Online only section
In this online section of our current opinion paper, we discuss differences in the three
guideline sets (1-9) in more detail split by the different domains of atrial fibrillation
management (10), i.e.
Diagnosis of atrial fibrillation
Antithrombotic therapy
Rate control, and
Rhythm control.
Definition and diagnosis of AF. All guidelines define AF by its pathophysiology
of fibrillating electrical activation in the atria, and all require an electrocardiogram
that documents the arrhythmia to confirm the diagnosis. All three sets of guidelines
recommend an initial work-up that encompasses a 12-lead ECG and an
echocardiogram to search for accompanying heart disease. In Europe, the
echocardiogram is recommended only in patients who show signs for heart disease
(Table 1), while the Canadian guidelines routinely recommend an echocardiogram for
all patients with AF, partly reflecting the usual local management pathway of AF
patients in Europe and Canada. Based on the increased stroke risk in patients with
“silent”, undetected AF (11), the focused update of the European guidelines
recommends an active opportunistic screening for AF in all persons over 65 years of
age, similar to the AHA guidelines for stroke prevention (12). This recommendation is
not given by CCS or ACCF/AHA/HRS.
Antithrombotic therapy.
Stroke risk stratification and decision for anticoagulation. Since 2001, the
European and US AF guidelines recommend oral anticoagulation for stroke
prevention in AF patients at risk for stroke (13, 14). This recommendation is based on
a large body of evidence from trials comparing vitamin K antagonists with aspirin, a
combination of antiplatelet agents, and placebo for stroke prevention in AF (15), and
was recently reinforced by a comparison of the new oral anticoagulant (NOAC)
apixaban and aspirin (16). All guideline sets recommend oral anticoagulation for
patients at high risk for stroke as identified by the “CHADS2 risk factors” comprising
the clinical risk factors age of 75 years or older, survived stroke or transient ischemic
attack (counted double), congestive heart failure, hypertension, and diabetes (Tables
2, 2a). All guidelines agree that patients with two of more of these clinical risk factors
should receive oral anticoagulation.
Approximately one third of AF patients are not considered at high risk of stroke by
the original CHADS2 classification (17, 18). In these patients, there has been a shift
towards recommending oral anticoagulation for most patients, especially when other
risk factors are present. This is reflected in the 2010 ESC guidelines and in their
update in 2012, and in the CCS guidelines. By nature, the focussed update of the
ACCF/AHA/HRS in 2011 only commented on new medications, and did not cover
changing indications for anticoagulant therapy in detail.
The best evaluated “additional risk factors” are age of 65 – 74 years, presence of
vascular disease, and female gender (19, 20). The ESC recommends the use of oral
anticoagulation when these factors are present (unless “female gender” is the only
risk factor), and formalizes this assessment into the so-called CHA2DS2VASc score
(21). The 2006 ACC/AHA/ESC guidelines recommend a similar assessment, albeit
not formalised in a score, but rather listed as “less validated risk factors.” Unlike the
ACCF/AHA/HRS guidelines, the CCS recommends oral anticoagulation in preference
to aspirin for stroke prevention in patients with only one of the CHADS2 risk factors,
in line with the focussed update of the ESC guidelines. The CCS reflects the
differential relevance of the additional or “VASc” risk factors by recommending a
graded use of anticoagulation depending on the individual factors: When age is > 65
years, or both vascular disease plus female sex are present, oral anticoagulation
should be used. Aspirin is suggested for patients with a single risk factor (vascular
disease or female sex). The use of these additional “VASc” risk factors (CCS
terminology) and the CHA2DS2VASc score (ESC wording) has recently been
validated in different cohorts (20, 22). The ESC update states that female sex on its
own should not be considered a risk factor, supported by a recent large cohort
analysis from Denmark (19), and does not recommend any anticoagulant therapy in
such patients, while CCS and ACCF/AHA/HRS suggest that aspirin be considered.
The ESC also introduces an assessment of bleeding risk on anticoagulant therapy,
and suggests the treatment of risk factors for bleeding, adaptation of the choice of
anticoagulant, and/or intensification of clinical monitoring of patients at increased
bleeding risk (21). Figure 1 depicts the similarities and differences between the three
guideline sets in the decision to recommend oral anticoagulant therapy.
Overall, the strong evidence for oral anticoagulation in high-risk patients is reflected
in all three sets of guidelines. There are differences in the recommended
antithrombotic therapy in patients at low to moderate risk for stroke, reflecting the
lack of controlled trials specifically conducted in such patients, their relatively low
absolute stroke risk, and the resulting large number of patients needed to treat for the
prevention of each event. These differences in recommendations illustrate that there
are evidence gaps at the “lower end” of stroke risk, e.g. in patients with only one of
the CHADS2 or VASc risk factors.
Use of new oral anticoagulants (NOAC). Between 2009 and 2011, the final
results of four large randomised trials comparing the oral thrombin inhibitor
dabigatran (23) and the factor Xa inhibitors rivaroxaban (24) and apixaban (16, 25)
to warfarin (23-25) or aspirin (16) have been published. These substances are
referred to as “new oral anticoagulants” in the ESC and CCS guidelines update. These
medications offer a clinical choice of different oral anticoagulants for stroke
prevention in AF. Based on the trial results without much additional “real-world”
information, all three guideline writing groups recommend the new oral
anticoagulants alongside vitamin K antagonists for stroke prevention in AF.
The 2010 ESC guidelines only covered dabigatran in a long footnote, reflecting that
trial data were available, but that the drug was not approved for clinical use in Europe
at that time. The updated ACCF/AHA/HRS Guidelines, reacting quickly to FDA
approval of dabigatran after the publication of the RELY trial (23), included a
recommendation for dabigatran as an alternative to warfarin for patients with AF.
Choosing an oral anticoagulant for stroke prevention in AF. While the new
anticoagulants are recommended in all three guidelines, the ESC and CCS express a
preference for anticoagulation using one of the NOACs rather than a vitamin K
antagonist (Class IIa recommendation in the ESC guideline, comparable grade
(“suggest”) in the CCS guideline), based on their better safety profile in the large trials
and the potentially higher efficacy. The ACCF/AHA/HRS update recommends
NOACs (dabigatran) as an alternative to vitamin K antagonists. The focussed update
of the ESC guidelines (21) and the update of the CCS guidelines (6), both published in
2012, recommend one of three NOACs (apixaban [pending approval], dabigatran,
rivaroxaban) as a preferred alternative to warfarin for oral anticoagulation in AF,
based on the superiority or at least equivalence to warfarin in stroke prevention, the
reduced rate of intracranial hemorrhage, and the convenience of the new agents.
Despite the much-debated perceived differences in their effectiveness – based
entirely on indirect comparisons across the different trials - none of the guidelines
chose to put forward recommendations to prefer one of the new oral anticoagulants
over another. The recommended doses of the NOACs rather reflect their regionally
approved dosing, which varies. This results in marked differences in the
recommended dose in some of the NOACs, and also limits the use of specific NOACs
in selected patient groups (see below).
Therapy of AF patients with concomitant unstable coronary artery
disease. All three guideline sets recommend the addition of antiplatelet therapy to
oral anticoagulation in AF patients with a recent myocardial infarction or unstable
coronary artery disease, and in those receiving a coronary stent (26, 27). The ESC and
CCS issued separate sets of recommendations for patients with AF undergoing stent
implantation. These recommendations acknowledge the higher bleeding risk in
patients receiving a combination of aspirin and oral anticoagulation compared to
patients on oral anticoagulation alone, but nonetheless recognise the need for
combination therapy in patients at risk for stroke in AF and at risk for coronary
thrombosis. Both guidelines recommend so-called “triple therapy” of aspirin,
clopidogrel and an oral anticoagulant for a short time after a myocardial infarction or
placement of a stent, and the use of bare metal stents to reduce the period needed for
such “triple therapy.” The ESC specifically recommends radial access for AF patients
in need for vascular interventions.
Rate control
All three sets of guidelines integrate the insights gained from the RACE II trial into
their rate control recommendations (28). At first sight, the recommendations appear
to be somewhat different, but on further analysis, they are fairly similar. The
ACCF/AHA/HRS guideline states that treatment to achieve strict rate control is not
beneficial (Class III recommendation), provided that the patient has stable
ventricular function (left ventricular ejection fraction >0.40) and no or acceptable
symptoms, and recognizes that uncontrolled tachycardia may cause a reversible
decline in ventricular performance. The European guideline advocates an initial
strategy of lenient rate control (Class IIa recommendation, rate < 110 bpm), with a
switch to a strict rate control strategy if symptoms persist or tachycardiomyopathy
occurs. The CCS also recommends an initial lenient rate control approach, but
recognizes that only 22% of patients in the RACE II study had resting heart rates
between 100-110 bpm. As such, a more careful deviation from the prior, stricter rate
control recommendations was chosen and a slightly lower target heart rate < 100
bpm is recommended in symptomatic patients.
After the publication of the PALLAS trial (29) which showed detrimental effects of
dronedarone in patients with permanent AF, both ESC and CCS included a
recommendation not to use dronedarone in patients with permanent AF, i.e. as a rate
controlling agent. There were no other major changes in rate control management
recommended in the three sets of guidelines, and the recommendations for rate
control are very comparable (Table 3).
Rhythm control
After six controlled trials of “rhythm versus rate control” in AF, rhythm control
therapy is currently recommended only for patients whose symptoms are not well
controlled by rate control alone. The Canadian and European guidelines state
explicitly that the primary purpose of antiarrhythmic therapy is to reduce
arrhythmia-related symptoms. This indication for any rhythm control intervention is
also implicit in the “old” 2006 ACC/AHA/ESC recommendations, and has not been
changed by the focussed update of ACCF/AHA/HRS. The ESC in 2010 and the CCS in
2011 chose to further emphasise that the indication for adding rhythm control
therapy on top of rate control therapy should be based on symptoms by introducing
dedicated symptom scores: The EHRA score (Europe) or the largely overlapping CCSSAF score (Canada). All three guidelines discuss the choice and purpose of
antiarrhythmic drug therapy and the place of catheter ablation in the management of
recurrent forms of AF. In 2010, the European guidelines fell in with previous
proposals and included an additional time-based category of longstanding-persistent
AF (1). This term re-designates an arrhythmia that had lasted more than one year
when a decision has been made that it is appropriate for an attempt at rhythm
control. Other categories of AF remained unchanged. This is not reflected in the CCS
or ACCF/AHA/HRS guidelines.
Both the US update and the ESC guideline adapted the recommendations for specific
rhythm control interventions based on new data:
Dronedarone was introduced in the ESC guidelines and in the CCS guidelines as an
antiarrhythmic drug with a low proarrhythmic potential (30-33). The US guidelines
also endorsed the use of dronedarone in patients with paroxysmal or persistent AF,
but recommended its use for the prevention of cardiovascular hospitalizations.
Similar to the US update, dronedarone is recommended to prevent cardiovascular
hospitalisations in the ESC guidelines (Class IIa, LoE B). Although not specifically
mentioned as an antiarrhythmic drug in the recommendations, the intended use of
dronedarone as an antiarrhythmic agent is evident from the rhythm control flow
chart in the US update (Figure 2). There are some differences in the patient
populations deemed suitable for dronedarone therapy. In the European guidelines,
dronedarone is recommended for recurrent AF in patients without heart disease, in
those with left ventricular hypertrophy, and in patients with coronary artery disease.
This is largely in line with the 2011 ACCF/AHA/HRS focussed update with the
exception of patients with left ventricular hypertrophy, where the use of dronedarone
is not recommended in the ACCF/AHA/HRS update (Figure 2). All guidelines
already warned against the use of dronedarone in severe (NYHA class IV, or recently
decompensated) heart failure in 2010, based on the outcomes of the ANDROMEDA
trial (34). The European Guidelines also discourage the use of dronedarone in
patients with NYHA III heart failure (Figure 2B), whereas the US guidelines state a
caution in the use of dronedarone “in the presence on a left ventricular ejection
fraction less than 35%,” reflecting one of the inclusion criteria of the ANDROMEDA
trial (34). The updates of the CCS and ESC guidelines integrate the new information
from the PALLAS trial demonstrating deleterious effects of dronedarone therapy in
patients with permanent AF (29). Based on this information, the ESC focussed
updates recommends against the use of dronedarone in permanent AF (class III
recommendation), and discourages the use of dronedarone in patients with heart
failure unless there is no alternative. The CCS limits the use of dronedarone to
patients without a history of heart failure and with preserved systolic heart function
(LVEF > 40%). This reliance on echocardiography to define systolic heart failure is a
consistent pattern in the CCS guidelines, while the other two sets of guidelines use
the same clinical definitions, often without echocardiographic assessment, as were
employed in the clinical trials to define heart failure. In addition, the CCS suggested
that dronedarone be used with caution in patients taking digoxin, based on a
potential interaction between digitalis glycosides, dronedarone, and adverse
outcomes in the PALLAS trial. In summary, dronedarone remains a recommended
antiarrhythmic agent in patients without heart disease, including patients with left
ventricular hypertrophy and in patients with coronary artery disease, while its use is
discouraged in most patients with heart failure with variable definitions of unsuitable
patients, reflecting different regulatory situations and the uncertainty surrounding
dronedarone’s safety in patients with light and moderate heart failure.
Vernakalant has recently been approved for pharmacological cardioversion of AF in
Europe. The intravenous formulation of vernakalant converts recent-onset AF (3537) and is recommended as an alternative to other agents for pharmacologic
cardioversion in patients with little or no underlying structural heart disease, and in
some patients with structural heart disease (hypertensive heart disease and chronic
ischaemic heart disease) as an alternative to amiodarone. Since vernakalant is not
available in the USA or Canada, it is not considered in the US or Canadian guidelines.
Duration of antiarrhythmic drug therapy after cardioversion. The focussed
update of the ESC guidelines also recommends considering short-term
antiarrhythmic drug therapy after cardioversion of AF as a safer, though slightly
inferior, alternative to long-term therapy based on the results of the Flec-SL trial
(38). This information was not available at the time of the updates of the CCS and
ACCF/AHA/HRS guidelines, and was therefore not considered.
The increasing evidence-base for the prevention of recurrent AF after catheter
ablation (predominantly pulmonary vein isolation) is reflected in all three guidelines
(39-43). The Canadian task force recommended catheter ablation as a secondary
rhythm control therapy after failure of antiarrhythmic drug therapy (Class IIa). In
2011, the ACCF/AHA/HRS guidelines issued a class I recommendation for catheter
ablation to improve symptoms related to AF in patients with paroxysmal AF and
minimal or no heart disease, provided that the patient was refractory to
antiarrhythmic drugs and the ablation was carried out by an expert in an experienced
centre. This approach was also reflected in a recent European/American consensus
document (44) and in the 2012 focussed update of the ESC guidelines (21). Both the
European and the Canadian guideline writers introduced the concept of proceeding
directly to ablation (Class IIa by the ESC focussed update, IIb in Canada and in the
ESC 2010 document) as an alternative to antiarrhythmic drug therapy in patients
with paroxysmal AF and little or no heart disease, based on accumulating recent
evidence.
Disclosures. All authors were involved in the writing of the most recent versions of
the guidelines on AF management issued by ESC (JC, PK) and ACCF/AHA/HRS (AC,
SW) and CCS (ACS,AMG). All authors have received honoraria for advising or
speaking for companies involved in the development of drugs and devices relevant to
the management of AF. AG has not received honoraria in the past 17 months, since
taking on her current role as president-elect and president of HRS. Details of our
disclosures are published in the relevant AF management guidelines or professional
society web pages.
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Online Tables:
Online Table 1: Recommendations for diagnosis and initial management
ESC/EHRA/EACTS
ACCF/AHA/HRS
CCS
ECG recording of AF
mandatory for diagnosis
No explicit
recommendations, text
consistent with ESC
recommendations.
EHRA / CCS-SAF score
not mentioned (was not
published in 2006).
ECG recording of AF
mandatory for diagnosis
EHRA symptoms score (45,
46)*
Prolonged ECG monitoring
to detect AF
CCS-SAF symptoms score
(45, 46)
Prolonged ECG
monitoring to detect AF
Holter ECG for safety (rate
control)
Holter ECG for safety (rate
control)
Referral to a cardiologist
when symptomatic or with
complications
Referral to a cardiologist
when symptomatic or with
complications
Structured, specialistprepared follow-up
Underlying, reversible
causes esp. hypertension
and sleep apnea should be
sought
* The EHRA score and the CCS-SAF symptoms score largely overlap.
Online Table 2A: Factors included in stroke risk estimation
ESC
ACCF/AHA/HRS
CCS
Congestive Heart Failure
Yes
yes
Yes
LVEF ≤ 35%
not specifically
stated, implicit in
CHF
yes
Yes
Hypertension
Yes
yes
Yes
Age ≥ 75
yes, strong
yes, strong
Yes
Age 65-74
Yes
less validated
Yes
Diabetes mellitus
Yes
yes
Yes
Prior Stroke
yes, strong
yes, strong
Yes
Vascular Disease
Yes
less validated
Yes
Sex Category (female)
Yes
less validated
Yes
Hypertrophic
cardiomyopathy
yes, strong
implicit
implicit
Mitral valve disease
yes, strong
yes, strong
yes
Thyrotoxicosis
Implicit
less validated
implicit
Online Table 2B: Recommended antithrombotic therapy based on stroke risk
ESC
ACCF/AHA/HRS
CCS
1 high risk factor
OAC
OAC
OAC
(prior stroke or age ≥ 75
years)
NOAC preferred
over VKA
NOAC or VKA
NOAC preferred
over VKA
2 or more risk factors
OAC
OAC
OAC
NOAC preferred
over VKA
NOAC or VKA
NOAC preferred
over VKA
OAC
OAC
OAC
NOAC preferred
over VKA
NOAC or VKA
NOAC preferred
over VKA
OAC or ASA, OAC
preferred
OAC or ASA
If age > 65, OAC.
If female or
vascular disease,
ASA
ASA
Nothing
2 risk factors*
1 risk factor
NOAC preferred
over VKA
No risk factors
Nothing
OAC oral anticoagulation; VKA vitamin K antagonists; NOAC new oral
anticoagulants, ASA aspirin. High risk factors: survived stroke or transient ischemic
attack, age 75 years or above. Other risk factors: congestive heart failure, left
ventricular dysfunction, hypertension, diabetes mellitus, female sex (ESC: unless
female sex is the sole risk factor), age 65-74 years, vascular disease / coronary artery
disease
*Table 13 in the US guidelines (9) is not explicit as to whether the less validated risk
factors (female sex, age 65-74, or coronary artery disease) are to be counted within
the “moderate” risk factors, but the text clearly classifies them as moderate risk
factors.
Online Table 2C. Detailed recommendations for antithrombotic therapy
based on stroke risk.
Abbreviations as follows: AF atrial fibrillation, ASA acetyl salicylic acid, DES drugeluting stent. INR international normalized ratio, OAC oral anticoagulant therapy.
PCI percutaneous coronary intervention, VKA vitamin K antagonist therapy.
*apixaban is recommended after approval by EMA/Health Canada.
ESC
ACCF/AHA/HRS
CCS
Antithrombotic therapy for all patients, except lone AF or patients with
contraindications (IA)
Selection of antithrombotic agents should be based on absolute risk for stroke and
bleeding, and relative risk and benefit for a given patient (IA)
In patients at high risk for
stroke, oral anticoagulation
with either a VKA (INR 23) or one of the NOACs
(apixaban*, dabigatran,
rivaroxaban) are
recommended (IA).
In patients at high risk for
stroke, VKA (INR2-3) are
recommended (IA), INR
>2.5 in patients with
mechanical valves (IB)
A NOAC should be
considered rather than
VKA therapy (IIa A).
In patients at high risk
for stroke (CHADS≥2),
OAC are recommended
(Strong, IA).
Dabigatran,
rivaroxaban, apixaban*
suggested over VKA
(INR 2-3) when OAC is
recommended
(Conditional IIa)
In patients with one
“major” (age >75, prior
stroke/TIA) or more than 1
“clinically relevant nonmajor” risk factor (age 6574 yrs, hypertension, heart
failure, impaired LV
function, diabetes mellitus,
vascular disease, female
sex), VKA is recommended
(IA)
VKA is recommended in
patients with more than one
moderate risk factor (age
>75 yrs, hypertension, heart
failure, impaired LV
function, diabetes mellitus,
IA)
OAC is recommended
for most with one
“major” risk factor
(CHADS2=1, Strong
(IA))
In patients with one
“clinically relevant nonmajor” risk factor (see prior
line for risk factors), VKA is
receommended based on
risk assessment and
individual therapy
suitability (IIaA)
In patients with one
moderate risk factor (see
prior line for risk factors),
ASA or VKA can be chosen
based on risk assessment
and individual therapy
suitability (IIaA)
Patients with no
“major” risk factors
(CHADS2=0) but age >
65, or both vascular
disease and female sex,
OAC is suggested
(Conditional, IIaC)
Patients with no
“major” risk factors
(CHADS2=0) but one of
vascular disease or
female sex, ASA is
suggested (Conditional,
IIaC)
In patients with one or more
of the less validated risk
factors age 65-74, female
gender, or coronary artery
disease, either aspirin or
VKA is recommended (IIaB)
Implicit (recommended in
section 3)
Antithrombotic therapy
decisions are independent of
the type of AF (IIaB)
Implicit
INR monitoring weekly
initially, then monthly (IA)
Interruption of OAC for a
short time (high stroke
risk: max 48 hrs) is
acceptable to perform
surgical procedures (IIaC).
Resumption of OAC on the
evening of surgery when
hemostasis is adequate
(IIaC)
Interruption of VKA therapy
is reasonable for up to 1 week
for vascular or surgical
procedures (IIaC)
Interruption of OAC for
a short time is based on
stroke risk and bleeding
risk (IIaC) With high
risk of stroke (mech
valve, recent TIA/stroke
CHADS2≥3) either
continue OAC (low
bleeding risk) or bridge
with LMWH.
With low or moderate
risk of stroke
(CHADS2≤2) and high
risk of bleeding,
interruption of OAC
suggested. If low risk of
bleeding, continue OAC
(Conditional, IIaC)
Re-evaluation of the need for anticoagulation at regular intervals (IIaC)
Atrial flutter should be treated like AF (IC)
No antithrombotic therapy
is a reasonable therapeutic
VKA is not recommended
in lone AF (<50 yrs without
No antithrombotic
therapy is a reasonable
strategy in patients at truly
“lone” AF (<65 yrs, no risk
factors, IIaC)
Patients receiving stents
while in need for OAC
should receive a bare metal
stent. After implantation,
combination therapy with
OAC, ASA, and clopidogrel
is recommended (IIaC,
partly IIbC)
heart disease or any stroke
risk factors, III)
therapeutic strategy in
patients at truly “lone”
AF (<65 yrs, no risk
factors, IIaC)
ASA 81 – 325 mg is an
alternative in low-risk
patients or those with
contraindications (IA)
ASA 81 – 325 mg is an
alternative in low-risk
patients (CHADS2≤1) or
those with
contraindications (IA)
Patients receiving stents
while in need for OAC
should receive a bare metal
stent. After implantation,
combination therapy with
OAC and clopidogrel is
recommended. (IIbC).
Patients receiving stents
while in need for OAC
should receive a bare
metal stent. After
implantation,
combination therapy with
OAC and clopidogrel is
recommended. ASA
(triple therapy) may be
needed for 1 month in
high stroke risk group
(CHADS2≥2) (IIbC)
Duration of combination
therapy
Duration of combination
therapy
bare metal stent 1 month
-limus DES 3 months
-taxel DES 6 months
- acute coronary syndromes
with or without PCI: 3-6
months
ESC recommends a longer
duration of dual
combination (up to 12
Duration of combination
therapy
bare metal stent 1 month
bare metal stent 1 month
-limus DES 3 months
-taxel DES 6 months
-limus DES 3 months
-taxel DES 6 months
acute coronary
syndromes without PCI:
If CHADS2≤1
ASA+clopidigrel up to 12
months. If CHADS2≥2
therapy as PCI.
months) of clopidogrel and
OAC.
Careful monitoring of
INR during combination
therapy
Careful monitoring of INR
during combination
therapy
Careful monitoring of INR
during combination
therapy
Patients suffering a stroke while on OAC should be
considered for higher INR therapy (3.0-3.5, IIb)
Patients suffering a
stroke while on OAC
should be considered for
novel OAC with superior
efficacy (Implicit)
Online Table 3: Recommendations for rate control therapy
ESC/EHRA/EACTS
ACCF/AHA/HRS
CCS
Implicit (section 2) assessment
by resting ECG in all patients,
and by heart rate response to
exercise in specific patients.
ECG measurement at rest
before and during rate
control therapy (IB)
ECG measurement
at rest or Holter
before and during
rate control therapy
(IB)
ß blockers or non-dihydropyridine calcium antagonists for acute rate control (ESC IA,
ACCF/AHA/HRS IB, CCS IB) and for chronic rate control (IB)
A combination of digoxin and ß blocker or nondihydropyridine calcium antagonist for
rate control, dose titration to avoid bradycardia (ESC: IB, ACCF/AHA/HRS, CCS:
IIaB)
When patients remain symptomatic, heart rate during exercise should be assessed
(ESC IC, CCS IB), and a stricter approach to rate control chosen (ESC; IIaB)
Digoxin p.o. can be used for resting heart rate control, especially in heart failure
patients and sedentary individuals (ESC: IIaC, ACCF/AHA/HRS IC, CCS IIaB)
Amiodarone can be used to control rate when other drugs fail (ESC: IIbC,
ACCF/AHA/HRS, CCS: IIaC)
AV nodal ablation when pharmacotherapy fails (ESC, ACCF/AHA/HRS: IIaB, CCS:
IB)
Rate control in patients with preexcitation
Rate control using
propafenone or amiodarone in
preexcitation patients (IC)
procainamide, disopyramide,
ibutilide, or amiodarone in
hemodynamically stable
patients with preexcitation
(IIbB)
DC cardioversion,
iv procainamide,
ibutilide for rapid
pre-excited AF (IC)
Rate control in patients with heart failure
Implicit, no specific
recommendation
* CCS focused update 2012
Digitalis or amiodarone for
acute rate control in heart
failure patients IB
Digoxin reserved
for rate control in
sedentary or LV
dysfunction (IIaB)