Management of Atrial Fibrillation: 2014 Guidelines
Mark S. Link, MD reviewing January CT et al. Circulation 2014 Mar 28.
New guidelines for AF should increase the number of patients who receive anticoagulants and who are advised to undergo catheter ablation.

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

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

Background and Objective

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

Key Points

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


Table 1: Dose Selection of Oral Anticoagulant Options for Patient with Nonvalvular AF and CKD (Based on Prescribing Information for the United States)* Reprinted with permission from January CT et al. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation. Circulation 2014 Mar 28; [e-pub ahead of print].
Patients with nonvalvular AF and a CHA2DS2-VASc score 2 should receive oral anticoagulation with warfarin, dabigatran, rivaroxaban, or apixaban (Class I). Modified dosages of some of the newer anticoagulants can be considered in patients with nonend-stage chronic kidney disease, depending on the severity of renal dysfunction (Class IIb; Table 1).

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

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

Dofetilide

Dronedarone

Flecainide

Propafenone

Sotalol

Amiodarone


Table 2: Recommended Drug Doses for Pharmacological Cardioversion of AF Recommended given in conjunction with a beta blocker or nondihydropyridine calcium channel antagonist administered 30 minutes before administering the Vaughan Williams Class IC agent Reprinted with permission from January CT et al. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation. Circulation 2014 Mar 28; [e-pub ahead of print].
Drug selection should depend on underlying heart disease and comorbidities (Table 2); however, owing to its potential toxicities, amiodarone should be used only when other agents have failed or are contraindicated and after thorough risk assessment (Class I).

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

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

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

What's Changed

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

Anticoagulation based on thrombotic risk, irrespective of AF pattern

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

Move from CHADS2 to CHA2DS2-VASc for risk assessment

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

Consideration of clopidogrel and an anticoagulant without aspirin after coronary reperfusion

Stronger recommendations for and cautions about AF catheter ablation

COMMENT

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

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

Editor Disclosures at Time of Publication
CITATION(S):

January CT et al. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: Executive summary: A report of the American College of Cardiology/American Heart Association Task Force on practice guidelines and the Heart Rhythm Society Circulation 2014 Mar 28; [e-pub ahead of print]. (http://dx.doi.org/10.1161/CIR.0000000000000040)
- See more at: http://www.jwatch.org/na34277/2014/05/19/management-atrial-fibrillation-2014-guidelines?query=etoc_jwcard#sthash.S9MtfPC8.dpuf