tested in large randomized trials. These trials have been
proposed. Obviously, repeat monitoring would be required to document the absence of
asymptomatic AF, although documentation of complete elimination of AF may be
impossible. At this stage, I would leave this decision to the electrophysiologist involved.
He or she may choose to continue the OAC for a period of time in the absence of clear
data. Most would agree that if the CHADS-VASc score was 0 (1 in female) OAC should
be discontinued. It would not be recommended if AF were present. If the CHADS score
was 2 or greater, most would continue the OAC indefinitely. A range of opinions would
be expressed for intermediate scores.
Atrial Fibrillation Guidelines
Practical Tips
•AF ablation should not be considered as an alternative to
oral anticoagulation.
•If a patient has a high thromboembolic risk profile, then the
patient should continue oral anticoagulation even after successful
AF ablation.
•Studies of long-term monitoring have consistently shown
asymptomatic episodes of AF both prior to and following ablation
•Initiation of oral anticoagulation should also not be delayed when
indicated in patients pending referral for AF ablation.
Atrial Fibrillation Guidelines
Case 5
46 year-old referred because pre-op ECG shows AF
Having ACL/MCL fixed
• Completely unaware of his heart
• Good exercise tolerance
• PMHx: Hypertension on perindopril and bisoprolol
• Obese BMI 36
Atrial Fibrillation Guidelines
Case 5
HR in office is 89, BP 145/85
Exam normal
Echo LV normal size function EF 55-60%
LA 45mm – mild MR
HbA1C 8.6%
Atrial Fibrillation Guidelines
What do you recommend for Case 5?
1. Holter to assess rate control
2. OAC of your choice (__ban / __tran)
3. ASA
Atrial Fibrillation Guidelines
What do you recommend for Case 5?
1.Holter to assess rate control
2.OAC of your choice (__ban / __tran) – Best answer!
The patient’s heart rate in the office at rest is adequate, ie < 100bpm, and he is without symptoms. He
meets guideline recommendations for rate control. A Holter monitor to assess his rate control is not
necessary, but not unreasonable to document adequate rate control throughout his daily activities. It is
also reassuring that his LV function is normal or near normal and he has no evidence of tachycardiainduced cardiomyopathy. The patient has hypertension. Despite his young age, he should be on an
OAC – either warfarin or one of the new OACs.. ASA is insufficient protection from stroke.
3.ASA
Atrial Fibrillation Guidelines
Case 5
Returns to see you in 3 months
Holter AF throughout
mean rate 89 (48 – 126)
3 runs of NSVT or aberrancy
Wants to discuss ablation with you to get:
1. back in shape
2. off OAC
Atrial Fibrillation Guidelines
What options do you offer Case 5 at this
point?
1. Refer for ablation
2. Counsel about diet and arrange F/U 6 mos
3. Refer for cardioversion and ablation
4. Arrange for sleep study first
Atrial Fibrillation Guidelines
What options do you offer Case 5 at this point?
1.Refer for ablation
2.Counsel about diet and arrange F/U 6 mos – Best answer!The
patient’s goal to get in shape and off OAC is best met with ongoing lifestyle management. It is important to point
out that catheter ablation is not a verified approach to replace OAC in someone who would otherwise need it.
Although it makes intuitive sense to patients – that is” fix the fib then I don’t need to take the blood thinner” – this is
not evidence based. Catheter ablation is a symptom-driven procedure that has little to offer a truly asymptomatic
patient. Consideration of obstructive sleep apnea (OSA) is important. Usually prior to a full sleep study, screening
for sleep apnea is worthwhile. There are occasions when patient’s symptoms are hard to attribute to AF. Under
these circumstances, we have performed DC cardioversion to determine if patients feel better in sinus rhythm and
are aware if they return to AF. If so, there may be some benefit to catheter ablation. In this man’s case, he is
completely asymptomatic. As such, catheter ablation is not indicated.
3.Refer for cardioversion and ablation
4.Arrange for sleep study first
Atrial Fibrillation Guidelines
Practical Tips
•AF ablation should not be considered as an alternative to
oral anticoagulation.
•If a patient has a high thromboembolic risk profile, then the
patient should continue oral anticoagulation even after successful
AF ablation.
•Studies of long-term monitoring have consistently shown
asymptomatic episodes of AF both prior to and following ablation
•Initiation of oral anticoagulation should also not be delayed when
indicated in patients pending referral for AF ablation.
Atrial Fibrillation Guidelines
Documented AF > 30 seconds after one procedure
with or without AAD
Results – Persistent AF
p=0.15
59%
48%
44%
Verma et al presented ESC 2014
Atrial Fibrillation Guidelines
Atrial Fibrillation Guidelines
Case 6 – Mr. OP
Peri-Procedure
by L. Brent Mitchell, MD FRCPC
October 2014
Disclosures
Dr. L. Brent Mitchell has received grant support
and/ or honoraria from:
•
•
•
•
www.ccs.ca
Bayer
Boehringer-Ingelheim
Bristol-Myers Squibb
Pfizer
Atrial Fibrillation Guidelines
A guidelines based approach to AF
management
• 67 year old male is scheduled for surgery
• Pre-op consult regarding OAC management
• Past history includes 2 years of auto-ratecontrolled persistent AF, controlled HT, controlled
type II diabetes, prior MI, NYHA class II CHF, no
angina, otherwise well
• On irbesartan / HCTZ 300 mg / 25 mg OD, insulin,
warfarin (INR 2.0-3.0)
• Cannot take a beta blocker as heart rate slow
www.ccs.ca
Atrial Fibrillation Guidelines
A guidelines based approach to AF
management
•
•
•
•
HR 48 bpm, irreg/irreg; BP 150/85 mm Hg
JVP 2 cm ASA, +ve HJR, S4, II/VI MR murmur
lungs clear, no pedal edema
ECG: rate-controlled AF, old inferior MI
L. Brent Mitchell CCS 2014
www.ccs.ca
Atrial Fibrillation Guidelines
Peri-Procedure/Anticoagulation Management
Recommendation
We recommend that, in a patient with AF/AFL, a decision to interrupt
antithrombotic therapy for an invasive procedure must balance the risks of a
thromboembolic event (as indicated by a higher CHADS2 score, mechanical
heart valve, or rheumatic heart disease) with those of a bleeding event (as
indicated by a higher HASBLED score and procedures with higher bleeding
risk).
(Strong Recommendation, Low Quality Evidence)
Atrial Fibrillation Guidelines
A guidelines based approach to AF
management
• Stroke risk considerations:
- CHADS2 score = 3; CHA2DS2-VASc = 5
- no mechanical heart valve
- no rheumatic heart disease
• Bleeding risk considerations:
- HASBLED score = 1
• No AT-Rx: stroke = 10.5%/yr: major bleed = 3.1%/yr
• On warfarin: stroke = 3.8%/yr: major bleed = 6.7%/yr
LaHaye SA et al: Eur J Cardiol 33:2164-71, 2012 (www.afib.ca)
www.ccs.ca
Atrial Fibrillation Guidelines
For peri-procedural bleeding risk, procedure matters:
For this patient, preparing for a PPM implant, I
would:
1. stop warfarin; no heparin bridging
2. stop warfarin; heparin bridging
3. continue warfarin
www.ccs.ca
Atrial Fibrillation Guidelines
For peri-procedural bleeding risk, procedure matters:
For this patient, preparing for a PPM implant, I
would:
1. stop warfarin; no heparin bridging
2. stop warfarin; heparin bridging
1. continue warfarin – Correct! the data to support that
contention are provided by the trial BRUISE
CONTROL given on the next slide
www.ccs.ca
Atrial Fibrillation Guidelines
A guidelines based approach to AF
management
BRUISE CONTROL: A RCT comparing continued
warfarin versus discontinued warfarin with heparin
bridging in patients undergoing PPM/ICD surgery.
N = 681
significant
hematoma
p<0.001
other
AEs
p=ns
Birnie DH et al. N Engl J Med 368:2084-93, 2013
www.ccs.ca
Atrial Fibrillation Guidelines
Peri-Procedure/Anticoagulation Management
Recommendation
• We suggest that interruption of anticoagulant therapy in a patient
with AF/AFL is not necessary for most procedures with a very low
risk of bleeding (Conditional Recommendation, Low Quality
Evidence), including cardiac device implantation (pacemaker or
implantable defibrillator) (Conditional Recommendation, High Quality
Evidence)
Other very low risk of bleeding procedures include most dental procedures,
anterior chamber eye surgery, most dermatologic procedures.
www.ccs.ca
Atrial Fibrillation Guidelines
Patient has PPM implanted with ongoing warfarin
therapy with no problems. One year later, requires
a thoracotomy for removal of suspicious mass.
For this patient preparing for a thoracotomy I
would:
1. stop warfarin; no heparin bridging
2. stop warfarin; heparin bridging
3. continue warfarin
www.ccs.ca
Atrial Fibrillation Guidelines
Patient has PPM implanted with ongoing warfarin
therapy with no problems. One year later, requires
a thoracotomy for removal of suspicious mass.
For this patient preparing for a thoracotomy I
would:
1. stop warfarin; no heparin bridging
2. stop warfarin; heparin bridging – Correct! According to
CCS AF Guidelines, this is the correct answer as this
patient has a CHADS score of 3. Nevertheless, the
evidence supporting a net benefit for heparin bridging is
weak. Clinical trials of heparin bridging are underway.
3. continue warfarin
www.ccs.ca
Atrial Fibrillation Guidelines
Peri-Procedure/Anticoagulation Management - Recommendation
Recommendation
We recommend that interruption of anticoagulant therapy in a patient with AF
or AFL will be necessary for most procedures with an intermediate or high risk
of major bleeding.
(Strong Recommendation, Low Quality Evidence)
When a decision to interrupt warfarin therapy for an invasive procedure has
been made for a patient with AF/AFL, we suggest that bridging therapy with
LMWH or UFH be instituted…in a patient at high risk of thromboembolic
events (CHADS2 ≥3, mechanical heart valve, stroke or TIA within 3 months,
rheumatic heart disease).
(Conditional Recommendation, Low Quality Evidence)
www.ccs.ca
Atrial Fibrillation Guidelines
A guidelines based approach to AF
management
In patients at high risk of thromboembolic events it is
customary to use bridging LMWH or UFH heparin during
warfarin withdrawal for an invasive procedure.
The wisdom of this practice has been questioned by a
meta-analysis of 33 observational trials and one RCT
reporting that bridging therapy is associated with:
– an increase in major bleeding (13.1% vs 3.4%, p<0.0001)
– no reduction in thromboembolic events (0.9% vs 0.6%)
Ongoing RCTs – PERIOP-2 and BRIDGE
Siegel D et al. Circulation 126:1630-9, 2012
www.ccs.ca
Atrial Fibrillation Guidelines
Thoracotomy accomplished without complications
after warfarin withdrawal and LMWH bridging. The
lung mass turns out to be benign. Patient switched
to apixaban 5 mg bid at his request. One year later
planned for knee replacement. eGFR = 85 ml/min/m2
For this patient preparing for a new knee would:
1. stop apixaban 5 days; heparin bridging
2. stop apixaban 2 days; no heparin bridging
3. switch to warfarin then do as before
www.ccs.ca
Atrial Fibrillation Guidelines
Thoracotomy accomplished without complications
after warfarin withdrawal and LMWH bridging. The
lung mass turns out to be benign. Patient switched
to apixaban 5 mg bid at his request. One year later
planned for knee replacement. eGFR = 85 ml/min/m2
For this patient preparing for a new knee would:
1. stop apixaban 5 days; heparin bridging
2. stop apixaban 2 days; no heparin bridging - Correct! The half life of
apixaban is sufficiently short and predictable that heparin bridging is
not required unless the apixaban was stopped too early or the
surgery was unexpectedly delayed. Nevertheless, neither of the
other two answers is wrong, just unnecessary.
3. switch to warfarin then do as before
www.ccs.ca
Atrial Fibrillation Guidelines
A guidelines based approach to AF
management
Days of withdrawal prior to high bleeding risk procedure
eGFR
ml/min/m2
apixaban
dabigatran
rivaroxaban
≥ 80
2-3
2-3
2-3
50 - 80
2-3
3
2-3
30 - 50
2-3
4
2-3
< 30*
2-3
5
2-3
2014 Focused Update CCS AF Guidelines Can J Cardiol (in press)
www.ccs.ca
Atrial Fibrillation Guidelines
Due to the rapid offset and onset kinetics of the
current NOACs, bridging LMWH or UFH therapy is
only required if the period of withdrawal is longer
than that recommended.
Assuming haemostasis, after the new knee I would:
1. restart apixaban 2.5 mg bid on PO day 2
2. restart apixaban 5 mg bid on PO day 2
3. restart apixaban 5 mg daily on PO day 3
www.ccs.ca
Atrial Fibrillation Guidelines
Due to the rapid offset and onset kinetics of the
current NOACs, bridging LMWH or UFH therapy is
only required if the period of withdrawal is longer
than that recommended.
Assuming haemostasis, after the new knee I would:
1. restart apixaban 2.5 mg bid on PO day 2
2. restart apixaban 5 mg bid on PO day 2
3. restart apixaban 5 mg daily on PO day 3 – Correct! Knee
replacement is intermediate risk of bleeding procedure.
Recognizing that once a NOAC is started, anticoagulation is (at
least transiently) obtained the same day, an optimal balance of risk
of post-op bleeding versus risk of thromboembolic event suggests
restarting the NOAC 72 hours after this surgery.
www.ccs.ca
Atrial Fibrillation Guidelines
Peri-Procedure/Anticoagulation Management
Recommendation
When apixaban, dabigatran, or rivaroxaban have been withdrawn for an
invasive procedure we suggest that such therapy be restarted after the
procedure one day after haemostasis is established (usually 48 hours
for a procedure with a low risk of bleeding and 72 hours for a
procedure with an intermediate or high risk of bleeding).
(Conditional Recommendation, Low Quality Evidence)
www.ccs.ca
Atrial Fibrillation Guidelines
THANK YOU !
Please visit our website for more
information
www.ccs.ca
Visit our Atrial Fibrillation Patient
Guide
www.heartandstroke.ca⁄AFguide
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Atrial Fibrillation Guidelines
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Atrial Fibrillation Guidelines
EXTRA SLIDES
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Atrial Fibrillation Guidelines
ATRIAL FIBRILLATION GUIDELINES
ATRIAL FIBRILLATION
GUIDELINES
ATRIAL FIBRILLATION GUIDELINES
The Canadian Cardiovascular Society’s
About this Slide Set
This slide set is a quick-reference tool that features essential diagnostic and treatment
recommendations based on the 2010 CCS Atrial Fibrillation Guidelines, the 2012 CCS Atrial
Fibrillation Guidelines Update and the 2014 Focused Update of the CCS guidelines for the
management of AF.
These recommendations are aimed to provide a reasonable and practical approach to care for
specialists and allied health professionals obliged with the duty of bestowing optimal care to
patients and families, and can be subject to change as scientific knowledge and technology
advance and as practice patterns evolve. The guideline is not intended to be a substitute for
physicians using their individual judgment in managing clinical care in consultation with the
patient, with appropriate regard to all the individual circumstances of the patient, diagnostic and
treatment options available and available resources. Adherence to these recommendations will
not necessarily produce successful outcomes in every case.
For the complete CCS Atrial Fibrillation Guidelines, or for additional resources, please visit our
guidelines website at www.ccs.ca.
The 2014 Focused Update of the Canadian Cardiovascular
Society
Guidelines for the Management of Atrial Fibrillation
Co-chairs and Authors
Jeff S. Healey and Atul Verma
Authors
John A. Cairns, Stuart Connolly, Jafna L. Cox, Paul Dorian, David Gladstone,
Gordon J. Gubitz, Noah Ivers, Kori Leblanc, Laurent Macle, Michael Sean McMurtry,
L. Brent Mitchell, Stanley Nattel, Pierre Pagé, Ratika Parkash, P. Timothy Pollak,
Allan C. Skanes, Ian G. Stiell, Mario Talajic, Teresa S. M. Tsang and Carl Van Walraven.
Publication date: October 2014
Baseline Evaluation for All Patients
History and Physical Exam
Establish Pattern (New Onset, Paroxysmal, Persistent or Permanent)
•Establish Severity (including impact on quality of life)
•Identify Etiology
•Identify reversible causes (hyperthyroidism, ventricular pacing, supraventricular tachycardia, exercise, etc)
•Identify risk factors whose treatment could reduce recurrent AF or improve
overall prognosis (i.e. hypertension, sleep apnea, left ventricular dysfunction,
etc)
•Take social history to identify potential triggers (i.e. alcohol, intensive
aerobic training, etc)
•Elicit family history to identify potentially heritable causes of AF (particularly
lone AF)
•Determine thromboembolic risks
•Determine bleeding risk to guide appropriate
antiplatelet or antithrombotic therapy
•Review prior pharmacologic therapy for AF,
both for efficacy and adverse effects
•Measure blood pressure and heart rate
•Determine patient height and weight
•Comprehensive precordial cardiac
examination and assessment of jugular
venous pressure, carotid and peripheral
pulses to detect evidence of structural heart
disease
12-Lead Electrocardiogram
•
Document presence of AF
•
Assess for structural heart disease (myocardial infarction, ventricular
hypertrophy, atrial enlargement, congenital heart disease) or electrical heart
disease (ventricular pre-excitation, Brugada syndrome)
•Identify risk factors for complications of
therapy for AF (conduction disturbance, sinus
node dysfunction or abnormal repolarization)
•Document baseline PR, QT and QRS
intervals.
Echocardiogram
•Document ventricular size, wall thickness and function
•Evaluate left atrial size (if possible, left atrial volume)
•Exclude significant valvular or congenital heart
disease (particularly atrial septal defects)
•Estimate ventricular filling pressures and
pulmonary arterial pressure
Other
•Complete blood count
•Coagulation profile
•Renal function
•Thyroid and liver function
•Fasting lipid profile
•Fasting glucose
Additional Investigations for Selected Patients
Investigation
Potential Role
Chest radiography
Exclude concomitant lung disease, heart failure, baseline in patients receiving
amiodarone
Ambulatory
electrocardiography
(Holter monitor, event
monitor,
loop monitor)
Document AF, exclude alternative diagnosis (atrial tachycardia, atrial flutter,
AVNRT/AVRT, ventricular tachycardia), symptom-rhythm correlation, assess
ventricular rate control
Treadmill exercise test
Investigation of patients with symptoms of coronary artery disease,
assessment of rate control
Trans-esophageal
echocardiography
Rule out left atrial appendage thrombus, facilitate cardioversion in patients not
receiving oral anti-coagulation, more precise characterization of structural
heart disease (mitral valve disease, atrial septal defects, cor triatriatum, etc)
Electrophysiologic Study
Serum calcium and
magnesium
Sleep Study (ambulatory
oximetry or polysomnography)
Ambulatory blood pressure
monitoring
Generic testing
Patients with documented regular supra-ventricular tachycardia (i.e. atrial
tachycardia, AVNRT/AVRT, atrial flutter) that is amenable to catheter ablation
In cases of suspected deficiency (i.e. diuretic use, gastro-intestinal losses)
which could influence therapy (i.e. sotalol)
In patients with symptoms of obstructive sleep apnea or in select patients with
advanced symptomatic heart failure
In cases of borderline hypertension or to assess blood pressure control
In rare cases of apparent familial AF (particularly with onset at a young age)
with additional features of conduction disease, Brugada syndrome or
cardiomyopathy
Established Patterns and Severity of Atrial Fibrillation
Patterns of Atrial Fibrillation
SAF Score*
SAF
Score
Newly
Diagnosed
AF
Class 0
Paroxysmal:
Selfterminating
<7d
Persistent:
Sustained
≥7d
Permanent:
Decision to
continue
in AF
* Dorian P, Cvitkovic SS, Kerr CR; et al. Can J Cardiol. 2006; 22(5): 383386
Impact on QOL**
Asymptomatic
1
Minimal effect on
QOL
2
Minor effect on QOL
3
Moderate effect on
QOL
4
Severe effect on
QOL
** QOL = quality of life
Overview of AF Management
AF Detected
Assessment of
Thromboembolic
Risk (CHADS2)
Appropriate
Antithrombotic
Therapy
Detection and
Treatment of
Precipitating Causes
Management of
Arrhythmia
Rate
Control
Rhythm
Control
Major Goals of AF/AFL Arrhythmia Management
•Identify and treat underlying structural heart disease and other predisposing conditions
•Relieve symptoms
•Improve functional capacity/quality of life
• Reduce morbidity/mortality associated with AF/AFL
Prevent tachycardia-induced cardiomyopathy
Reduce/prevent emergency room visits or hospitalizations secondary to AF/AFL
• Prevent stroke or systemic thromboembolism
Recommendations
• We recommend that the goals of ventricular rate control should be to improve symptoms and
clinical outcomes which are attributable to excessive ventricular rates. (Strong Recommendation,
Low Quality Evidence)
• We recommend that the goals of rhythm control therapy should be to improve patient symptoms
and clinical outcomes, and that these do not necessarily imply the elimination of all AF. (Strong
Recommendation, Moderate Quality Evidence)
Rate vs Rhythm Control for Patients with Symptomatic
AF
SYMPTOMATIC AF
ATTEMPT RATE CONTROL
Beta-blocker
Calcium channel blocker
Special circumstances in
which to consider early
rhythm control:
Highly symptomatic
Multiple recurrences
Extreme impairment in QOL
Arrhythmia-induced
cardiomyopathy
YES
SYMPTOMS RESOLVE
NO
CONTINUE RATE
CONTROL
MODIFY RATE CONTROL - CONSIDER RHYTHM CONTROL
Paroxysmal AF
Low burden
recurrence
Pill in pocket
antiarrhythmic therapy
High burden recurrence
Maintenance
antiarrhythmic therapy
Catheter ablation
Persistent AF
Consider cardioversion
Symptoms
Symptoms
improve,
improve,
and patient
but AF recurs maintains sinus
rhythm
Symptoms
don’t change
in sinus
rhythm and
AF recurs
Observe. If AF
recurs, determine if symptomatic
Rate Management
Recommendations
• We recommend that ventricular rate be assessed at rest in all patients with persistent and permanent AF or AFL (Strong
Recommendation, Moderate Quality Evidence).
• We recommend that heart rate during exercise be assessed in patients with persistent or permanent AF or AFL and associated
exertional symptoms (Strong Recommendation, Moderate Quality Evidence).
• We recommend that treatment for rate control of persistent or permanent AF or AFL should aim for a resting heart rate of
bpm (Strong Recommendation, High Quality Evidence).
<100
• We recommend beta-blockers or nondihydropyridine calcium channel blockers as initial therapy for rate control of AF or AFL in
most patients without a past history of myocardial infarction or left ventricular dysfunction (Strong Recommendation, Moderate
Quality Evidence).
• We recommend beta-blockers as initial therapy for rate control of AF or AFL in patients with myocardial infarction or left ventricular
systolic dysfunction (Strong Recommendation, High Quality Evidence).
• We recommend AV junction ablation and implantation of a permanent pacemaker in symptomatic patients with uncontrolled
ventricular rates during AF despite maximally tolerated combination pharmacologic therapy (Strong Recommendation, Moderate
Quality Evidence).
• We suggest that digoxin not be used as initial therapy for active patients and be reserved for rate control in patients who are
sedentary or who have left ventricular systolic dysfunction. (Conditional Recommendation, Moderate Quality Evidence)
• We suggest that digoxin be added to therapy with beta-blockers or calcium channel blockers in patients whose heart rate remains
uncontrolled. (Conditional Recommendation, Moderate Quality Evidence)
• We suggest that amiodarone for rate control should be reserved for exceptional cases in which other means are not feasible or
are insufficient (Conditional Recommendation, Low Quality Evidence).
Overview of Rate Management
Rate Control Drug Choices
Heart Failure
CAD
No Heart Failure
or CAD
β-blockers
± Digoxin
β-blockers*
Calcium Channel
Blockers#
Combination Rx
β-blockers*
Calcium Channel
Blockers#
Digoxin†
Combination Rx
Drugs are listed in alphabetical order
*β-blockers preferred in CAD
# Non-dihydropyridine calcium channel blockers (diltiazem, verapamil)
†Digoxin may be considered as monotherapy only in particularly sedentary
individuals
Managing Rate Control - Recommended Drugs
ß-Blockers
Drug
Dose
Adverse Effects
Atenolol
50 - 150 mg p.o. daily
bradycardia, hypotension, fatigue,
depression
Bisoprolol
2.5 - 10 mg p.o. daily
as per atenolol
Metoprolol
25 mg - 200 mg p.o. bid
as per atenolol
20 - 160 mg p.o daily - bid
as per atenolol
80 - 240 mg p.o. tid
as per atenolol
Nadolol
Propranolol
Calcium Channel Blockers and Digoxin
Drug
Dose
Adverse Effects
Verapamil
120 - 480 mg p.o. daily
120 - 240 mg p.o. bid
bradycardia, hypotension, constipation
Diltiazem
120 - 480 mg p.o. daily
120 - 240 mg p.o. bid
bradycardia, hypotension, ankle swelling
Digoxin
0.0625 mg - 0.25 mg p.o. daily
bradycardia, nausea, vomiting,visual
disturbance
Rhythm Management
Recommendations
• We recommend the optimal treatment of precipitating or reversible predisposing conditions of AF prior to attempts to restore
or maintain sinus rhythm (Strong Recommendation, Low Quality Evidence).
• We recommend a rhythm-control strategy for patients with AF or AFL who remain symptomatic with rate-control therapy or
in whom rate-control therapy is unlikely to control symptoms (Strong Recommendation, Moderate Quality Evidence).
• We recommend that the goal of rhythm-control therapy should be improvement in patient symptoms and clinical outcomes,
and not necessarily the elimination of all AF (Strong Recommendation, Moderate Quality Evidence).
• We recommend use of maintenance oral antiarrhythmic therapy as first-line therapy for patients with recurrent AF in whom
long-term rhythm control is desired (see Figures) (Strong Recommendation, Moderate Quality Evidence).
• We recommend intermittent antiarrhythmic drug therapy (“pill in the pocket”) in symptomatic patients with infrequent, longerlasting episodes of AF or AFL as an alternative to daily antiarrhythmic therapy (Strong Recommendation, Moderate Quality
Evidence).
• We recommend that oral antiarrhythmic drug therapy should be avoided in patients with AF or AFL and advanced sinus or
AV nodal disease unless the patient has a pacemaker or implantable defibrillator (Strong Recommendation, Low Quality
Evidence).
Rhythm Management
Recommendations
• We recommend that an AV blocking agent should be used in patients with AF or AFL being treated with a class I
antiarrhythmic drug (eg, propafenone or flecainide) in the absence of advanced AV node disease (Strong
Recommendation, Low Quality Evidence).
• We recommend electrical or pharmacologic cardioversion for restoration of sinus rhythm in patients with AF or AFL who
are selected for rhythm-control therapy and are unlikely to convert spontaneously (Strong Recommendation, Low
Quality Evidence).
• We recommend pre-treatment with antiarrhythmic drugs prior to electrical cardioversion in patients who have had AF
recurrence post cardioversion without antiarrhythmic drug pre-treatment (Strong Recommendation, Moderate Quality
Evidence).
• We suggest that patients requiring pacing for the treatment of symptomatic bradycardia secondary to sinus node
dysfunction, atrial or dual-chamber pacing be generally used for the prevention of AF (Conditional Recommendation,
High Quality Evidence).
• We suggest that, in patients with intact AV conduction, pacemakers be programmed to minimize ventricular pacing for
prevention of AF (Conditional Recommendation, Moderate Quality Evidence).
Rhythm Management
Recommendations
• We recommend that dronedarone not be used in patients with permanent AF nor for the sole purpose of rate control
(Strong Recommendation, High Quality Evidence).
• We recommend dronedarone not be used in patients with a history of heart failure or a left ventricular ejection fraction <
40% (Strong Recommendation, Moderate Quality Evidence).
• We suggest dronedarone be used with caution in patients taking digoxin (Conditional Recommendation, Moderate
Quality Evidence).
Practical Tip
Dronedarone is a reasonable choice for rhythm control in selected patients with AF. Typically, these would be patients with
nonpermanent (predominantly paroxysmal) AF with minimal structural heart disease. Consideration should be given to
monitoring for liver enzyme elevations within 6 months of initiating therapy with dronedarone.
Overview of Rhythm Management
Rhythm Control Choices
Normal Systolic Function
No Hx of CHF
Dronedarone+
Flecainide*
Propafenone*
Sotalol#
Rhythm Control Choices
Hx of CHF or Left Ventricular
Systolic Dysfunction
EF > 35%
EF ≤ 35%
Amiodarone
Sotalol**
Amiodarone
Catheter
Ablation
Amiodarone
Catheter Ablation
Drugs are listed in alphabetical order
+ Dronedarone should be used with caution in combination with digoxin
• Class I agents should be AVOIDED in CAD and should be COMBINED
with AV-nodal blocking agents
# Sotalol should be used with caution in those at risk for torsades de
pointes VT (e.g. female, age > 65 yr, taking diuretics)
** Sotalol should be used with caution with EF 35-40% and those at risk
for torsades de pointes VT (e.g. female, age > 65 yr, taking diuretics)
Managing Rhythm Control - Recommended Drugs
Drug/Dos
e
Efficac
y
Flecainide
50-150 mg
BID
30-50%
Propafenone
150-300 mg
TID
30-50%
Amiodarone
100-200 mg
OD (after
10g
loading)
Dronedarone
400 mg BID
Sotalol
80-160 mg
BID
60-70%
40%
30-50%
Toxicity
Ventricular tachycardia
Bradycardia
Rapid ventricular response to
AF
or atrial flutter (1:1 conduction)
Ventricular tachycardia
Bradycardia
Rapid ventricular response to
AF
or atrial flutter (1:1 conduction)
Abnormal taste
Photosensitivity, Bradycardia,
GI upset, Thyroid dysfunction,
Hepatic toxicity, Neuropathy,
Tremor, Pulmonary toxicity,
Torsades de pointes (rare)
Comments
Contraindicated in patients with CAD or LV dysfunction
Should be combined with an AV nodal blocking agent
Contraindicated in patients with CAD or LV dysfunction
Should be combined with an AV nodal blocking agent
Low risk of proarrhythmia
Limited by systemic side effects
Most side effects are dose & duration related
GI upset
Bradycardia
Hepatic toxicity
Should not be used for rate control or for rhythm control in
patients with a history of CHF or LV EF < 40%.
Should be used with caution when added to digoxin.
Liver enzyme monitoring required.
New agent – limited experience outside clinical trials.
Torsades de pointes
Bradycardia
Beta-blocker side effects
Should be avoided in patients at high risk of torsades de
pointes VT – especially women >65 years taking diuretics
or those with renal insufficiency
QT interval should be monitored 1 week after starting
Use cautiously when EF<40%
Catheter Ablation
Recommendations
• We recommend catheter ablation of AF in patients who remain symptomatic following an adequate trial of antiarrhythmic
drug therapy and in whom a rhythm control strategy remains desired. (Strong Recommendation, Moderate Quality
Evidence).
• We suggest catheter ablation to maintain sinus rhythm as first-line therapy for relief of symptoms in highly selected
patients with symptomatic, paroxysmal atrial fibrillation. (Conditional Recommendation, Moderate Quality Evidence)
• We recommend curative catheter ablation for symptomatic patients with typical atrial flutter as first line therapy or as a
reasonable alternative to pharmacologic rhythm or rate control therapy (Strong Recommendation, Moderate Quality
Evidence).
• In patients with evidence of ventricular preexcitation during AF, we recommend catheter ablation of the accessory
pathway, especially if AF is associated with rapid ventricular rates, syncope, or a pathway with a short refractory period
(Strong Recommendation, Low Quality Evidence).
• In young patients with lone, paroxysmal AF, we suggest an electrophysiological study to exclude a re-entrant
tachycardia as a cause of AF; if present, we suggest curative ablation of the tachycardia (Conditional Recommendation,
Very Low Quality Evidence).
Catheter Ablation
Practical Tip
AF ablation should not be considered as an alternative to oral anticoagulation. If a patient has a high thromboembolic risk
profile, then the patient should continue oral anticoagulation even after successful AF ablation. Studies of long-term
monitoring have consistently shown asymptomatic episodes of AF both prior to and following ablation. Initiation of oral
anticoagulation should also not be delayed when indicated in patients pending referral for AF ablation.
Practical Tip
• The following represents a typical, but not exclusive, profile of a patient who is referred for consideration of AF ablation
today:
 Age less than 80
 Patients who are symptomatic with their AF
 Patients who have tried but failed or are intolerant of antiarrhythmic drug therapy
 Paroxysmal AF or short-standing persistent AF
 Minimal to moderate structural heart disease (such as LV dysfunction or valvular disease)
Risk/Benefit Ratio for Ablation in Patients with Symptomatic AF
Longstanding¶
Persistent
Paroxysmal
1st line
--
--
+
Failed 1st drug
--
+
++
Failed 2nd drug
+
++
+++
Failed multiple
drugs
++
+++
+++
+ Balance of risk and benefit in favor of catheter ablation
¶ Ongoing symptomatic AF ≥ 1 year
Prevention of Stroke in AF/AFL
CHADS2 Score
Risk Factor
CHA2DS2-VASc Score
Score
Risk Factor
Score
Congestive Heart Failure 1
Congestive Heart Failure 1
Hypertension
1
Hypertension
1
Age ≥ 75
1
Age ≥ 75
2
Diabetes Mellitus
1
Diabetes Mellitus
1
Stroke/TIA/Thromboembolism
Maximum Score
6
2
Stroke/TIA/Thromboembolism
Vascular Disease
1
Age 65-74
1
Female
1
Maximum Score
9
2
Prevention of Stroke in AF/AFL
Recommendations
• We recommend that all patients with AF or AFL (paroxysmal, persistent or permanent), should be stratified using a
predictive index for stroke risk (for example, the “CCS algorithm” based on the CHADS2 model). (Strong
Recommendation, High Quality Evidence).
• We recommend that OAC therapy be prescribed for most patients with age ≥ 65 years or CHADS2 ≥ 1 (the “CCS
algorithm”) (Strong Recommendation, Moderate Quality Evidence).
• We recommend that when OAC-therapy is indicated for patients with non-valvular AF, most should receive dabigatran,
rivaroxaban, apixaban or edoxaban (when approved) in preference to warfarin. (Strong Recommendation, High Quality
Evidence).
• We recommend that when OAC is indicated, warfarin be used rather than one of the NOACs for those patients with a
mechanical prosthetic valve, those with rheumatic mitral stenosis and those with an CrCl of 15 - 30 mL/min (Strong
Recommendation, Moderate Quality Evidence).
• We recommend that patients whose risk of stoke warrants OAC therapy, but who refuse any OAC, should receive ASA
81 mg/ day plus clopidogrel 75 mg/ day (Strong Recommendation, High Quality Evidence).
• We suggest that ASA (81 mg/day) be prescribed for patients with none of the risks outlined in the “CCS algorithm” (age
< 65 years and no CHADS2 risk factors) who have arterial vascular disease (coronary, aortic, or peripheral).
(Conditional Recommendation, Moderate Quality Evidence)
• We suggest no antithrombotic therapy for patients with none of the risks outlined in the “CCS algorithm” (age < 65
years and no CHADS2 risk factors) and free of arterial vascular disease (coronary, aortic, peripheral). (Conditional
Recommendation, Low Quality Evidence)
The “CCS Algorithm” for OAC Therapy in AF
YES
Age ≥ 65
OAC*
NO
Prior Stroke/TIA/SE
Hypertension
Heart failure
Diabetes Mellitus
or
or
or
YES
OAC*
(CHADS2 risk factors)
NO
Consider and modify (if possible) all
factors influencing risk of bleeding on
OAC (hypertension, antiplatelet drugs,
NSAIDSs, excessive alcohol, labile
INRs) and specifically bleeding risks
for NOACs (low CrCl, age ≥ 75, low
body weight)**
** may require lower dosing
CAD or
Arterial vascular disease
YES
ASA
(aortic, peripheral)
NO
No Antithrombotic
* We suggest that a NOAC be used in preference to warfarin for non-valvular AF.
Prevention of Stroke in Patients with Chronic Kidney Disease (CKD)
Recommendations
• We recommend that patients with AF who are receiving OAC should have their renal function assessed at least annually
by measuring serum creatinine and calculating CrCl and should be regularly considered for the need for alteration of
OAC drug and/or dose changes based on CrCl (Strong Recommendation, Moderate Quality Evidence).
For antithrombotic therapy of CKD patients, therapy should relate to CrCl as follows:
• CrCl >30 mL/min: We recommend that such patients receive antithrombotic therapy according to their risk as
determined by the “CCS algorithm” as detailed in recommendations for patients with normal renal function (Strong
Recommendation, High Quality Evidence).
• CrCl 15-30 mL/min and not on dialysis: We suggest that such patients receive antithrombotic therapy according to
their risk as determined by the “CCS algorithm” as for patients with normal renal function. The preferred agent for these
patients is warfarin (Conditional Recommendation, Low Quality Evidence).
• CrCl <15mL/min (on dialysis): We suggest that such patients not routinely receive either OAC or ASA for stroke
prevention in AF (Conditional Recommendation, Low Quality Evidence).
Prevention of Stroke in Patients with Chronic Kidney Disease (CKD) – Therapeutic
Choices
Therapeutic Choices in Patients with Chronic Kidney Disease and Stroke Risk Factors (CHADS2 ≥ 1)
GFR
Warfarin
Dabigatran
Rivaroxaban
Apixaban
GFR ≥ 60 mL/min
Dose adjusted for
INR 2.0-3.0
150 mg bid or
110 mg bid
20 mg daily
5 mg bid†
GFR 50-59
mL/min
Dose adjusted for
INR 2.0-3.0
150 mg bid or
110 mg bid
20 mg daily
5 mg bid†
GFR 30-49
mL/min
Dose adjusted for
INR 2.0-3.0
150 mg bid or
110 mg bid
15 mg daily
GFR 15-29
mL/min (not on
dialysis)
No RCT Data‡
No RCT Data§
No RCT Data¶
GFR < 15 mL/min
(on dialysis)
No RCT Data‡
No RCT Data¶
No RCT Data¶
5 mg bid
Consider 2.5 mg
bid†
5 mg bid (for GFR
> 25 mL/min only)
Consider 2.5 mg
bid†
No RCT Data
† Consider Apixaban 2.5
2 mg po bid if age ≥ 80 and body weight ≤ 60 kg.
‡ Dose adjusted warfarin has been used, but observational data regarding safety and efficacy is conflicting.
§ Modelling studies suggest that dabigatran 75 mg bid might be safe for patients with GFR 15-29 mL/min, but this has not been validated in a prospective cohort.
¶ No published studies support a dose for this level of renal function; product monographs suggest the drug is contraindicated for this level of renal function.
Antithrombotic Management of AF/AFL in CAD - Recommendations
• We suggest that patients with AF or AFL who have experienced ACS or who have undergone PCI, should receive
antithrombotic therapy selected based on a balanced assessment of their risks of stroke, of recurrent coronary artery
events and of hemorrhage associated with the use of combinations of antithrombotic therapies, which in patients at
higher risk of stroke may include aspirin plus clopidogrel plus OAC. (Conditional Recommendation, Low Quality
Evidence).
Stable CAD
Recent ACS
PCI
Choose antithrombotic
based on stroke risk
Choose antithrombotic
based on balance
of risks and benefits
Choose antithrombotic
based on balance
of risks and benefits
CHADS2 = 0
ASA
CHADS2 ≥ 1
CHADS2 ≤ 1
CHADS2 ≥ 2
CHADS2 ≤ 1
CHADS2 ≥ 2
OAC
ASA +
clopidogrel
ASA +
clopidogrel +
OAC
ASA +
clopidogrel
ASA +
clopidogrel +
OAC
Management of AF in the ED
Recommendations
• For patients with no high-risk factors of stroke with cardioversion (recent stroke or TIA within 6 months; rheumatic heart
disease; mechanical valve) and clear AF onset within 48 hours or therapeutic OAC therapy for ≥ 3 weeks, we
recommend that they may undergo cardioversion in the ED without immediate initiation of anticoagulation. After
attempted or successful cardioversion, antithrombotic therapy should be initiated as per the CCS algorithm (Strong
Recommendation, Moderate-Quality Evidence)
• For patients at high risk of stroke with cardioversion (not receiving therapeutic OAC therapy for ≥ 3 weeks with any of
the following: AF episode duration not clearly < 48 hours, stroke or TIA within 6 months, rheumatic heart disease,
mechanical valve), we recommend optimized rate control and therapeutic OAC for 3 weeks before and at least 4 weeks
after cardioversion. (Strong Recommendation, Moderate-Quality Evidence)
• We suggest that patients at high risk of stroke* during or after cardioversion may undergo cardioversion guided by
transesophageal echocardiography. Anticoagulation should be initiated immediately using intravenous heparin or low
molecular weight heparin prior to cardioversion. OAC therapy should then be initiated and maintained for at least 4
weeks post cardioversion. Patients should also be referred for early expert follow-up to review ongoing antithrombotic
therapy, based upon stroke risk factors. (Conditional Recommendation, Moderate Quality Evidence)
• We suggest that after conversion to sinus rhythm has been achieved, whether antiarrhythmic drug therapy is indicated
should be based on the estimated probability of recurrence and the symptoms during AF. Long-term therapy will need to
be determined by an appropriate outpatient consultation (Conditional Recommendation, Low Quality Evidence).
Management of AF in the ED – Recommendations
YES
Is Patient Stable?
NO
Immediate Risk
for Stroke?
Low Risk
1. Clear onset <48 hours,
or
2. Therapeutic OAC ≥ 3
wks
No therapeutic High
OACRisk**
≥ 3 weeks and one
of:
1. Onset >48 hours or unknown, or
2. Stroke/TIA <6 months, or
3. Mechanical or rheumatic valve
disease.
Unstable – AF causing:
1. Hypotension, or
2. Cardiac ischemia,
or
3. Pulmonary edema
Rate-control
Pharmacological or
electrical CV at 150-200 J
Trans-esophageal
echocardiography (TEE)
guided CV
Consider urgent electrical
CV if rate control not
effective
Antithrombotic therapy
Antithrombotic therapy
Antithrombotic therapy
-Initiate (or continue) OAC upon
- Continue OAC for ≥4 weeks
discharge from ED if age ≥ 65 or
after CV
CHADS2 ≥ 1
- Early follow-up to review
-Otherwise, initiate ASA if CAD/Vascular long-term OAC
Disease
Emergency
Management
of AF
-Early follow-up
to review
long-term OAC
- Initiate immediate OAC* in ED
and continue for ≥4 weeks
- Early follow-up to review
long-term OAC
(Immediate anticoagulation in ED
before CV not required)
Antithrombotic therapy
Therapeutic OAC for
3 weeks before
outpatient CV
- Initiate immediate OAC* in ED and
continue for ≥4 weeks if ‘high risk’ **
Early follow-up to review
long-term OAC
* Immediate OAC = a dose of OAC should be given just prior to cardioversion – either a novel direct oral anticoagulant (NOAC)
or a dose of heparin or low molecular weight heparin with bridging to warfarin if a NOAC is contraindicated.
Management of AF in the ED – Recommendations
Recommended IV Drugs for Rate Control
Drug
Dose
Risks
Diltiazem*
0.25 mg/kg IV bolus over 10 min; repeat at 0.35
mg/kg IV
Hypotension, bradycardia
Metoprolol
2.5-5mg IV bolus over 2 min; up to 3 doses
Hypotension, bradycardia
Verapamil*
0.075-0.15mg/kg over 2 min
Hypotension, bradycardia
Digoxin
0.25 mg IV each 2 h; up to 1.5mg
Bradycardia, Digitalis toxicity
*Calcium-channel blockers should not be used in patients with heart failure or left ventricular dysfunction
Recommended Drugs for Pharmacological Conversion
Drug
Class 1 A
Procainamide
Class IC*
Propafenone
Flecainide
Class III
Ibutilide
Dose
Efficacy
15-17 mg/kg IV over 60 min
++
5% hypotension
+++
+++
++
Hypotension,
1:1 flutter,
bradycardia
2-3% Torsades
de pointes
450-600 mg PO
300-400 mg PO
1-2 mg IV over 10-20 min
Pre-treat with MgSO4 1-2 gm IV
*Class IC drugs should be used in combination with AV nodal blocking agents (beta-blockers or calcium-channel inhibitors).
Class IC agents should also be avoided in patients with structural heart disease.
Risks
Peri-Procedure / Antithrombotic Management
Recommendations
• We recommend that in a patient with AF or atrial flutter, a decision to interrupt antithrombotic therapy for an invasive
procedure must balance the risks of a thromboembolic event (as indicated by a higher CHADS2 score, mechanical heart
valve, or rheumatic heart disease) with those of a bleeding event (as indicated by a higher HASBLED score and
procedures with higher bleeding risks) (Strong Recommendation, Low Quality Evidence).
• We suggest that interruption of antithrombotic therapy in a patient with AF or AFL is not necessary for most procedures
with a very low risk of bleeding and many procedures with a low risk of bleeding including cardiac device implantation
(pacemaker or implantable defibrillator)(see Table) (Conditional Recommendation, Low Quality Evidence, High Quality
Evidence for cardiac device implantation).
• We recommend that interruption of antithrombotic therapy in a patient with AF or AFL will be necessary for most
procedures with an intermediate or high risk of major bleeding (see Table) (Strong Recommendation, Low Quality
Evidence).
Bleeding Risks for Various Invasive / Surgical Procedures
High
Risk
Intermediate
Risk
Low
Risk
•neurosurgery (intracranial or
spinal surgery)
•cardiac surgery (coronary artery
bypass or heart valve
replacement)
•major vascular surgery
(abdominal aortic aneurysm
repair, aortofemoral bypass)
•major urologic surgery
(prostatectomy, bladder tumour
resection)
•major lower limb orthopedic
surgery (hip/knee joint
replacement surgery)
•lung resection surgery
•intestinal anastomosis surgery
•selected invasive procedures
(kidney biopsy, prostate biopsy,
cervical cone biopsy,
pericardiocentesis, colonic
polypectomy or biopsies)
•other
intraabdominal
surgery
•other
intrathoracic
surgery
•other orthopedic
surgery
•other vascular
surgery
•laparoscopic
cholecystectomy
•laparoscopic inguinal hernia
repair
•dental procedures
•dermatologic procedures
•ophthalmologic procedures*
•coronary angiography
•gastroscopy or colonoscopy
•selected invasive procedures
(bone marrow aspirate and
biopsy, lymph node biopsy,
thoracentesis, paracentesis,
arthrocentesis)
•cardiac device implantation
surgery (pacemaker or
implantable defibrillator)**
* Selected ophthalmic procedures may be high risk such as those with retrobulbar block
**Based on results from BRUISE CONTROL trial (Birnie et al, N Engl J Med 2013; 368:2084-2093)
Very Low
Risk
•dental
extractions (1
or 2 teeth) or
teeth cleaning
•skin biopsy or
skin cancer
removal
•cataract
removal
Pre-Procedure / Antithrombotic Management
Recommendations
•When a decision to interrupt aspirin or clopidogrel therapy for an invasive procedure has been made for a patient with AF
or
AFL,
we suggest that the interruption begin 5-7 days prior to the day of the procedure excepting those procedures with a very
high risk of bleeding when we suggest that the interruption begin 7-10 days prior to the procedure (Conditional
Recommendation, Low Quality Evidence).
•When a decision to interrupt warfarin therapy for an invasive procedure has been made for a patient with AF or AFL, we
suggest that the interruption begin 5 days prior to the procedure and that a procedure with a low bleeding risk may
proceed when the INR is <1.5 and a procedure with an intermediate or high bleeding risk may proceed when the INR is
<1.2 (Conditional Recommendation, Low Quality Evidence).
•When a decision to interrupt warfarin therapy for an invasive procedure has been made for a patient with AF or AFL, we
• We recommend that when LMWH or UFH bridging is used for an invasive procedure such therapy be started prior to the
suggest that bridging therapy with LMWH or UFH be instituted when the INR is below that patient’s therapeutic INR
procedure when the INR is less than 2.0 and be stopped 24 hours prior to the procedure for LMWH and 4-6 hours prior
target in a patient at high risk of thromboembolic events (CHADS2 ≥3, mechanical heart valve, stroke or TIA within three
to the procedure for UFH (Strong recommendation, Low Quality Evidence)
months, rheumatic heart disease) (Conditional Recommendation, Low Quality Evidence).
• When a decision to interrupt apixaban or rivaroxaban therapy for an invasive procedure has been made for a patient
with AF or AFL, we suggest that the interruption begin 1-2 days prior to the day of a procedure with a low risk of major
bleeding and 2-3 days prior to the day of a procedure with an intermediate or high risk of major bleeding (Conditional
Recommendation, Low Quality Evidence).
• When a decision to interrupt dabigatran therapy for an invasive procedure has been made for a patient with AF or AFL,
we suggest that the interruption begin 1-2 days prior to the day of a procedure with a low risk of major bleeding and 2-3
days prior to the day of a procedure with an intermediate or high risk of major bleeding provided that the CrCl is ≥80
mL/min (Conditional Recommendation, Low Quality Evidence). The longer portion of these ranges should be used in
patients with CrCl 50-80 mL/min, an additional day should be added for patients with CrCl 30-50 mL/min. In case the
patient’s CrCl is found to be <30 mL/min, one more day of dabigatran withdrawal should be added (Conditional
Recommendation, Low Quality Evidence).
Post-Procedure / Antithrombotic Management
Recommendations
• When LMWH or UFH bridging is used for an invasive procedure, we suggest that such therapy be restarted after the
procedure when hemostasis is established (usually 24 hours for a procedure with a low risk of bleeding and 48-72
hours for a procedure with an intermediate or high risk of bleeding) in prophylactic dosages for the first 24 to 72 hours
and then increased to therapeutic dosages. Bridging is then continued until an OAC is therapeutic (Conditional
Recommendation, Low Quality Evidence).
• When warfarin, ASA, or clopidogrel therapy has been interrupted for an invasive procedure, we suggest that such
therapy be restarted after the procedure when hemostasis is established (usually 24-48 hours for a procedure with a
low risk of bleeding and 48-72 hours for a procedure with an intermediate or high risk of bleeding) (Conditional
Recommendation, Low Quality Evidence).
• When apixaban, dabigatran, or rivaroxaban therapy has been withdrawn for an invasive procedure, we suggest that
such therapy be restarted after the procedure one day after hemostasis is established (usually 48 hours for a
procedure with a low risk of bleeding and 72 hours for a procedure with an intermediate or high risk of bleeding)
(Conditional Recommendation, Low Quality Evidence).
Prevention and Treatment of AF following Cardiac Surgery
Assess AF Risk Factors
Low Risk
High Risk
On Beta-Blocker?
On Beta-Blocker?
No
Yes
No
Yes
Beta-Blocker
Contraindicated?
Continue BB
Beta-Blocker
Contraindicated?
Sotalol or Amiodarone or
BB plus IV Mg or Atrial
Pacing
No
Yes
No
Yes
Beta-Blocker
Amiodarone
Contraindicated?
Sotalol or Amiodarone or
BB and IV Mg or Atrial Pacing
Amiodarone
Contraindicated?
No
Yes
No
Yes
Amiodarone
IV Magnesium or
Biatrial Pacing
Amiodarone with or without
IV Mg or Atrial Pacing
IV Magnesium or
Biatrial Pacing
Prophylactic Therapies for the Prevention of Post-Operative Atrial
Tachyarrhythmias
Therapy
Dosage*
Cautions
Adverse Effects
Pre-op
beta
blocker
any in usual therapeutic dose (i.e. metoprolol 50 mg)
PO q12h or q8h for at least 2 pre-op days, day of surgery,
and at least 6 post-op days
reactive airways disease,
decompensated CHF
sinus bradycardia
AV block
hypotension
bronchospasm
Pre-op
amiodarone
10 mg/kg/day (rounded to nearest 100 mg) divided into two
daily PO dosages for 6 pre-op days, day of surgery, and 6
post-op days
30%-50% reduction in the
dosages of other drugs with
antiarrhythmic or sinus/AV
nodal effects and warfarin
will be required
sinus bradycardia
AV block
hypotension
torsade de pointes VT (rare)
pulmonary toxicity (rare)
Post-op
amiodarone
900 – 1200 mg IV over 24 hrs beginning within 6 hours of
surgery, then 400 mg PO tid each of the next 4 days
30%-50% reduction in the
dosages of other drugs with
antiarrhythmic or sinus/AV
nodal effects and warfarin will
be required
sinus bradycardia
AV block
hypotension
torsade de pointes VT (rare)
pulmonary toxicity (rare)
Magnesium
sulfate
1.5 gm IV over 4 hrs first pre-op day, immediately post-op,
and next 4 post-op days. Other trials have omitted the preop dosage
renal failure
hypotension (rare)
sedation (very rare)
respiratory depression
(very rare)
* Dosages used in the randomized studies vary widely and the optimal dosages for this indication have not been established.
The dosages provided are those used in the largest positive trial of that therapy and are referenced to that study.