Management of Patients with Atrial Fibrillation

Publication Date: January 28, 2019

Key Points

Key Points

  • The diagnosis of atrial fibrillation (AF) in a patient is based on the patient’s clinical history and physical examination and is confirmed by electrocardiogram (ECG), ambulatory rhythm monitoring (e.g., telemetry, Holter monitor, event recorders), implanted loop recorders, pacemakers or defibrillators, or, in rare cases, by electrophysiological study. The clinical evaluations, including additional studies that may be required, are summarized in Table 3.
  • The initial evaluation of a patient with suspected or proven AF involves characterizing the pattern of the arrhythmia (paroxysmal, persistent, longstanding persistent, or permanent), determining its cause, defining associated cardiac and extracardiac disease, and assessing thromboembolic risk.
  • AF is a supraventricular tachyarrhythmia with uncoordinated atrial activation and consequently ineffective atrial contraction.
  • AF incidence increases with advancing age.
  • Rate control (principally with beta-blockers and/or non-dihydropyridine calcium channel blockers) versus rhythm control (cardioversion, antiarrhythmic drugs, AF ablation) strategies may be considered in treating patients with AF.
  • Hemodynamic consequences of AF can result from a variable combination of suboptimal ventricular rate control (either too rapid or too slow), loss of coordinated atrial contraction, beat-to-beat variability in ventricular filling, and sympathetic activation.
  • Consequences for individual patients vary, ranging from no symptoms to fatigue, palpitations, dyspnea, hypotension, syncope, or HF. The most common symptom of AF is fatigue.
  • The appearance of AF is often associated with exacerbation of underlying heart disease, either because AF is a cause or consequence of deterioration, or because it contributes directly to deterioration.
  • AF confers an increased risk of stroke and/or peripheral thromboembolism owing to the formation of atrial thrombi, usually in the left atrial appendage (LAA).
  • Treatment strategies to reduce the risk of thromboembolism may include anticoagulation with warfarin or newer anticoagulants, and are guided using the CHA2DS2-VASc score.
  • The purpose of this document is to update the “2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation” (S1.3-1) (2014 AF Guideline) in areas for which new evidence has emerged since its publication.
  • The scope of this focused update of the 2014 AF Guideline includes revisions to the section on anticoagulation (because of the approval of new medications and thromboembolism protection devices), revisions to the section on catheter ablation of AF, revisions to the section on the management of AF complicating acute coronary syndrome (ACS), and new sections on device detection of AF and weight loss.

Diagnosis

...Di...

...e 1. Definitions Term Def...


...Atrial Tachycardias...


...Figure 2. Mechanisms of AF...


...nical EvaluationECG documentation is re...


...able 3. Initial Clinical Evaluation in Patien...


Treatment

...Treatment...

...Table 4. Risk-Based Antith...

...abigatran, rivaroxaban, apixaban, and edoxaban) a...

...ED: In patients with AF, anticoagu...

...lection of anticoagulant therapy should be ba...

...D: In patients with AF2 (except wit...

MODIFIED: For patients with AF who have mecha...

...(INR 2.0-3.0) ( A , I )706...

...rivaroxaban or apixaban ( B , I )706...

Edoxaban ( B-R ,...

...DIFIED: Among patients treated with w...

...For patients with AF (except with mo...

...luation of the need for and choice of an...

...FIED: Renal function and hepatic function should...

...tients with atrial flutter, antico...

...For patients with AF (except with mode...

...For patients with AF2 who have a CHADS-...

...IFIED: For patients with AF2 (except with moder...

...IFIED: For patients with AF (except with...

...patients with AF undergoing percut...

...ng coronary revascularization (percut...

...: In patients with AF and end-stage...

...The direct thrombin inhibitor dabigatran...


...Table...

...g therapy with unfractionated heparin (UFH) o...

...r patients with AF without mechanical hea...

...EW: Idarucizumab is recommended for t...

...alfa can be useful for the reversal of ri...


...Table 6. Cardiac Surgery...

...s LAA occlusion may be considered i...

...cal occlusion of the LAA may be considered in pati...


...omparison of the CHADS2 and CHA2DS2-VASc Risk...


...Selection of Oral Anticoagulant Options for...


...Table 9....

...ventricular rate using a beta blocker or n...

...stration of a beta blocker or nondih...

...ts who experience AF-related symptoms during a...

...ate control (resting heart rate...

IV amiodarone can be useful for rate control in...

...ablation with permanent ventricular pacing is reas...

...trol strategy (resting heart rate...

...ral amiodarone may be useful for ventricular rat...

...al ablation with permanent ventricular...

...ydropyridine calcium channel antagonists s...

...patients with pre-excitation and AF, digoxin, non...

...hould NOT be used to control the ventricular rate...


.... Approach to Selecting Drug Therapy for Vent...


...on Medication Dosage for Rate Control of AF...


...Table 11....

...Prevention of Thromboe...

...For patients with AF or atrial flut...

...ents with AF or atrial flutter of >48 ho...

...After cardioversion for AF of any duration, the...

...tients with AF2 or atrial flutter of...

...ents with AF or atrial flutter of ≥48 hours dura...

...with AF or atrial flutter of ≥48 hour duration o...

MODIFIED: For patients with AF2 or atrial fl...

...Dir...

...n pursuing a rhythm-control strategy, cardio...

...on is recommended when a RVR to AF...

...version is recommended for patients...

...reasonable to perform repeated cardioversio...

...Pharmacologic...

...etilide, propafenone, and intravenou...

...dministration of oral amiodarone is a reaso...

...r flecainide (“pill-in-the-pocket...

...apy should NOT be initiated out of hospital becaus...


...gure 4. Strategies for Rhythm Cont...


...Recommended Drug Doses for Pharmacological Ca...


...Table 13. Antiar...

...ng antiarrhythmic drug therapy, treat...

...tiarrhythmic drugs are recommended in pa...

...f the antiarrhythmic drug, including proarrhyth...

...ecause of its potential toxicities, amiodarone sho...

...ntrol strategy with pharmacological therapy...

...be reasonable to continue current antia...

70...

...nedarone. ( B , III (harm) )706...

...should NOT be used for treatment of AF in...


...Table 14....

...inhibitor or ARB is reasonable for...

...ACE inhibitor or ARB may be consider...

...py may be reasonable for primary prevention of...

...an ACE inhibitor, ARB, or statin is...


Table 15. Dosage and Safety Considerati...


...Tabl...

...er ablation is useful for symptomatic paroxys...

...ore consideration of AF catheter ablati...

...r ablation is reasonable for some patients with...

...ents with recurrent symptomatic paroxysmal...

...er ablation may be considered for sympto...

...atheter ablation may be reasonable...

...heter ablation may be considered before initiation...

...F catheter ablation should NOT be perfo...

...catheter ablation to restore sinu...


...Complications of Radiofrequency Catheter Abla...


...makers and Implantable Cardioverter-Def...


...Paroxysmal or persistent AF is common in ath...


...derly It is critical to consider...


...Table 18. Sur...

...cal ablation procedure is reasonabl...

...surgical ablation procedure may be reasonable fo...


...Tabl...

...ion is indicated in patients with HCM...

...tiarrhythmic medications can be useful to prevent...

...er ablation can be beneficial in patients...

...dofetilide, and dronedarone may be consi...


...Table 20. AF C...

...For patients with ACS and AF2 at increas...

...direct-current cardioversion of new-on...

...avenous beta blockers are recommended to slow a...

...If triple therapy (oral anticoagulant, aspirin, a...

...s with AF2 at increased risk of stroke (based on C...

...In patients with AF2 at increased risk...

...n patients with AF2 at increased risk of stro...

...therapy (oral anticoagulant, aspirin, and P2Y12 i...

...inistration of amiodarone or digoxin...

...ration of nondihydropyridine calcium antagonis...


...Table 21...

...ts with cardiac implantable electron...

...patients with cryptogenic stroke (i.e., stroke of...


...Table...

...weight and obese patients with AF, w...


...Table 23. Hyperthyroidism...

...ckers are recommended to control ventricular ra...

...tances in which a beta blocker cannot be used,...


...Table 24. Pu...

...ondihydropyridine calcium channel antag...

...rrent cardioversion should be attempted in...


...Table 25. WPW...

...rect-current cardioversion is recomme...

...nous procainamide or ibutilide to restore s...

...theter ablation of the accessory pathway is r...

...ration of intravenous amiodarone, adenosi...


...Table 26. Heart Fai...

...sting heart rate using either a beta blocker...

...nce of pre-excitation, intravenous...

...he absence of pre-excitation, intravenous d...

Assessment of heart rate control during exercise...

...ffective to control resting heart rate...

A combination of digoxin and a beta blocker (or a...

...to perform AV node ablation with ventricular...

Intravenous amiodarone can be usefu...

...patients with AF and RVR causing or suspected...

...ith chronic HF who remain symptomat...

...amiodarone may be considered when resting and exer...

...V node ablation may be considered when the rate c...

...tion should NOT be performed without a pharmaco...

...rate control, intravenous nondihydropyr...


...Table...

...ith AF and multigenerational family members...


...Table 28. Postop...

...s who develop AF after cardiac surgery...

...nondihydropyridine calcium channe...

...e administration of amiodarone redu...

...ble to restore sinus rhythm pharmacologically wit...

...easonable to administer antiarrhythmic medication...

...onable to administer antithrombotic...

...to manage well-tolerated, new-onset post...

...inistration of sotalol may be considere...

...dministration of colchicine may be considered...