2014 AHA/ACC/HRS Guideline for the€Management of Patients With Atrial Fibrillation

35 Pages·2015·2.46 MB·English

JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY VOL. 64, NO. 21, 2014
ª2014 BY THE AMERICAN HEART ASSOCIATION, INC., ISSN 0735-1097/$36.00
THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION, http://dx.doi.org/10.1016/j.jacc.2014.03.021
AND THE HEART RHYTHM SOCIETY
PUBLISHED BY ELSEVIER INC.
CLINICAL PRACTICE GUIDELINE
2014 AHA/ACC/HRS Guideline for
the Management of Patients With
Atrial Fibrillation: Executive Summary
AReportoftheAmericanCollegeofCardiology/AmericanHeartAssociation
TaskForceonPracticeGuidelinesandtheHeartRhythmSociety
DevelopedinCollaborationWiththeSocietyofThoracicSurgeons
Writing CraigT.January,MD,PHD,FACC,Chair RalphL.Sacco,MD,FAHAy
Committee L.SamuelWann,MD,MACC,FAHA,ViceChair* WilliamG.Stevenson,MD,FACC,FAHA,FHRS*{
Members* PatrickJ.Tchou,MD,FACCz
JosephS.Alpert,MD,FACC,FAHA*y CynthiaM.Tracy,MD,FACC,FAHAy
HughCalkins,MD,FACC,FAHA,FHRS*zx ClydeW.Yancy,MD,FACC,FAHAy
JoaquinE.Cigarroa,MD,FACCy
JosephC.ClevelandJR,MD,FACCjj
JamieB.Conti,MD,FACC,FHRS*y *Writingcommitteemembersarerequiredtorecusethemselvesfrom
PatrickT.Ellinor,MD,PHD,FAHAz voothtienrgenontitsieecstmioanysatpopwlyh;iscehetAhpeipresnpdeicxifi1cforrerlaetciuosnaslhinipfsorwmitahtiionnd.uyAstCryC/aAnHdA
MichaelD.Ezekowitz,MB,CHB,FACC,FAHA*y Representative.zHeartRhythmSocietyRepresentative.xACC/AHATask
MichaelE.Field,MD,FACC,FHRSy ForceonPerformanceMeasuresLiaison.kSocietyofThoracicSurgeons
KatherineT.Murray,MD,FACC,FAHA,FHRSy Representative.{ACC/AHATaskForceonPracticeGuidelinesLiaison.
ACC/AHATask JeffreyL.Anderson,MD,FACC,FAHA,Chair RichardJ.Kovacs,MD,FACC,FAHA
ForceMembers JonathanL.Halperin,MD,FACC,FAHA,Chair-Elect E.MagnusOhman,MD,FACC
SusanJ.Pressler,PhD,RN,FAHA
NancyM.Albert,PhD,RN,FAHA FrankW.Sellke,MD,FACC,FAHA
BiykemBozkurt,MD,PhD,FACC,FAHA Win-KuangShen,MD,FACC,FAHA
RalphG.Brindis,MD,MPH,MACC WilliamG.Stevenson,MD,FACC,FAHA#
MarkA.Creager,MD,FACC,FAHA# ClydeW.Yancy,MD,FACC,FAHA#
LesleyH.Curtis,PhD,FAHA
DavidDeMets,PhD#
RobertA.Guyton,MD,FACC# #Former TaskForcemember;currentmemberduringthe
writing effort.
JudithS.Hochman,MD,FACC,FAHA#
ThisdocumentwasapprovedbytheAmericanCollegeofCardiologyBoardofTrustees,theAmericanHeartAssociationScienceAdvisoryand
CoordinatingCommittee,andtheHeartRhythmSocietyBoardofTrusteesinMarch2014.
TheAmericanCollegeofCardiologyFoundationrequeststhatthisdocumentbecitedasfollows:JanuaryCT,WannLS,AlpertJS,CalkinsH,CigarroaJE,
ClevelandJCJr,ContiJB,EllinorPT,EzekowitzMD,FieldME,MurrayKT,SaccoRL,StevensonWG,TchouPJ,TracyCM,YancyCW.2014AHA/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. J Am Coll Cardiol 2014;64:2246–80.
ThisarticleiscopublishedinCirculation.
Copies:ThisdocumentisavailableontheWorldWideWebsitesoftheAmericanHeartAssociation(my.americanheart.org),theAmericanCollegeof
Cardiology(www.cardiosource.org),andtheHeartRhythmSociety(www.hrsonline.org).Forcopiesofthisdocument,pleasecontacttheElsevierInc.
ReprintDepartmentviafax(212)[email protected].
Permissions:Multiplecopies,modification,alteration,enhancement,and/ordistributionofthisdocumentarenotpermittedwithouttheexpress
permission of the American College of Cardiology. Requests may be completed online via the Elsevier site (http://www.elsevier.com/authors/
obtainingpermission-to-re-useelsevier-material).
Listentothismanuscript’saudiosummarybyJACCEditor-in-ChiefDr.ValentinFuster.
Youcanalsolistentothisissue’saudiosummarybyJACCEditor-in-ChiefDr.ValentinFuster.
JACC VOL. 64, NO. 21, 2014 Januaryetal. 2247
DECEMBER 2, 2014:2246–80 ExecutiveSummary:AHA/ACC/HRSAtrialFibrillationGuideline
TABLE OF CONTENTS
PREAMBLE.................................... 2247 6.5. Wolff-Parkinson-WhiteandPre-Excitation
Syndromes ..............................2264
1.INTRODUCTION ............................. 2250 6.6. HeartFailure.............................2264
1.1. MethodologyandEvidenceReview ..........2250 6.7. Familial(Genetic)AF ......................2264
1.2. OrganizationoftheWritingCommittee .......2250 6.8. PostoperativeCardiacandThoracicSurgery ... 2265
1.3. DocumentReviewandApproval.............2250
7.EVIDENCEGAPSANDFUTURERESEARCH
1.4. ScopeoftheGuideline .....................2250
DIRECTIONS ................................ 2265
2.CLINICALCHARACTERISTICSAND
REFERENCES ................................. 2266
EVALUATIONOFAF ......................... 2251
2.1. AFClassification .......................... 2251
APPENDIX1
2.2. MechanismsofAFandPathophysiology ...... 2251
AuthorRelationshipsWithIndustryand
2.3. RiskFactorsandAssociatedHeartDisease..... 2251 OtherEntities(Relevant)....................... 2271
2.4. ClinicalEvaluation:Recommendation ........ 2251
APPENDIX2
3.THROMBOEMBOLICRISKANDTREATMENT .... 2251 ReviewerRelationshipsWithIndustryand
OtherEntities(Relevant)....................... 2273
3.1. Risk-BasedAntithromboticTherapy:
Recommendations ........................ 2251
APPENDIX3
3.2. RiskStratificationSchemes
(CHADS andCHA DS -VASc) ............... 2253 InitialClinicalEvaluationinPatientsWithAF .....2280
2 2 2
3.3. ConsiderationsinSelectingAnticoagulants ....2254
PREAMBLE
3.4. CardiacSurgery—LeftAtrialAppendage
Occlusion/Excision:Recommendation ........2254
The medical profession should play a central role in
evaluating the evidence related to drugs, devices, and
4.RATECONTROL:RECOMMENDATIONS......... 2254
procedures for the detection, management, and preven-
tionofdisease.Whenproperlyapplied,expertanalysisof
5.RHYTHMCONTROL:RECOMMENDATIONS ...... 2255 availabledataonthebenefitsandrisksofthesetherapies
5.1. PreventionofThromboembolism ............ 2255 andprocedurescanimprovethequalityofcare,optimize
patient outcomes, and favorably affect costs by focusing
5.2. Direct-CurrentCardioversion................2256
resources on the most effective strategies. An organized
5.3. PharmacologicalCardioversion ..............2256 and directed approach to a thorough review of evidence
has resulted in the production of clinical practice guide-
5.4. AntiarrhythmicDrugstoMaintain
SinusRhythm ............................2258 lines that assist clinicians in selecting the best manage-
mentstrategyforanindividualpatient.Moreover,clinical
5.5. UpstreamTherapy ........................2258
practice guidelines can provide a foundation for other
5.6. AFCatheterAblationtoMaintain applications,suchasperformancemeasures,appropriate
SinusRhythm ............................2259 use criteria, and both quality improvement and clinical
5.7. SurgicalMazeProcedures .................. 2261 decisionsupporttools.
The American College of Cardiology (ACC) and the
AmericanHeartAssociation(AHA)havejointlyengagedin
6.SPECIFICPATIENTGROUPSANDAF:
theproductionofguidelinesintheareaofcardiovascular
RECOMMENDATIONS ........................ 2261
diseasesince1980.TheACC/AHA TaskForceonPractice
6.1. HypertrophicCardiomyopathy .............. 2261 Guidelines (Task Force), whose charge is to develop,
6.2. AFComplicatingAcuteCoronarySyndromes ..2263 update, or revise practice guidelines for cardiovascular
diseases and procedures, directs this effort. Writing
6.3. Hyperthyroidism .........................2263
committees are charged with the task of performing an
6.4. PulmonaryDisease........................2264 assessmentoftheevidenceandactingasanindependent
2248 Januaryetal. JACC VOL. 64, NO. 21, 2014
ExecutiveSummary:AHA/ACC/HRSAtrialFibrillationGuideline DECEMBER 2, 2014:2246–80
group of authors to develop, update, or revise written In view of the advances in medical therapy across
recommendationsforclinicalpractice. the spectrum of cardiovascular diseases, the Task
Expertsinthesubjectunderconsiderationareselected Force has designated the term guideline-directed medical
frombothorganizationstoexaminesubject-specificdata therapy to represent optimal medical therapy as defined
andwriteguidelines.Writingcommitteesarespecifically by ACC/AHA guideline (primarily Class I)–recommended
chargedtoperformaliteraturereview;weighthestrength therapies.Thisnewterm,guideline-directedmedicalther-
ofevidencefororagainstparticulartests,treatments,or apy,isusedhereinandthroughoutsubsequentguidelines.
procedures; and include estimates of expected health Therapies not available in the United States are dis-
outcomes where such data exist. Patient-specific modi- cussed in the text without a specific COR. For studies
fiers, comorbidities, and issues of patient preference performed in large numbers of subjects outside North
that may influence the choice of tests or therapies are America, each writing committee reviews the potential
considered, as well as frequency of follow-up and cost- impact of different practice patterns and patient pop-
effectiveness. When available, information from studies ulationsonthetreatmenteffectandrelevancetotheACC/
oncostisconsidered;however,reviewofdataonefficacy AHAtargetpopulationtodeterminewhetherthefindings
andoutcomesconstitutestheprimarybasisforpreparing shouldinformaspecificrecommendation.
recommendationsinthisguideline. TheACC/AHApracticeguidelinesareintendedtoassist
In analyzing the data, and developing recommenda- clinicians in clinical decision making by describing a
tions and supporting text, the writing committee uses rangeofgenerallyacceptableapproachestothediagnosis,
evidence-based methodologies developed by the Task management,andpreventionofspecificdiseasesorcon-
Force(1).TheClassificationofRecommendation(COR)is ditions. The guidelines attempt to define practices that
an estimate of the size of the treatment effect, with meet the needs of most patients in most circumstances.
consideration given to risks versus benefits, as well as The ultimatejudgmentaboutcare of aparticularpatient
evidence and/or agreement that a given treatment or must be made by the clinician and patient in light of
procedure is or is not useful/effective or in some situa- all the circumstances presented by that patient. As a
tionsmaycauseharm;thisisdefinedinTable1.TheLevel result, situations may arise in which deviations from
of Evidence (LOE) is an estimate of the certainty or these guidelines may be appropriate. Clinical decision
precisionof the treatmenteffect. The writing committee making should involve consideration of the quality and
reviewsandranksevidencesupportingeachrecommenda- availability of expertise in the area where care is pro-
tion,withtheweightofevidencerankedasLOEA,B,orC, vided. When these guidelines are used as the basis for
according to specific definitions that are included in regulatory or payer decisions, the goal should be
Table 1. Studies are identified as observational, retro- improvement in quality of care. The Task Force recog-
spective,prospective,orrandomized,asappropriate.For nizes that situations arise in which additional data are
certain conditions for which inadequate data are avail- needed to inform patient care more effectively; these
able, recommendations are based on expert consensus areas are identified within each respective guideline
and clinical experience and are ranked as LOE C. When whenappropriate.
recommendations at LOE C are supported by historical Prescribed courses of treatment in accordance with
clinical data, appropriate references (including clinical these recommendations are effective only if followed.
reviews)arecitedifavailable. Because lack of patient understanding and adherence
For issues with sparse available data, a survey of cur- may adversely affect outcomes, clinicians should make
rentpracticeamongtheclinicianmembersofthewriting everyefforttoengagethepatient’sactiveparticipationin
committeeisthebasisforLOECrecommendationsandno prescribed medical regimens and lifestyles. In addition,
referencesarecited. patients should be informed of the risks, benefits, and
TheschemaforCORandLOEissummarizedinTable1, alternatives to a particular treatment and should be
which also provides suggested phrases for writing rec- involved in shared decision making whenever feasible,
ommendationswithineachCOR. particularlyforCORIIaandIIb,forwhichthebenefit-to-
Anewadditiontothismethodologyistheseparationof riskratiomaybelower.
the Class III recommendations to delineate whether the The Task Force makes every effort to avoid actual,
recommendationisdeterminedtobeof“nobenefit”oris potential,orperceivedconflictsofinterestthatmayarise
associatedwith“harm”tothepatient.Inaddition,inview as a result of relationships with industry and other en-
of the increasing number of comparative effectiveness tities (RWI) among the members of the writing commit-
studies, comparator verbs and suggested phrases for tee.Allwritingcommitteemembersandpeerreviewersof
writing recommendations for the comparative effective- the guideline are required to disclose all current
ness of one treatment or strategy versus another are healthcare-relatedrelationships,includingthoseexisting
includedforCORIandIIa,LOEAorBonly. 12monthsbeforeinitiationofthewritingeffort.
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TABLE 1 ApplyingClassificationofRecommendationsandLevelofEvidence
ArecommendationwithLevelofEvidenceBorCdoesnotimplythattherecommendationisweak.Manyimportantclinicalquestionsaddressedintheguidelinesdonotlend
themselvestoclinicaltrials.Althoughrandomizedtrialsareunavailable,theremaybeaveryclearclinicalconsensusthataparticulartestortherapyisusefuloreffective.
*Dataavailablefromclinicaltrialsorregistriesabouttheusefulness/efficacyindifferentsubpopulations,suchassex,age,historyofdiabetesmellitus,historyofpriormyocardial
infarction,historyofheartfailure,andprioraspirinuse.
†Forcomparative-effectivenessrecommendations(ClassIandIIa;LevelofEvidenceAandBonly),studiesthatsupporttheuseofcomparatorverbsshouldinvolvedirectcomparisons
ofthetreatmentsorstrategiesbeingevaluated.
In December 2009, the ACC and AHA implemented a in the list of writing committee members, and specific
new RWI policy that requires the writing committee section recusals are noted in Appendix 1. Authors’ and
chair plus a minimum of 50% of the writing committee peer reviewers’ RWI pertinent to this guideline are dis-
to have no relevant RWI (Appendix 1 includes the ACC/ closed in Appendices 1 and 2. In addition, to ensure
AHA definition of relevance). The Task Force and all complete transparency, writing committee members’
writing committee members review their respective comprehensive disclosure information—including RWI
RWI disclosures during each conference call and/or not pertinent to this document—is available as an online
meetingofthewritingcommittee,andmembersprovide supplement. Comprehensive disclosure information for
updates to their RWI as changes occur. All guideline theTaskForceisalsoavailableasanOnlineSupplement.
recommendations require a confidential vote by the The ACC and AHA exclusively sponsor the work of the
writing committee and require approval by a consensus writingcommittee,withoutcommercialsupport.Writing
of the voting members. Members may not draft or vote committee members volunteered their time for this
on any recommendations pertaining to their RWI. Mem- activity. Guidelines are official policy of both the ACC
bers who recused themselves from voting are indicated and AHA.
2250 Januaryetal. JACC VOL. 64, NO. 21, 2014
ExecutiveSummary:AHA/ACC/HRSAtrialFibrillationGuideline DECEMBER 2, 2014:2246–80
In an effort to maintain relevance at the point of care previously published by the ACC and AHA. References
for clinicians, the Task Force continues to oversee an selectedandpublishedinthisdocumentarerepresentative
ongoing process improvement initiative. As a result, in andnotall-inclusive.
response to pilot projects, several changes to this guide-
line will be apparent, including limited narrative text, a 1.2. OrganizationoftheWritingCommittee
focus on summary and evidence tables (with references The 2014 AF writing committee was composed of clini-
linked to abstracts in PubMed), and more liberal use of cianswithbroadexpertiserelatedtoAFanditstreatment,
summary recommendation tables (with references that includingadult cardiology, electrophysiology, cardiotho-
supporttheLOE)toserveasaquickreference. racic surgery, and heart failure (HF). The writing com-
InApril2011,theInstituteofMedicinereleased2reports: mitteewasassistedbystafffromtheACCandAHA.Under
Finding What Works in Health Care: Standards for Sys- theguidanceoftheTaskForce,theHeartRhythmSociety
tematic Reviews and Clinical Practice Guidelines We Can was invited to be a partner organization and provided
Trust(2,3).ItisnoteworthythattheInstituteofMedicine representation. The writing committee also included a
cited ACC/AHA practice guidelines as being compliant representativefromtheSocietyofThoracicSurgeons.The
withmanyoftheproposedstandards.Athoroughreview rigorousmethodologicalpoliciesandproceduresnotedin
ofthesereportsandofourcurrentmethodologyisunder the Preamble differentiate ACC/AHA guidelines from
way,withfurtherenhancementsanticipated. otherpublishedguidelinesandstatements.
Therecommendationsinthisguidelineareconsidered
current until they are superseded by a focused update, 1.3. DocumentReviewandApproval
the full-text guideline is revised, or until a published Thisdocumentwasreviewedby2officialreviewerseach
addendum declares it out of date and no longer official nominatedby the ACC,AHA,andHeartRhythmSociety,
ACC/AHApolicy.Thereaderisencouragedtoconsultthe as well as 1 reviewer from the Society of Thoracic Sur-
full-textguideline(4)foradditionalguidanceanddetails geonsand43individualcontentreviewers(fromtheACC
about atrial fibrillation (AF), because the executive sum- ElectrophysiologySectionLeadershipCouncil,ACCAdult
marycontainsmainlytherecommendations. Congenital and Pediatric Cardiology Section Leadership
JeffreyL.Anderson,MD,FACC,FAHA Council,ACCAssociationofInternationalGovernors,ACC
Chair,ACC/AHATaskForceonPracticeGuidelines HeartFailureandTransplantSectionLeadershipCouncil,
ACC Imaging Section Leadership Council, ACC Interven-
1. INTRODUCTION tional Section Leadership Council, ACC Surgeons’ Coun-
cil, and the Heart Rhythm Society Scientific Documents
1.1. MethodologyandEvidenceReview Committee). All information on reviewers’ RWI was
The recommendations listed in this document are, distributed to the writing committee and is published in
whenever possible, evidence based. An extensive evi- thisdocument(Appendix2).
dence review was conducted, focusing on 2006 through This document was approved for publication by the
October2012andselectedotherreferencesthroughMarch governing bodies of the ACC, AHA, and Heart Rhythm
2014.Therelevantdataareincludedinevidencetablesin SocietyandendorsedbytheSocietyofThoracicSurgeons.
the Online Data Supplement. Searches were extended
to studies, reviews, and other evidence conducted in 1.4. ScopeoftheGuideline
human subjects, published in English, and accessible The task of the 2014 writing committee was to establish
throughPubMed,EMBASE,Cochrane,AgencyforHealth- revised guidelines for optimum management of AF. The
careResearchandQualityReports,andotherselectedda- new guideline incorporates new and existing knowledge
tabases relevant to this guideline. Key search words derived from published clinical trials, basic science, and
included but were not limited to the following: age, comprehensive review articles, along with evolving
antiarrhythmic,atrialfibrillation,atrialremodeling,atrio- treatment strategies and new drugs. This guideline
ventricular conduction, atrioventricular node, cardiover- supersedes the “ACC/AHA/ESC 2006 Guidelines for the
sion, classification, clinical trial, complications, concealed Management of Patients With Atrial Fibrillation” (5) and
conduction,cost-effectiveness,defibrillator,demographics, the 2 subsequent focused updates from 2011 (6,7). In
epidemiology, experimental, heart failure, hemodynamics, addition,the ACC,AHA,American CollegeofPhysicians,
human, hyperthyroidism, hypothyroidism, meta-analysis, andAmericanAcademyofFamilyPhysicianssubmitteda
myocardialinfarction,pharmacology,postoperative,preg- proposal to the Agency for Healthcare Research and
nancy, pulmonary disease, quality of life, rate control, Quality to perform a systematic review on specific ques-
rhythm control, risks, sinus rhythm, symptoms, and tions related to the treatment of AF. The data from that
tachycardia-mediated cardiomyopathy. Additionally, the report were reviewed by the writing committee and
writing committee reviewed documents related to AF incorporatedwhereappropriate(8a,8b).
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The 2014 AF guideline is organized thematically, with 2. Selectionofantithrombotictherapyshouldbebasedonthe
recommendations, where appropriate, provided with risk of thromboembolism irrespective of whether the AF
each section. Some recommendations from earlier pattern is paroxysmal, persistent, or permanent (64–67).
(LevelofEvidence:B)
guidelineshavebeeneliminatedorupdatedaswarranted
by new evidence or a better understanding of earlier 3. InpatientswithnonvalvularAF,theCHA DS -VASc*score
2 2
evidence. In developing the 2014 AF guideline, the is recommended for assessment of stroke risk (68–70).
writing committee reviewed prior published guidelines (LevelofEvidence:B)
and related statements. Table 2 lists these publications
4. For patients with AF who have mechanical heart valves,
and statements deemed pertinent to this effort and is
warfarin is recommended, and the target international
intendedforuseasaresource.
normalized ratio (INR) intensity (2.0 to 3.0 or 2.5 to 3.5)
2. CLINICAL CHARACTERISTICS AND shouldbebasedonthetypeandlocationoftheprosthesis
EVALUATION OF AF (71–73).(LevelofEvidence:B)
5. For patients with nonvalvular AF with prior stroke, transient
2.1. AFClassification ischemicattack(TIA),oraCHA2DS2-VAScscoreof2orgreater,
oralanticoagulantsarerecommended.Optionsincludewarfarin
AF may be described in terms of the duration of episodes
using a simplified scheme shown in Table 3 (5,29,30). (INR2.0to3.0)(68–70)(LevelofEvidence:A),dabigatran(74)
(LevelofEvidence:B),rivaroxaban(75)(LevelofEvidence:B),or
Implanted loop recorders, pacemakers, and defibrillators
apixaban(76).(LevelofEvidence:B)
offer the possibility of reporting frequency, rate, and dura-
tion of abnormal atrial rhythms, including AF (31,32). Epi- 6. Among patients treated with warfarin, the INR should be
sodesoftenincreaseinfrequencyanddurationovertime. determined at least weekly during initiation of antith-
rombotic therapy and at least monthly when anticoagula-
2.2. MechanismsofAFandPathophysiology tion(INRinrange)isstable(77–79).(LevelofEvidence:A)
AF occurs when structural and/or electrophysiological 7. For patients with nonvalvular AF unable to maintain a
abnormalities alter atrial tissue to promote abnormal therapeutic INR level with warfarin, use of a direct
impulse formation and/or propagation (Figure 1). These thrombinorfactorXainhibitor(dabigatran,rivaroxaban,or
abnormalities are caused by diverse pathophysiological apixaban)isrecommended.(LevelofEvidence:C)
mechanisms (29,33,34), such that AF represents a final 8. Reevaluationoftheneedforandchoiceofantithrombotic
common phenotype for multiple disease pathways and therapy at periodic intervals is recommended to reassess
mechanismsthatareincompletelyunderstood. strokeandbleedingrisks.(LevelofEvidence:C)
9. Bridgingtherapywithunfractionatedheparinorlow-molecular-
2.3. RiskFactorsandAssociatedHeartDisease
weightheparin(LMWH)isrecommendedforpatientswithAF
Multiple clinical risk factors, electrocardiographic and
andamechanicalheartvalveundergoingproceduresthatrequire
echocardiographicfeatures,andbiochemicalmarkersare
interruptionofwarfarin.Decisionsonbridgingtherapyshould
associatedwithanincreasedriskofAF(Table4). balancetherisksofstrokeandbleeding.(LevelofEvidence:C)
2.4. ClinicalEvaluation:Recommendation 10. ForpatientswithAFwithoutmechanicalheartvalveswho
require interruption of warfarin or new anticoagulants for
SeeAppendix3forinformationoninitialclinicalevalua-
procedures, decisions about bridging therapy (LMWH or
tioninpatientswithAF.
unfractionatedheparin)shouldbalancetherisksofstroke
andbleedingandthedurationoftimeapatientwillnotbe
CLASSI
anticoagulated.(LevelofEvidence:C)
1. Electrocardiographic documentation is recommended to
establishthediagnosisofAF.(LevelofEvidence:C) 11. Renal function should be evaluated before initiation of
direct thrombin or factor Xa inhibitors and should be
3. THROMBOEMBOLIC RISK ANDTREATMENT
reevaluatedwhenclinicallyindicatedandatleastannually
(80–82).(LevelofEvidence:B)
3.1. Risk-BasedAntithromboticTherapy:Recommendations
12. For patients with atrial flutter, antithrombotic therapy is
SeeTable5forasummaryofrecommendationsfromthis recommended according to the same risk profile used for
section. AF.(LevelofEvidence:C)
CLASSI
1. InpatientswithAF,antithrombotictherapyshouldbeindivid-
ualizedbasedonshareddecisionmakingafterdiscussionofthe *CHA2DS2-VASc indicates Congestive heart failure, Hypertension, Age $75
absolute and relative risks of stroke and bleeding and the years(doubled),Diabetesmellitus,priorStrokeorTIAorthromboembolism
patient’svaluesandpreferences.(LevelofEvidence:C) (doubled),Vasculardisease,Age65to74years,Sexcategory.
2252 Januaryetal. JACC VOL. 64, NO. 21, 2014
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TABLE 2 AssociatedGuidelinesandStatements
Title Organization PublicationYear/Reference
Guidelines
SeventhReportoftheJointNationalCommitteeonPrevention,Detection,Evaluation, NHLBI 2003(9)
andTreatmentofHighBloodPressure(JNC7)
AssessmentofCardiovascularRiskinAsymptomaticAdults ACC/AHA 2010(10)
CoronaryArteryBypassGraftSurgery ACC/AHA 2011(11)
HypertrophicCardiomyopathy ACC/AHA 2011(12)
PercutaneousCoronaryIntervention ACC/AHA/SCAI 2011(13)
SecondaryPreventionandRiskReductionTherapyforPatientsWithCoronaryand AHA/ACC 2011(14)
OtherAtheroscleroticVascularDisease
AtrialFibrillation* CCS 2012(15)
AtrialFibrillation ESC 2012(16)
StableIschemicHeartDisease ACC/AHA/ACP/AATS/PCNA/SCAI/STS 2012(17)
AntithromboticTherapy ACCP 2012(18)
Device-BasedTherapy ACC/AHA/HRS 2012(19)
HeartFailure ACC/AHA 2013(20)
ST-ElevationMyocardialInfarction ACC/AHA 2013(21)
UnstableAngina/Non-ST-ElevationMyocardialInfarction ACC/AHA 2014(22)
ValvularHeartDisease AHA/ACC 2014(23)
AssessmentofCardiovascularRisk ACC/AHA 2013(24)
LifestyleManagementtoReduceCardiovascularRisk AHA/ACC 2013(25)
ManagementofOverweightandObesityinAdults AHA/ACC/TOS 2013(26)
TreatmentofBloodCholesteroltoReduceAtheroscleroticCardiovascularRiskinAdults ACC/AHA 2013(27)
Statements
TreatmentofAtrialFibrillation AHRQ 2013(8a,8b)
OralAntithromboticAgentsforthePreventionofStrokeinNonvalvular AHA/ASA 2012(28)
AtrialFibrillation:AScienceAdvisoryforHealthcareProfessionals
ExpertConsensusStatementonCatheterandSurgicalAblationofAtrialFibrillation: HRS/EHRA/ECAS 2012(29)
RecommendationsforPatientSelection,ProceduralTechniques,Patient
ManagementandFollow-Up,Definitions,Endpoints,andResearchTrialDesign
*Includesthefollowingsections:CatheterAblationforAF/AtrialFlutter;PreventionandTreatmentofAFFollowingCardiacSurgery;RateandRhythmManagement;Preventionof
StrokeandSystemicThromboembolisminAFandFlutter;ManagementofRecent-OnsetAFandFlutterintheEmergencyDepartment;SurgicalTherapy;TheUseofAntiplatelet
TherapyintheOutpatientSetting;andFocused2012UpdateoftheCCSAFGuidelines:RecommendationsforStrokePreventionandRate/RhythmControl.
AATSindicatesAmericanAssociationforThoracicSurgery;ACC,AmericanCollegeofCardiology;ACCP,AmericanCollegeofChestPhysicians;ACP,AmericanCollegeofPhysicians;
AF,atrialfibrillation;AHA,AmericanHeartAssociation;AHRQ,AgencyforHealthcareResearchandQuality;ASA,AmericanStrokeAssociation;CCS,CanadianCardiologySociety;ECAS,
EuropeanCardiacArrhythmiaSociety;EHRA,EuropeanHeartRhythmAssociation;ESC,EuropeanSocietyofCardiology;HRS,HeartRhythmSociety;JNC,JointNationalCommittee;
NHLBI,NationalHeart,Lung,andBloodInstitute;PCNA,PreventiveCardiovascularNursesAssociation;SCAI,SocietyforCardiovascularAngiographyandInterventions;STS,Societyof
ThoracicSurgeons;andTOS,TheObesitySociety.
CLASSIIa 2. For patients with nonvalvular AF and moderate-to-severe
1. ForpatientswithnonvalvularAFandaCHA2DS2-VAScscore CKD with CHA2DS2-VASc scores of 2 or greater, treatment
of0,itisreasonabletoomitantithrombotictherapy(80,81). withreduceddosesofdirectthrombinorfactorXainhibitors
(LevelofEvidence:B) may be considered (e.g., dabigatran, rivaroxaban, or apix-
aban), but safety and efficacy have not been established.
2. ForpatientswithnonvalvularAFwithaCHA DS -VAScscore
2 2 (LevelofEvidence:C)
of 2 or greater and who have end-stage chronic kidney
disease (CKD) (creatinine clearance <15 mL/min) or are on 3. In patients with AF undergoing percutaneous coronary
hemodialysis,itisreasonabletoprescribewarfarin(INR2.0 intervention,y bare-metal stents may be considered to
to3.0)fororalanticoagulation(82).(LevelofEvidence:B) minimizetherequireddurationofdualantiplatelettherapy.
Anticoagulation may be interrupted at the time of the
CLASSIIb
1. ForpatientswithnonvalvularAFandaCHA DS -VAScscore
2 2
of 1, no antithrombotic therapy or treatment with an oral
anticoagulant or aspirin may be considered. (Level of Evi- ySeethe2011percutaneouscoronaryinterventionguidelinefortypeofstent
dence:C) anddurationofdualantiplatelettherapyrecommendations(13).
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TABLE 3 DefinitionsofAF:ASimplifiedScheme
Term Definition
ParoxysmalAF (cid:2) AFthatterminatesspontaneouslyorwithinterventionwithin7dofonset.
(cid:2) Episodesmayrecurwithvariablefrequency.
PersistentAF (cid:2) ContinuousAFthatissustained>7d.
Long-standingpersistentAF (cid:2) ContinuousAF>12moinduration.
PermanentAF (cid:2) Theterm“permanentAF”isusedwhenthepatientandclinicianmakeajointdecisiontostopfurtherattempts
torestoreand/ormaintainsinusrhythm.
(cid:2) AcceptanceofAFrepresentsatherapeuticattitudeonthepartofthepatientandclinicianratherthananinherent
pathophysiologicalattributeofAF.
(cid:2) AcceptanceofAFmaychangeassymptoms,efficacyoftherapeuticinterventions,andpatientandclinicianpreferencesevolve.
NonvalvularAF (cid:2) AFintheabsenceofrheumaticmitralstenosis,amechanicalorbioprostheticheartvalve,ormitralvalverepair.
AFindicatesatrialfibrillation.
procedure to reduce the risk of bleeding at the site of pe- ofevidencefromclinicaltrialsregardingthebalanceofrisks
ripheralarterialpuncture.(LevelofEvidence:C) andbenefits(74–76,84–86).(LevelofEvidence:C)
4. Following coronary revascularization (percutaneous or sur-
CLASSIII:HARM
gical)inpatientswithAFandaCHA DS -VAScscoreof2or
2 2
1. Thedirectthrombininhibitordabigatranshouldnotbeused
greater,itmaybereasonabletouseclopidogrel(75mgonce
inpatientswithAFandamechanicalheartvalve(87).(Level
daily) concurrently with oral anticoagulants but without
ofEvidence:B)
aspirin(83).(LevelofEvidence:B)
CLASSIII:NOBENEFIT 3.2. RiskStratificationSchemes(CHADS2andCHA2DS2-VASc)
1. The direct thrombin inhibitor dabigatran and the factor One meta-analysis has stratified ischemic stroke risk
Xa inhibitor rivaroxaban are not recommended in patients among patients withnonvalvular AF usingthe following
withAFandend-stageCKDorondialysisbecauseofthelack scoringsystems:AFInvestigators(88),CHADS (Congestive
2
FIGURE1 MechanismsofAF
AFindicatesatrialfibrillation;Caþþ,ionizedcalcium;andRAAS,renin-angiotensin-aldosteronesystem.
2254 Januaryetal. JACC VOL. 64, NO. 21, 2014
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4. RATE CONTROL: RECOMMENDATIONS
TABLE 4 SelectedRiskFactorsandBiomarkersforAF
ClinicalRiskFactors References
See Table 8 for a summary of recommendations for this
Increasingage (35) section and Table 9 for common medication dosages for
Hypertension (35) ratecontrolofAF.
Diabetesmellitus (35)
CLASSI
MI (35)
1. Controloftheventricularrateusingabetablockerornon-
VHD (35)
dihydropyridinecalciumchannelantagonistisrecommended
HF (35,36)
for patients with paroxysmal, persistent, or permanent AF
Obesity (37–39)
(93–95).(LevelofEvidence:B)
Obstructivesleepapnea (39)
2. Intravenous administration of a beta blocker or nondi-
Cardiothoracicsurgery (40)
hydropyridinecalciumchannelblockerisrecommendedtoslow
Smoking (41)
theventricularheartrateintheacutesettinginpatientswithout
Exercise (42–44)
pre-excitation.Inhemodynamicallyunstablepatients,electrical
Alcoholuse (45–47) cardioversionisindicated(96–99).(LevelofEvidence:B)
Hyperthyroidism (48–50)
3. In patients who experience AF-related symptoms during
Increasedpulsepressure (51)
activity, the adequacy of heart rate control should be
Europeanancestry (52) assessed during exertion, adjusting pharmacological treat-
Familyhistory (53) ment as necessary to keep the ventricular rate within the
Geneticvariants (54–57) physiologicalrange.(LevelofEvidence:C)
ECG
CLASSIIa
LVH (58)
1. Aheartratecontrol(restingheartrate<80beatsperminute
Echocardiographic
[bpm])strategyisreasonableforsymptomaticmanagement
LAenlargement (58,59) ofAF(95,100).(LevelofEvidence:B)
DecreasedLVfractionalshortening (58)
2. Intravenousamiodaronecanbeusefulforratecontrolincritically
IncreasedLVwallthickness (58)
illpatientswithoutpre-excitation(101–103).(LevelofEvidence:B)
Biomarkers
3. Atrioventricular (AV) nodal ablation with permanent ven-
IncreasedCRP (60,61)
tricular pacing is reasonable to control heart rate when
IncreasedBNP (62,63)
pharmacologicaltherapyisinadequateandrhythmcontrolis
AFindicatesatrialfibrillation;BNP,B-typenatriureticpeptide;CRP,C-reactiveprotein; notachievable(104–106).(LevelofEvidence:B)
ECG,electrocardiographic;HF,heartfailure;LA,leftatrial;LV,leftventricular;LVH,left
ventricularhypertrophy;MI,myocardialinfarction;andVHD,valvularheartdisease.
CLASSIIb
heartfailure,Hypertension,Age$75years,Diabetesmellitus, 1. Alenientrate-controlstrategy(restingheartrate<110bpm)
Prior Stroke or TIA or Thromboembolism [doubled]) (89), maybereasonableaslongaspatientsremainasymptomatic
or CHA2DS2-VASc (Congestive heart failure, Hypertension, and left ventricular systolic function is preserved (100).
Age$75years[doubled],Diabetesmellitus,PriorStrokeorTIA (LevelofEvidence:B)
orthromboembolism[doubled],Vasculardisease,Age65to74
2. Oral amiodarone may be useful for ventricular rate control
years,Sexcategory)(Table6). when other measures are unsuccessful or contraindicated.
(LevelofEvidence:C)
3.3. ConsiderationsinSelectingAnticoagulants
For patients with CKD, dose modifications of the new
CLASSIII:HARM
agents are available (Table 7); however, for those with
1. AVnodalablationwithpermanentventricularpacingshouldnot
severe or end-stage CKD, warfarin remains the anticoag-
beperformedtoimproveratecontrolwithoutpriorattemptsto
ulant of choice, as there are no or very limited data for achieveratecontrolwithmedications.(LevelofEvidence:C)
thesepatients.Amongpatientsonhemodialysis,warfarin
2. Nondihydropyridinecalciumchannelantagonistsshouldnot
hasbeenusedwithacceptablerisksofhemorrhage(82).
beusedinpatientswithdecompensatedHFasthesemaylead
3.4. CardiacSurgery—LeftAtrialAppendageOcclusion/Excision: tofurtherhemodynamiccompromise.(LevelofEvidence:C)
Recommendation
3. In patients with pre-excitation and AF, digoxin, non-
CLASSIIb dihydropyridinecalciumchannelantagonists,orintravenous
1. Surgical excision of the left atrial appendage may be amiodaroneshouldnotbeadministeredastheymayincrease
consideredinpatientsundergoingcardiacsurgery.(Levelof the ventricular response and may result in ventricular
Evidence:C) fibrillation(107).(LevelofEvidence:B)
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TABLE 5 SummaryofRecommendationsforRisk-BasedAntithromboticTherapy
Recommendations COR LOE References
Antithrombotictherapybasedonshareddecisionmaking,discussionofrisksofstrokeandbleeding, I C N/A
andpatient’spreferences
Selectionofantithrombotictherapybasedonriskofthromboembolism I B (64–67)
CHA2DS2-VAScscorerecommendedtoassessstrokerisk I B (68–70)
WarfarinrecommendedformechanicalheartvalvesandtargetINRintensitybasedontypeand I B (71–73)
locationofprosthesis
Withpriorstroke,TIA,orCHA2DS2-VAScscore$2,oralanticoagulantsrecommended.Optionsinclude:
Warfarin I A (68–70)
Dabigatran,rivaroxaban,orapixaban I B (74–76)
Withwarfarin,determineINRatleastweeklyduringinitiationoftherapyandmonthlywhenstable I A (77–79)
DirectthrombinorfactorXainhibitorrecommendedifunabletomaintaintherapeuticINR I C N/A
Reevaluatetheneedforanticoagulationatperiodicintervals I C N/A
BridgingtherapywithUFHorLMWHrecommendedwithamechanicalheartvalveifwarfarinis I C N/A
interrupted.Bridgingtherapyshouldbalancerisksofstrokeandbleeding
Forpatientswithoutmechanicalheartvalves,bridgingtherapydecisionsshouldbalancestrokeand I C N/A
bleedingrisksagainstdurationoftimepatientwillnotbeanticoagulated
EvaluaterenalfunctionbeforeinitiationofdirectthrombinorfactorXainhibitors,andreevaluate I B (80–82)
whenclinicallyindicatedandatleastannually
Foratrialflutter,antithrombotictherapyisrecommendedasforAF I C N/A
WithnonvalvularAFandCHA2DS2-VAScscoreof0,itisreasonabletoomitantithrombotictherapy IIa B (80,81)
WithCHA2DS2-VAScscore$2andend-stageCKD(CrCl<15mL/min)oronhemodialysis, IIa B (82)
itisreasonabletoprescribewarfarinfororalanticoagulation
WithnonvalvularAFandaCHA2DS2-VAScscoreof1,noantithrombotictherapyortreatment IIb C N/A
withoralanticoagulantoraspirinmaybeconsidered
Withmoderate-to-severeCKDandCHA2DS2-VAScscores$2,reduceddosesofdirectthrombin IIb C N/A
orfactorXainhibitorsmaybeconsidered
ForPCI,*BMSmaybeconsideredtominimizedurationofDAPT IIb C N/A
AftercoronaryrevascularizationinpatientswithCHA2DS2-VAScscore$2,itmaybereasonable IIb B (83)
touseclopidogrelconcurrentlywithoralanticoagulantsbutwithoutaspirin
DirectthrombindabigatranandfactorXainhibitorrivaroxabanarenotrecommendedinpatients III:NoBenefit C (74–76,84–86)
withAFandend-stageCKDorondialysisbecauseofalackofevidencefromclinicaltrials
regardingthebalanceofrisksandbenefits
Directthrombininhibitordabigatranshouldnotbeusedwithamechanicalheartvalve III:Harm B (87)
*Seethe2011PCIguidelinefortypeofstentanddurationofDAPTrecommendations(13).
AFindicatesatrialfibrillation;BMS,bare-metalstent;CHA2DS2-VASc,Congestiveheartfailure,Hypertension,Age$75years(doubled),Diabetesmellitus,PriorStrokeorTIAor
thromboembolism(doubled),Vasculardisease,Age65to74years,Sexcategory;CKD,chronickidneydisease;COR,ClassofRecommendation;CrCl,creatinineclearance;DAPT,dual
antiplatelettherapy;INR,internationalnormalizedratio;LMWH,low-molecular-weightheparin;LOE,LevelofEvidence;N/A,notapplicable;PCI,percutaneouscoronaryintervention;
TIA,transientischemicattack;andUFH,unfractionatedheparin.
4. Dronedarone should not be used to control the ventricular anticoagulation with warfarin (INR 2.0 to 3.0) is recom-
rateinpatientswithpermanentAFasitincreasestheriskof mendedfor atleast3 weeksbeforeand4weeksaftercar-
the combined endpoint of stroke, myocardial infarction, dioversion, regardless of the CHA DS -VASc score and the
2 2
systemic embolism, or cardiovascular death (108,109). method(electricalorpharmacological)usedtorestoresinus
(LevelofEvidence:B) rhythm(110–113).(LevelofEvidence:B)
2. ForpatientswithAForatrialflutterofmorethan48hours’
5. RHYTHM CONTROL: RECOMMENDATIONS durationorunknownduration thatrequiresimmediatecar-
dioversion for hemodynamic instability, anticoagulation
See Table 10 for a summary of recommendations for shouldbeinitiatedassoonaspossibleandcontinuedforat
rhythmcontrol. least 4 weeks after cardioversion unless contraindicated.
(LevelofEvidence:C)
5.1. PreventionofThromboembolism
3. ForpatientswithAFor atrial flutterofless than48hours’
CLASSI durationandwithhighriskofstroke,intravenousheparinor
1. For patients with AF or atrial flutter of 48 hours’ duration LMWH, or administration of a factor Xa or direct thrombin
or longer, or when the duration of AF is unknown, inhibitor, is recommended as soon as possible before or