Atrial Fibrillation Guidelines Pocket Guide & App

Atrial Fibrillation GUIDELINES Pocket Guide

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American College of Cardiology Foundation

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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

Table 1. Definitions

Term	Definitions
Paroxysmal AF	AF that terminates spontaneously or with intervention within 7 d of onset. Episodes may recur with variable frequency.
Persistent AF	Continuous AF that is sustained >7 d.
Longstanding persistent AF	Continuous AF of >12 mo duration.
Permanent AF	Permanent AF is used when there has been a joint decision by the patient and clinician to cease further attempts to restore and/or maintain sinus rhythm. Acceptance of AF represents a therapeutic attitude on the part of the patient and clinician rather than an inherent pathophysiological attribute of the AF. Acceptance of AF may change as symptoms, the efficacy of therapeutic interventions, and patient and clinician preferences evolve.
Nonvalvular AF	AF in the absence of rheumatic mitral stenosis, a mechanical or bioprosthetic heart valve, or mitral valve repair.

Figure 1. Atrial Tachycardias

Figure 2. Mechanisms of AF

Table 2. Clinical Evaluation

Recommendations	COR	LOE
ECG documentation is recommended to establish the diagnosis of AF.	I	C

Table 3. Initial Clinical Evaluation in Patients With AF

Minimum Evaluation
History and physical examination, to define	Presence and nature of symptoms associated with AF Clinical type of AF (paroxysmal, persistent, or permanent) Onset of the first symptomatic attack or date of discovery of AF Frequency, duration, precipitating factors, and modes of initiation or termination of AF Response to any pharmacological agents that have been administered Presence of any underlying heart disease or reversible conditions (e.g., hyperthyroidism or alcohol consumption)
ECG, to identify	Rhythm (verify AF) LVH P-wave duration and morphology or fibrillatory waves Pre-excitation Bundle-branch block Prior MI Other atrial arrhythmias To measure and follow the R-R, QRS, and QT intervals in conjunction with antiarrhythmic drug therapy
TTE, to identify	VHD LA and RA size LV and RV size and function Peak RV pressure (pulmonary hypertension) LV hypertrophy LA thrombus (low sensitivity) Pericardial disease
Blood tests of thyroid, renal, and hepatic function	For a first episode of AF When the ventricular rate is difficult to control
6-min walk test	If the adequacy of rate control is in question
Exercise testing	To reproduce exercise-induced AF To exclude ischemia before treatment of selected patients with a type IC^a antiarrhythmic drug
Holter or event monitoring	If diagnosis of the type of arrhythmia is in question As a means of evaluating rate control
TEE	To identify LA thrombus (in the LAA) To guide cardioversion
Electrophysiological study	To clarify the mechanism of wide–QRS-complex tachycardia To identify a predisposing arrhythmia such as atrial flutter or paroxysmal supraventricular tachycardia To seek sites for curative AF ablation or AV conduction block/modification
Chest radiograph, to evaluate	Lung parenchyma, when clinical findings suggest an abnormality Pulmonary vasculature, when clinical findings suggest an abnormality

^a Type IC refers to the Vaughan Williams classification of antiarrhythmic drugs.

Treatment

Table 4. Risk-Based Antithrombotic Therapy

Recommendations	COR	LOE
NEW: NOACs (dabigatran, rivaroxaban, apixaban, and edoxaban) are recommended over warfarin in NOAC-eligible patients with AF (except with moderate-to-severe mitral stenosis or a mechanical heart valve).	I	A
MODIFIED: In patients with AF, anticoagulant therapy should be individualized on the basis of shared decision-making after discussion of the absolute risks and relative risks of stroke and bleeding, as well as the patient’s values and preferences.	I	C
MODIFIED: Selection of anticoagulant therapy should be based on the risk of thromboembolism, irrespective of whether the AF pattern is paroxysmal, persistent, or permanent.	I	B
MODIFIED: In patients with AF (except with moderate-to-severe mitral stenosis or a mechanical heart valve), the CHA₂DS₂-VASc score is recommended for assessment of stroke risk.	I	B
MODIFIED: For patients with AF who have mechanical heart valves, warfarin is recommended.	I	B
MODIFIED: For patients with AF and an elevated CHA₂DS₂-VASc score of 2 or greater in men or 3 or greater in women, oral anticoagulants are recommended. Options include:
Warfarin (INR 2.0-3.0)	I	A
Dabigatran, rivaroxaban or apixaban		B
Edoxaban		B-R
MODIFIED: Among patients treated with warfarin, the international normalized ratio (INR) should be determined at least weekly during initiation of anticoagulant therapy and at least monthly when anticoagulation (INR in range) is stable.	I	A
MODIFIED: For patients with AF (except with moderate-to-severe mitral stenosis or a mechanical heart valve) who are unable to maintain a therapeutic INR level with warfarin, use of a NOAC is recommended.	I	C-EO
MODIFIED: Reevaluation of the need for and choice of anticoagulant therapy at periodic intervals is recommended to reassess stroke and bleeding risks.	I	C
MODIFIED: Renal function and hepatic function should be evaluated before initiation of a NOAC and should be reevaluated at least annually.	I	B-NR
MODIFIED: For patients with atrial flutter, anticoagulant therapy is recommended according to the same risk profile used for AF.	I	C
MODIFIED: For patients with AF (except with moderate-to-severe mitral stenosis or a mechanical heart valve) and a CHA₂DS₂-VASc score of 0 in men or 1 in women, it is reasonable to omit anticoagulant therapy.	IIa	B
MODIFIED: For patients with AF who have a CHA₂DS₂-VASc score of ≥2 in men or ≥3 in women and who have end-stage chronic kidney disease (CKD; creatinine clearance [CrCl] <15 mL/min) or are on dialysis, it might be reasonable to prescribe warfarin (INR 2.0 to 3.0) or apixaban for oral anticoagulation.	IIb	B-NR
MODIFIED: For patients with AF (except with moderate-to-severe mitral stenosis or a mechanical heart valve) and a CHA₂DS₂-VASc score of 1 in men and 2 in women, prescribing an oral anticoagulant to reduce thromboembolic stroke risk may be considered.	IIb	C-LD
MODIFIED: For patients with AF (except with moderate-to-severe mitral stenosis or a mechanical heart valve) and moderate-to-severe CKD (serum creatinine ≥1.5 mg/dL [apixaban], CrCl 15 to 30 mL/min [dabigatran], CrCl <50 mL/min [rivaroxaban], or CrCl 15 to 50 mL/min [edoxaban]) with an elevated CHA₂DS₂-VASc score, treatment with reduced doses of direct thrombin or factor Xa inhibitors may be considered (e.g., dabigatran, rivaroxaban, apixaban, or edoxaban).	IIb	B-R
In patients with AF undergoing percutaneous coronary intervention, bare-metal stents may be considered to minimize the required duration of dual antiplatelet therapy. Anticoagulation may be interrupted at the time of the procedure to reduce the risk of bleeding at the site of peripheral arterial puncture.	IIb	C
Following coronary revascularization (percutaneous or surgical) in patients with AF and a CHA₂DS₂-VASc score ≥2, it may be reasonable to use clopidogrel (75 mg QD) concurrently with oral anticoagulants but without aspirin.	IIb	B
MODIFIED: In patients with AF and end-stage CKD or on dialysis, the direct thrombin inhibitor dabigatran or the factor Xa inhibitors rivaroxaban or edoxaban are NOT recommended because of the lack of evidence from clinical trials that benefit exceeds risk.	III: No Benefit	C-EO
MODIFIED: The direct thrombin inhibitor dabigatran should NOT be used in patients with AF and a mechanical heart valve.	III: Harm	B-R

Table 5. Recommendations for Interruption and Bridging Anticoagulation

Recommendations	COR	LOE
Bridging therapy with unfractionated heparin (UFH) or low-molecular-weight heparin (LMWH) is recommended for patients with AF and a mechanical heart valve undergoing procedures that require interruption of warfarin. Decisions regarding bridging therapy should balance the risks of stroke and bleeding.	I	C
MODIFIED: For patients with AF without mechanical heart valves who require interruption of warfarin for procedures, decisions about bridging therapy (UFH or LMWH) should balance the risks of stroke and bleeding and the duration of time a patient will not be anticoagulated.	I	B-R
NEW: Idarucizumab is recommended for the reversal of dabigatran in the event of life-threatening bleeding or an urgent procedure.	I	B-NR
NEW: Andexanet alfa can be useful for the reversal of rivaroxaban and apixaban in the event of life-threatening or uncontrolled bleeding.	IIa	B-NR

Table 6. Cardiac Surgery/Percutaneous Approaches— LAA Occlusion/Excision

Recommendations	COR	LOE
NEW: Percutaneous LAA occlusion may be considered in patients with AF at increased risk of stroke who have contraindications to long-term anticoagulation.	IIb	B-NR
MODIFIED: Surgical occlusion of the LAA may be considered in patients with AF undergoing cardiac surgery, as a component of an overall heart team approach to the management of AF.	IIb	B-NR

Table 7. Comparison of the CHADS₂ and CHA₂DS₂-VASc Risk Stratification Scores for Subjects With Nonvalvular AF

Definition and Scores for CHADS₂ and CHA₂DS₂-VASc		Stroke Risk Stratification With the CHADS₂ and CHA₂DS₂-VASc Scores
	Score		Adjusted Stroke Rate (% per y)
CHADS₂		CHADS₂^a
Congestive HF	1	0	1.9
Hypertension	1	1	2.8
Age ≥75 y	1	2	4.0
Diabetes mellitus	1	3	5.9
Stroke/TIA/thromboembolic events (TE)	2	4	8.5
Maximum Score:	6	5	12.5
		6	18.2
CHA₂DS₂-VASc		CHA₂DS₂-VASc^b
Congestive HF	1	0	0
Hypertension	1	1	1.3
Age ≥75 y	2	2	2.2
Diabetes mellitus	1	3	3.2
Stroke/TIA/TE	2	4	4.0
Vascular disease (prior MI, PAD, or aortic plaque)	1	5	6.7
Age 65–74 y	1	6	9.8
Sex category (i.e., female sex)	1	7	9.6
Maximum Score:	9	8	6.7
		9	15.20

^a These adjusted stroke rates are based on data for hospitalized patients with AF and were published in 2001. Because stroke rates are decreasing, actual stroke rates in contemporary nonhospitalized cohorts might vary from these estimates.
^b Adjusted stroke rate scores are based on data from Lip and colleagues. Actual rates of stroke in contemporary cohorts might vary from these estimates.

Table 8. Dose Selection of Oral Anticoagulant Options for Patients with Nonvalvular AF and CKD (Based on Prescribing Information for the United States)^a

Renal Function	Warfarin	Dabigatran^b	Rivaroxaban^b	Apixaban^b
Normal/Mild Impairment	Dose adjusted for INR 2.0-3.0	150 mg BID (CrCl >30 mL/min)	20 mg QD with the evening meal (CrCl >50 mL/min)	5.0 or 2.5 mg BID^c
Moderate Impairment	Dose adjusted for INR 2.0-3.0	150 mg BID (CrCl >30 mL/min)	15 mg QD with the evening meal (CrCl 30-50 mL/min)	5.0 or 2.5 mg BID^c
Severe Impairment	Dose adjusted for INR 2.0-3.0^d	75 mg BID^e (CrCl 15-30 mL/min)	15 mg QD with the evening meal (CrCl 15-30 mL/min)	No recommendation^f
End-Stage CKD Not on Dialysis	Dose adjusted for INR 2.0-3.0^d	Not recommended^f (CrCl <15 mL/min)	Not recommended^f (CrCl <15 mL/min)	No recommendation^f
End-Stage CKD on Dialysis	Dose adjusted for INR 2.0-3.0^d	Not recommended^f (CrCl <15 mL/min)	Not recommended^f (CrCl <15 mL/min)	No recommendation^f,g

^a Renal function should be evaluated prior to initiation of direct thrombin or factor Xa inhibitors and should be reevaluated when clinically indicated and at least annually. CrCl should be measured using the Crockoft-Gault method.
^b The concomitant use of P-glycoprotein inducers or inhibitors with dabigatran, or the concomitant use of dual P-glycoprotein and strong CYP3A4 inducers or inhibitors with either rivaroxaban or apixaban, particularly in the setting of CKD, may require dosing adjustment or avoidance of concomitant drug use (see the FDA drug label at http://www.accessdata.fda.gov/drugsatfda_docs/label/2014/202155s002lbl.pdf ).
^c Use apixaban 2.5 mg BID if any 2 patient characteristics present: Cr ≥ 1.5 mg/dL, ≥80 years of age, body weight ≤60 kg. Apixaban is not recommended in patients with severe hepatic impairment.
^d Dose-adjusted warfarin has been used, but observational data regarding safety and efficacy are conflicting.
^e Modeling studies suggest that dabigatran 75 mg BID might be safe for patients with CrCl 15-30 mL/min, but this has not been validated in a prospective cohort. Some countries outside the United States use 110 mg BID.
^f No published studies support a dose for this level of renal function.
^g In patients with end-stage CKD on stable hemodialysis, prescribing information indicates the use of apixaban 5 mg BID with dose reduction to 2.5 mg BID if the patient is either ≥80 years of age or body weight ≤60 kg.

Table 9. Rate Control

Recommendations	COR	LOE
Control of the ventricular rate using a beta blocker or nondihydropyridine calcium channel antagonist is recommended for patients with paroxysmal, persistent, or permanent AF.	I	B
IV administration of a beta blocker or nondihydropyridine calcium channel blocker is recommended to slow ventricular heart rate in the acute setting in patients without pre-excitation. In hemodynamically unstable patients, electrical cardioversion is indicated.	I	B
In patients who experience AF-related symptoms during activity, the adequacy of heart rate control should be assessed during exertion, adjusting pharmacological treatment as necessary to keep the ventricular rate within the physiological range.	I	C
A heart rate control (resting heart rate <80 bpm) strategy is reasonable for symptomatic management of AF.	IIa	B
IV amiodarone can be useful for rate control in critically ill patients without pre-excitation.	IIa	B
AV nodal ablation with permanent ventricular pacing is reasonable to control heart rate when pharmacological therapy is inadequate and rhythm control is not achievable.	IIa	B
Lenient rate control strategy (resting heart rate <110 bpm) may be reasonable as long as patients remain asymptomatic and LV systolic function is preserved.	IIb	B
Oral amiodarone may be useful for ventricular rate control when other measures are unsuccessful or contraindicated.	IIb	C
AV nodal ablation with permanent ventricular pacing should NOT be performed to improve rate control without prior attempts to achieve rate control with medications.	III: Harm	C
Nondihydropyridine calcium channel antagonists should NOT be used in patients with decompensated HF as these may lead to further hemodynamic compromise.	III: Harm	C
In patients with pre-excitation and AF, digoxin, nondihydropyridine calcium channel antagonists, or intravenous amiodarone should NOT be administered as they may increase the ventricular response and may result in ventricular fibrillation.	III: Harm	B
Dronedarone should NOT be used to control the ventricular rate in patients with permanent AF as it increases the risk of the combined endpoint of stroke, MI, systemic embolism, or cardiovascular death.	III: Harm	B

Figure 3. Approach to Selecting Drug Therapy for Ventricular Rate Control^a

Table 10. Common Medication Dosage for Rate Control of AF

	Intravenous Administration	Usual Oral Maintenance Dose
Beta blockers
Metoprolol tartrate	2.5-5.0 mg IV bolus over 2 min; up to 3 doses	25-100 mg BID
Metoprolol XL (succinate)	N/A	50-400 mg QD
Atenolol	N/A	25-100 mg QD
Esmolol	500 mcg/kg IV bolus over 1 min, then 50-300 mcg/kg/min IV	N/A
Propranolol	1 mg IV over 1 min, up to 3 doses at 2-min intervals	10-40 mg TID or QID
Nadolol	N/A	10-240 mg QD
Carvedilol	N/A	3.125-25 mg BID
Bisoprolol	N/A	2.5-10 mg QD
Nondihydropyridine calcium channel antagonists
Verapamil	0.075-0.15 mg/kg IV bolus over 2 min, may give an additional 10.0 mg after 30 min if no response, then 0.005 mg/kg/min infusion	180-480 mg QD (ER)
Diltiazem	0.25 mg/kg IV bolus over 2 min, then 5-15 mg/h	120-360 mg QD (ER)
Digitalis glycosides
Digoxin	0.25 mg IV with repeat dosing to a maximum of 1.5 mg over 24 h	0.125-0.25 mg QD
Others
Amiodarone^a	300 mg IV over 1 h, then 10-50 mg/h over 24 h	100-200 mg QD

^a Multiple dosing schemes exist for the use of amiodarone.

Table 11. Electrical and Pharmacological Cardioversion of AF and Atrial Flutter

Recommendations	COR	LOE
Prevention of Thromboembolism
MODIFIED: For patients with AF or atrial flutter of ≥48 hours’ duration, or when the duration of AF is unknown, anticoagulation with warfarin (INR 2.0 to 3.0), a factor Xa inhibitor, or direct thrombin inhibitor is recommended for ≥3 weeks before and ≥4 weeks after cardioversion, regardless of the CHA₂DS₂-VASc score or the method (electrical or pharmacological) used to restore sinus rhythm.	I	B-R
For patients with AF or atrial flutter of >48 hours duration or unknown duration that requires immediate cardioversion for hemodynamic instability, anticoagulation should be initiated as soon as possible and cont'd for ≥4 weeks after cardioversion unless contraindicated.	I	C
MODIFIED: After cardioversion for AF of any duration, the decision about long-term anticoagulation therapy should be based on the thromboembolic risk profile and bleeding risk profile.	I	C-EO
MODIFIED: For patients with AF or atrial flutter of <48 hours’ duration with a CHA₂DS₂-VASc score of ≥2 in men and ≥3 in women, administration of heparin, a factor Xa inhibitor, or a direct thrombin inhibitor is reasonable as soon as possible before cardioversion, followed by long-term anticoagulation therapy.	IIa	B-NR
For patients with AF or atrial flutter of ≥48 hours duration or of unknown duration who have not been anticoagulated for the preceding 3 weeks, it is reasonable to perform TEE before cardioversion and proceed with cardioversion if no LA thrombus is identified, including in the LAA, provided that anticoagulation is achieved before TEE and maintained after cardioversion for ≥4 weeks.	IIa	B
For patients with AF or atrial flutter of ≥48 hour duration or when duration of AF is unknown, anticoagulation with dabigatran, rivaroxaban, or apixaban is reasonable for ≥3 weeks before and 4 weeks after cardioversion.	IIa	C
MODIFIED: For patients with AF or atrial flutter of less than 48 hours’ duration with a CHA₂DS₂-VASc score of 0 in men or 1 in women, administration of heparin, a factor Xa inhibitor, or a direct thrombin inhibitor, versus no anticoagulant therapy, may be considered before cardioversion, without the need for postcardioversion oral anticoagulation.	IIb	B-NR
Direct-Current Cardioversion
In pursuing a rhythm-control strategy, cardioversion is recommended for patients with AF or atrial flutter as a method to restore sinus rhythm. If cardioversion is unsuccessful, repeated attempts at direct-current cardioversion may be made after adjusting the location of the electrodes, applying pressure over the electrodes or following administration of an antiarrhythmic medication.	I	B
Cardioversion is recommended when a RVR to AF or atrial flutter does not respond promptly to pharmacological therapies and contributes to ongoing myocardial ischemia, hypotension, or HF.	I	C
Cardioversion is recommended for patients with AF or atrial flutter and pre-excitation when tachycardia is associated with hemodynamic instability.	I	C
It is reasonable to perform repeated cardioversions in patients with persistent AF, provided that sinus rhythm can be maintained for a clinically meaningful period between cardioversion procedures. Severity of AF symptoms and patient preference should be considered when embarking on a strategy requiring serial cardioversion procedures.	IIa	C
Pharmacological Cardioversion
Flecainide, dofetilide, propafenone, and intravenous ibutilide are useful for pharmacological cardioversion of AF or atrial flutter, provided contraindications to the selected drug are absent.	I	A
Administration of oral amiodarone is a reasonable option for pharmacological cardioversion of AF.	IIa	A
Propafenone or flecainide (“pill-in-the-pocket”) in addition to a beta blocker or nondihydropyridine calcium channel antagonist is reasonable to terminate AF outside the hospital once this treatment has been observed to be safe in a monitored setting for selected patients.	IIa	B
Dofetilide therapy should NOT be initiated out of hospital because of the risk of excessive QT prolongation that can cause torsades de pointes.	III: Harm	B

Figure 4. Strategies for Rhythm Control in Patients With Paroxysmal^a and Persistent AF^b

Table 12. Recommended Drug Doses for Pharmacological Cardioversion of AF

Drug	Route of Administration	Dosage		Potential Adverse Effects
Amiodarone^a	Oral	600-800 mg QD in divided doses to a total load of ≤10 g, then 200 mg QD as maintenance		Phlebitis (IV), hypotension, bradycardia, QT prolongation, torsades de pointes (rare), GI upset, constipation, increased INR
Amiodarone^a	IV	150 mg over 10 min, then 1 mg/min for 6 h, then 0.5 mg/min for 18 h or change to oral dosing
Dofetilide	Oral	CrCl (mL/min)	Dose (mcg BID)	QT prolongation, torsades de pointes; adjust dose for renal function, body size, and age
Dofetilide	Oral	>60 40-60 20-40 <20	500 250 125 Not recommended
Flecainide	Oral	200-300 mg × 1^b		Hypotension, atrial flutter with 1:1 AV conduction, ventricular proarrhythmia; avoid in patients with CAD and significant structural heart disease
Ibutilide	IV	1 mg over 10 min; may repeat 1 mg once if necessary (weight <60 kg use 0.01 mg/kg)		QT prolongation, torsades de pointes, hypotension
Propafenone	Oral	450-600 mg × 1^b		Hypotension, atrial flutter with 1:1 AV conduction, ventricular proarrhythmia; avoid in patients with CAD and significant structural heart disease

^a Multiple dosing schemes exist for the use of amiodarone.
^b Recommended given in conjunction with a beta blocker or nondihydropyridine calcium channel antagonist administered ≥30 minutes before administering the Vaughan Williams Class IC agent.

Table 13. Antiarrhythmic Drugs to Maintain Sinus Rhythm

Recommendations	COR	LOE
Before initiating antiarrhythmic drug therapy, treatment of precipitating or reversible causes of AF is recommended.	I	C
The following antiarrhythmic drugs are recommended in patients with AF to maintain sinus rhythm, depending on underlying heart disease and comorbidities: Amiodarone Dofetilide Dronedarone Flecainide Propafenone Sotalol	I	A
The risks of the antiarrhythmic drug, including proarrhythmia, should be considered before initiating therapy with each drug.	I	C
Because of its potential toxicities, amiodarone should only be used after consideration of risks and when other agents have failed or are contraindicated.	I	C
A rhythm-control strategy with pharmacological therapy can be useful in patients with AF for the treatment of tachycardia-induced cardiomyopathy.	IIa	C
It may be reasonable to continue current antiarrhythmic drug therapy in the setting of infrequent, well-tolerated recurrences of AF when the drug has reduced the frequency or symptoms of AF.	IIb	C
Antiarrhythmic drugs for rhythm control should NOT be continued when AF becomes permanent, including dronedarone.	III: Harm	C
	III: Harm	B
Dronedarone should NOT be used for treatment of AF in patients with NYHA class III and IV HF or patients who have had an episode of decompensated HF in the past 4 weeks.	III: Harm	B

Table 14. Upstream Therapy

Recommendations	COR	LOE
An ACE inhibitor or ARB is reasonable for primary prevention of new-onset AF in patients with HF with reduced LVEF.	IIa	B
Therapy with an ACE inhibitor or ARB may be considered for primary prevention of new-onset AF in the setting of hypertension.	IIb	B
Statin therapy may be reasonable for primary prevention of new-onset AF after coronary artery surgery.	IIb	A
Therapy with an ACE inhibitor, ARB, or statin is NOT beneficial for primary prevention of AF in patients without cardiovascular disease.	III: No Benefit	B

Table 15. Dosage and Safety Considerations for Maintenance of Sinus Rhythm in AF

Drug	Usual Doses	Exclude/Use With Caution	Major Pharmacokinetic Drug Interactions
Vaughan Williams Class IA
Disopyramide	Immediate release: 100-200 mg once every 6 h Extended release: 200-400 mg once every 12 h	HF Prolonged QT interval Prostatism, glaucoma Avoid other QT interval-prolonging drugs	Metabolized by CYP3A4: caution with inhibitors (e.g., verapamil, diltiazem, ketoconazole, macrolide antibiotics, protease inhibitors, grapefruit juice) and inducers (e.g., rifampin, phenobarbital, phenytoin)
Quinidine	324-648 mg every 8 h	Prolonged QT interval Diarrhea	Inhibits CYP2D6: ↑concentrations of tricyclic antidepressants, metoprolol, antipsychotics; ↓efficacy of codeine Inhibits P-glycoprotein: ↑digoxin concentration
Vaughan Williams Class IC
Flecainide	50-200 mg once every 12 h	Sinus or AV node dysfunction HF CAD Atrial flutter Infranodal conduction disease Brugada syndrome Renal or liver disease	Metabolized by CYP2D6 (inhibitors include quinidine, fluoxetine, tricyclics; also genetically absent in 7%-10% of population) and renal excretion (dual impairment can ↑↑plasma concentration)
Propafenone	Immediate release: 150-300 mg once every 8 h Extended release: 225-425 mg once every 12 h	Sinus or AV node dysfunction HF CAD Atrial flutter Infranodal conduction disease Brugada syndrome Liver disease Asthma	Metabolized by CYP2D6 (inhibitors include quinidine, fluoxetine, tricyclics; also genetically absent in 7%-10% of population)—poor metabolizers have ↑beta blockade Inhibits P-glycoprotein: ↑digoxin concentration Inhibits CYP2C9: ↑warfarin concentration (↑INR 25%)
Vaughan Williams Class III
Amiodarone	Oral: 400-600 mg QD in divided doses for 2-4 wk; maintenance typically 100- 200 mg QD IV: 150 mg over 10 min; then 1 mg/min for 6 h; then 0.5 mg/min for 18 h or change to oral dosing; after 24 h, consider decreasing dose to 0.25 mg/min	Sinus or AV node dysfunction Infranodal conduction disease Lung disease Prolonged QT interval	Inhibits most CYPs to cause drug interaction: ↑concentrations of warfarin (↑INR 0%-200%), statins, many other drugs Inhibits P-glycoprotein: ↑digoxin concentration
Dofetilide	125-500 mcg once every 12 h	Prolonged QT interval Renal disease Hypokalemia Hypomagnesemia Diuretic therapy Avoid other QT interval-prolonging drugs	Primary renal elimination involving glomerular filtration and active tubular secretion: verapamil, HCTZ, cimetidine, ketoconazole, trimethoprim, prochlorperazine, and megestrol are contraindicated; discontinue amiodarone ≥3 mo before initiation
Dronedarone	400 mg once every 12 h	Bradycardia HF Long-standing persistent AF/flutter Liver disease Prolonged QT interval	Metabolized by CYP3A: caution with inhibitors (e.g., verapamil, diltiazem, ketoconazole, macrolide antibiotics, protease inhibitors, grapefruit juice) and inducers (e.g., rifampin, phenobarbital, phenytoin) Inhibits CYP3A, CYP2D6, P-glycoprotein: ↑concentrations of some statins, sirolimus, tacrolimus, beta blockers, digoxin
Sotalol	40-160 mg once every 12 h	Prolonged QT interval Renal disease Hypokalemia Hypomagnesemia Diuretic therapy Avoid other QT interval-prolonging drugs Sinus or AV nodal dysfunction HF Asthma	None (renal excretion)

Table 16. AF Catheter Ablation to Maintain Sinus Rhythm

Recommendations	COR	LOE
AF catheter ablation is useful for symptomatic paroxysmal AF refractory or intolerant to at least 1 class I or III antiarrhythmic medication when a rhythm-control strategy is desired.	I	A
Before consideration of AF catheter ablation, assessment of the procedural risks and outcomes relevant to the individual patient is recommended.	I	C
AF catheter ablation is reasonable for some patients with symptomatic persistent AF refractory or intolerant to at least 1 class I or III antiarrhythmic medication.	IIa	A
In patients with recurrent symptomatic paroxysmal AF, catheter ablation is a reasonable initial rhythm-control strategy before therapeutic trials of antiarrhythmic drug therapy, after weighing the risks and outcomes of drug and ablation therapy.	IIa	B
AF catheter ablation may be considered for symptomatic long-standing (>12 months) persistent AF refractory or intolerant to at least 1 class I or III antiarrhythmic medication when a rhythm-control strategy is desired.	IIb	B
NEW: AF catheter ablation may be reasonable in selected patients with symptomatic AF and HF with reduced left ventricular (LV) ejection fraction (HFrEF) to potentially lower mortality rate and reduce hospitalization for HF.	IIb	B-R
AF catheter ablation may be considered before initiation of antiarrhythmic drug therapy with a class I or III antiarrhythmic medication for symptomatic persistent AF when a rhythm-control strategy is desired.	IIb	C
AF catheter ablation should NOT be performed in patients who cannot be treated with anticoagulant therapy during and following the procedure.	III: Harm	C
AF catheter ablation to restore sinus rhythm should NOT be performed with the sole intent of obviating the need for anticoagulation.	III: Harm	C

Table 17. Complications of Radiofrequency Catheter Ablation for AF

Complication	Symptoms/Signs	Treatment
Air embolism	Acute ischemia, cardiac arrest, AV block, hypotension	Supplemental oxygen, fluids, CPR, or pacing if indicated
Atrial-esophageal fistula	Usually 1-4 wk after ablation, dysphagia, unexplained fever, chills, sepsis, neurological events (septic emboli)	CT or MRI of esophagus, avoiding endoscopy, immediate surgical correction
Cardiac tamponade/perforation	Abrupt or gradual fall in blood pressure	Pericardiocentesis, emergent surgical drainage if pericardiocentesis fails
Phrenic nerve injury resulting in diaphragmatic paralysis	Shortness of breath, elevated hemidiaphragm	None, usually resolves spontaneously
Iatrogenic atrial flutter	Tachycardia	Cardioversion, antiarrhythmic drugs, or repeat ablation
Gastric motility disorder	Nausea, vomiting, bloating, abdominal pain	Depends on severity of symptoms
Mitral valve injury requiring surgery	Entrapment of catheter	Advance sheath with gentle catheter retraction, surgical removal
MI	Chest pain, ST changes, hypotension	Standard therapy
Pericarditis	Chest pain, typical quality	NSAIDs, colchicine, steroids
Pulmonary vein stenosis	Shortness of breath, cough, hemoptysis	PV dilation/stent or no therapy
Radiation injury	Pain and reddening at radiation site, can present late	Treat as burn injury
Stroke or TIA	Neurological deficit	Consider lysis therapy
Death	N/A	N/A
Vascular access complication
Femoral pseudoaneurysm	Pain or pulsatile mass at groin	Observation, compression, thrombin injection, possible surgery
Arteriovenous fistula	Pain, bruit at groin site	Observation, compression, possible surgery
Hematoma	Pain, swelling	Compression
Death	N/A	N/A

Pacemakers and Implantable Cardioverter-Defibrillators in the Management of AF

The primary role of pacemakers in the treatment of patients with AF is to treat of symptomatic bradycardia. Permanent pacing is not indicated for the prevention of AF in patients without other indications for pacemaker implantation.

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Atrial Fibrillation GUIDELINES Pocket Guide

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Key Points

Diagnosis

Table 1. Definitions

Figure 1. Atrial Tachycardias

Figure 2. Mechanisms of AF

Table 2. Clinical Evaluation

Table 3. Initial Clinical Evaluation in Patients With AF

Treatment

Table 4. Risk-Based Antithrombotic Therapy

Table 5. Recommendations for Interruption and Bridging Anticoagulation

Table 6. Cardiac Surgery/Percutaneous Approaches— LAA Occlusion/Excision

Table 7. Comparison of the CHADS2 and CHA2DS2-VASc Risk Stratification Scores for Subjects With Nonvalvular AF

Table 8. Dose Selection of Oral Anticoagulant Options for Patients with Nonvalvular AF and CKD (Based on Prescribing Information for the United States)a

Table 9. Rate Control

Figure 3. Approach to Selecting Drug Therapy for Ventricular Rate Controla

Table 10. Common Medication Dosage for Rate Control of AF

Table 11. Electrical and Pharmacological Cardioversion of AF and Atrial Flutter

Figure 4. Strategies for Rhythm Control in Patients With Paroxysmala and Persistent AFb

Table 12. Recommended Drug Doses for Pharmacological Cardioversion of AF

Table 13. Antiarrhythmic Drugs to Maintain Sinus Rhythm

Table 14. Upstream Therapy

Table 15. Dosage and Safety Considerations for Maintenance of Sinus Rhythm in AF

Table 16. AF Catheter Ablation to Maintain Sinus Rhythm

Table 17. Complications of Radiofrequency Catheter Ablation for AF

Pacemakers and Implantable Cardioverter-Defibrillators in the Management of AF

Table 7. Comparison of the CHADS₂ and CHA₂DS₂-VASc Risk Stratification Scores for Subjects With Nonvalvular AF

Table 8. Dose Selection of Oral Anticoagulant Options for Patients with Nonvalvular AF and CKD (Based on Prescribing Information for the United States)^a

Figure 3. Approach to Selecting Drug Therapy for Ventricular Rate Control^a

Figure 4. Strategies for Rhythm Control in Patients With Paroxysmal^a and Persistent AF^b