-
Acute AF w/ rapid ventricular response
Without acute medical illness/post noncardiac surgery Assess hemodynamic stability. If unstable, perform immediate synchronized cardioversion [I][C]. If unstable or severely depressed LVEF, consider IV amiodarone, digoxin, or esmolol for HR control [II][B]. If stable, consider electric cardioversion as initial strategy, or after failed pharmacologic cardioversion. If stable, rate control is reasonable strategy. Electrical cardioversion preferred if: - Pt able to tolerate sedation
- Desires immediate conversion
- Failed/not candidate for pharm conversion
If stable and pharm conversion preferred, multiple drug options: - ibutilide (≥60 kg: 1 mg over 10min; <60 kg: 0.01 mg/kg over 10min). If arrhythmia does not terminate w/in 10min after 1st infusion, may administer a 2nd dose. Rapid onset. AEs: nonsustained VT, QT prolongation, TdP. Avoid if LVEF ≤40%.
- amiodarone (5-7 mg/kg or 300 mg, then 1200-3000 mg IV over 24h). Slow onset (8-12h). AEs: bradycardia, hypotension, QT prolongation, phlebitis, TdP. May use if LVEF ≤40%.
- procainamide (1 g IV over 30min, then 2 mg/min over 1h). Less effective than ibutilide. AEs: granulocytosis, AV block, HFrEF exacerbation, hypotension, neutropenia, QT prolongation, rash, thrombocytopenia, TdP. Avoid if initially treated w/ amiodarone or ibutilide. Consider only if ibutilide or amiodarone not optimal. Considered safe in pregnancy.
- IV sotalol not recommended.
If stable and rate control preferred, BBs or non-DHP CCBs (verapamil, diltiazem; if EF >40%) preferred meds. - Target rate guided by sx. Generally, goal HR <100-110.
- If known mod-severe LV dysfunction, w/ or w/o decompensated HF, avoid non-DHP CCBs.
- If BBs/CCBs ineffective or contraindicated, consider digoxin alone or in combo w/ BBs/CCBs.
- Consider adding IV Mg to achieve and maintain rate control.
- If critically ill or decompensated HF and BBs/CCBs infective/contraindicated, consider IV amiodarone.
- BB options:
◦ metoprolol 2.5- to 5-mg bolus over 2min, up to 3 doses
◦ esmolol 500-mcg/kg bolus over 1min, then 50-300 mcg/kg/min
◦ propranolol 1 mg over 1min, repeat q2min prn, up to 3 doses - Non-DHP CCB options (avoid in HFrEF):
◦ diltiazem 0.25 mg/kg over 2min. May repeat 0.35 mg/kg over 2min, then 5-15 mg/h continuous infusion.
◦ verapamil 5-10 mg over 2min. May repeat x2, then 5 mg/h continuous infusion (max 20 mg/h).
If refractory to rate-control meds and noncandidate/failed rhythm control, AVNA can improve sx and QOL but creates dependence on pacing. - Consider consequences of lifelong pacemaker implantation, esp. w/ respect to age and comorbidities in decision-making regarding benefit.
- No evidence supports AVNA as 1st-line tx.
- Implant pacemaker before or same day as ablation to ensure adequacy of pacing leads prior to ablation.
- Program initial pacemaker lower rate to 80-90 bpm to reduce risk of sudden death.
With acute medical illness/post noncardiac surgery If hemodynamically unstable due to AF, DC cardioversion. If stable, then rate and/or rhythm control. Treat underlying illness. Detect and treat potential triggers, optimize hemodynamics, assess risks/benefits of anticoagulation. Counsel about risks of recurrent AF. - Individualize rate vs. rhythm control to balance AF impact on hemodynamics vs. ability to tolerate tx.
- If AF in setting of sepsis, benefits of anticoagulation during critical illness uncertain.
- Base decisions about anticoagulation on risk stratification of pt and comorbidities. Consider timing, bleeding risks, and complexity of acute illness.
- Refer for outpt f/u for rhythm monitoring, lifestyle and risk factor modification, risk stratification for OAC initiation or continuation, need for continued rhythm/rate control.
If hemodynamically unstable or poorly tolerated sx, DC cardioversion. If stable, rate control w/ BB/non-DHP CCB (target HR <100) or rhythm control equal options. - If AF >48h, consider imaging to r/o thrombus before cardioversion.
- Post-op amiodarone recommended [I][A].
- Anticoagulate x60 days when deemed safe regarding surgical bleeding.
- If rate control strategy used, perform rhythm assessment at 30-60 days post-op. If persistent AF, consider anticoagulation and cardioversion.
-
Ongoing/acute AF, nonrapid ventricular response
Without HF, awaiting decision about rate- or rhythm-control approach In all pts, perform basic clinical eval, address modifiable risk factors (obesity, physical inactivity, EtOH consumption, smoking, DM, HTN), and assess stroke risk to determine need for anticoagulation ( CHA2DS2-VASc). Focus early on ongoing mgmt to maintain SR and minimize AF burden. Basic eval: - Assess sx and AF burden.1
- Confirm rhythm w/ 12-lead ECG.
- CBC, CMP, TSH, HbA1c
- Transthoracic echo when it will guide mgmt [I][C]
- In newly diagnosed AF, routine testing for ischemia, ACS, or PE not indicated unless s/sx suggest these diseases.
- Consider in select pts: ambulatory ECG monitoring to assess burden and rate control; exercise ECG to evaluate rate control/effects of class IC antiarrhythmics; NT-proBNP, troponin to investigate CV dz; TEE to assess for thrombus/valve dz; if ischemia suspected, coronary CT/angiography/imaging; CMR to evaluate for cardiomyopathies/plan interventions; brain imaging and cognitive function tests to evaluate for cerebrovascular dz/dementia risk.
Risk factor modifications: - If overweight/obese, target 10% wt loss to reduce AF sx, burden, recurrence, and progression to persistent [I][B]. If BMI ≥40, consider bariatric surgery [IIb][C].
- Initiate tailored exercise program to improve fitness and reduce AF recurrence [I][B].
- Stop smoking to mitigate increased risk of AF-related CV complications and other adverse outcomes.
- Reduce EtOH use (≤3 drinks/wk, or ≤30 g/wk) to reduce AF recurrence and burden [I][B].
- Caffeine abstention has no benefit in preventing AF but may reduce sx in pts who report caffeine as trigger.
- If HTN, prescribe BP-lowering tx (ACE/ARB preferred), target 120-129 mm Hg / 70-79 mm Hg in most adults (or as low as reasonably achievable) [I][B].
- Manage OSA [IIb][B]. Do not screen for OSA w/ sx-based questionnaires only [II][B].
- Target effective glycemic control [I][C].
Risk stratification for thrombosis risk and anticoagulation: - Use validated score (e.g., CHA2DS2-VASc preferred w/o consideration of sex/gender). If CHA2DS2-VASc score ≥2, anticoagulate [I][C]; if CHA2DS2-VASc score ≥1, consider anticoagulation [IIa][C].
- Consider other factors that might modify their stroke risk to help inform the decision (e.g., BMI ≥30 kg/m^2, HCM, poorly controlled HTN, eGFR <45 mL/h, proteinuria >150 mg/24h, enlarged LA).
- Stroke risk is based on score and risk factors, not AF pattern [III].
- If congenital heart dz or HCM, anticoagulate regardless of stroke risk score.
- Re-evaluate risks periodically [I][B].
- Assess and manage bleeding risks (control BP, prior bleeding, interacting meds) [I][B].
- Do not use bleeding risk score to withhold anticoagulation [III][B].
- Consider and manage potentially modifiable bleeding risk factors:
◦ Anemia
◦ Reduced plt count or function
◦ Renal impairment
◦ Risk of falls
◦ DM
◦ CHF - Consider impact of nonmodifiable risk factors w/ shared decision making:
◦ Age
◦ Previous major bleeding
◦ Severe renal impairment, dialysis, or renal transplant
◦ Severe hepatic dysfunction or cirrhosis
◦ Malignancy
◦ Genetic factors (e.g., CYP2C9 polymorphisms)
◦ Previous stroke
◦ Cognitive impairment or dementia
◦ Intracerebral pathology - Contraindications to long-term anticoagulation:
◦ Severe bleeding due to a nonreversible cause involving the GI, pulmonary, or GU systems
◦ Primary intracranial tumors/cerebral amyloid angiopathy - Long-term anticoagulation reasonable if:
◦ Temporary bleeding condition and source managed
Considerations for rhythm vs. rate control: - Consider rhythm control in all suitable AF pts, w/ explicit discussion of benefits and risks.
- Consider implementation of a rhythm control strategy w/in 12mo of dx in selected patients w/ AF at risk of thromboembolic events, to reduce the risk of cardiovascular death or hospitalization [II][B].
- If reduced LV function, trial of rhythm control recommended to evaluate if AF is contributing to reduced LV function. Consider trial of electrical cardioversion as diagnostic tool [IIa][C].
- If symptomatic, rhythm control can improve sx. If uncertain about sx being due to AF, rhythm control trial may clarify. Consider trial of electrical cardioversion as diagnostic tool [IIa][C].
- If AF dx <1y, rhythm control can reduce hospitalizations, stroke, and mortality.
- If HF, rhythm control reduces mortality and hospitalizations for HF and ischemia.
- Rhythm control can reduce likelihood of AF progression.
- If adult w/ congenital heart dz, rhythm control preferred.
- If hx of pulm HTN, rhythm control preferred.
- Rhythm control may reduce development of dementia or worsening cardiac structural abnormalities.
- Avoid AAD tx in pts w/ advanced conduction disturbances unless antibradycardia pacing provided [III][C].
- Rhythm control favored if:
◦ Suspected tachycardiomyopathy
◦ Brief AF hx
◦ Nondilated LA
◦ Pt preference - Rate control favored if:
◦ Pt preference
◦ Older age
◦ Longer AF hx
◦ Fewer sx
◦ Easily controlled HR
◦ Larger LA
◦ Less LV dysfunction
◦ Less AV regurgitation
◦ No or minor sx1
◦ Risks of restoring SR > benefits1
Footnotes 1 Van Gelder IC, et al. 2024 ESC Guidelines for the management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J. 2024 Sep 29;45(36):3314-3414. Full-text article
Without HF, rate-control approach desired No anti-coag risk factors Long-term rate control w/ BBs or non-DHP CCBs as 1st line [I][B] - If BBs/CCBs contraindicated, not tolerated, or not preferred, digoxin is option [I][B]. Target digoxin level <1.2 ng/mL. May be used in combo w/ BBs/CCBs.
- If pregnant, BB or digoxin 1st line for rate control.
- Target HR based on sx. Aim for <110 bpm. Reserve stricter control for those w/ ongoing AF-related sx [IIa][B].
- Consider combo tx if single drug doesn’t control sx/HR, and avoid bradycardia w/ close monitoring [IIa][C].
- Reserve amiodarone, sotalol for rhythm control. Avoid dronedarone.
If refractory to rate-control meds and noncandidate/failed rhythm control, or severely symptomatic w/ >1 hospitalization for HF, consider AVNA w/ pacemaker implantation tx to reduce sx, physical limitations, recurrent HF hospitalizations, and mortality [II][B]. Creates dependence on pacing. - Consider consequences of lifelong pacemaker implantation, esp. w/ respect to age and comorbidities in decision-making regarding benefit.
- Procedure has low complication rate and low long-term mortality risk.
- No evidence supports AVNA as 1st-line tx.
- Implant pacemaker a few weeks before ablation to ensure adequacy of pacing leads prior to ablation.
- Program initial pacemaker lower rate to 70-90 bpm to reduce risk of sudden death.
Anticoagulate based on CHA2DS2-VASc score. DOACs preferred. Reassess thromboembolic risk at periodic interval to ensure anticoagulation started in appropriate pts [I][B]. - If CHA2DS2-VASc score ≥2, anticoagulate [I][C].
- If CHA2DS2-VASc score ≥1, consider anticoagulation [IIa][C].
- If hypertrophic cardiomyopathy or cardiac amyloidosis, anticoagulate regardless of CHA2DS2-VASc score [I][B].
- Use DOAC vs. VKA unless mech valve/mod-severe mitral stenosis [I][A].
- Avoid reduced-dose DOAC unless pt meets DOAC-specific criteria [III][B].
- If stroke risk <1% per year, no anticoagulation. Aspirin not recommended.
- Aspirin alone or w/ clopidogrel not recommended as alternative to anticoagulation.
- Do not combine antiplatelets w/ anticoagulation [III].
- If mitral stenosis or mech heart valve, warfarin 1st line.
- If post bariatric surgery, warfarin 1st line due to concerns about DOAC absorption.
- If hx/active CA, DOACs 1st line.
- Consider drug interactions when prescribing warfarin and DOACs, esp. CYP3A4 and/or p-glycoprotein inhibitors or inducers. May require altered dosing.
- DOAC options
◦ Direct thrombin inhibitor: dabigatran
◦ Factor Xa inhibitors: rivaroxaban; apixaban; edoxaban
◦ If liver dz (Child-Pugh Class B): Avoid rivaroxaban. - If on VKA, target INR 2-3 [I][B] w/ ≥70% time in therapeutic range [IIa][A] or switch to DOAC [I][B].
- If age ≥75 yo on clinically stable VKA w/ polypharmacy, maintain VKA to avoid excess bleeding risk [IIb][B].
- If ACS or PCI, DOAC + antiplatelet preferred over warfarin. If PCI, d/c aspirin early (1-4wk) and continue DOAC + P2Y12 inhibitor vs. triple tx to reduce bleed risk.
- If CAD/PVD w/ OAC, avoid antiplatelets beyond 12mo.
- If mild-mod CKD (CrCl >30), DOACs preferred vs. VKA, w/ appropriate dosing adjustments.
- If stage 3 or 4 CKD w/ elevated stroke risk, prescribe warfarin, or DOAC dose adjusted for CrCl.
- If ESRD (CrCl <15 mL/min) or dialysis w/ elevated stroke risk, prescribe warfarin or appropriate-dose apixaban. Avoid dabigatran if CrCl <30 mL/min.
- If pregnant, DOACs not recommended. LMWH preferred. Avoid warfarin in 1st trimester, due to risk of miscarriage/teratogenicity, and after 36 wk, due to bleeding risk if early unexpected delivery. If warfarin dose >5 mg/day, use LMWH throughout 1st trimester, then transition to warfarin for remainder of antenatal period until 36h before planned delivery; at this time, start unfractionated heparin.
Long-term rate control w/ BBs or non-DHP CCBs as 1st line [I][B]. - If BBs/CCBs contraindicated, not tolerated, or not preferred, digoxin is option [I][B]. Target digoxin level <1.2 ng/mL. May be used in combo w/ BBs/CCBs.
- If pregnant, BB or digoxin 1st line for rate control.
- Target HR based on sx. Aim for <100-110 bpm1 [IIa][B].
- Consider combo tx if single drug doesn’t control sx/HR, and avoid bradycardia w/ close monitoring [IIa][C].
- Reserve amiodarone, sotalol for rhythm control. Avoid dronedarone.
If refractory to rate-control meds and noncandidate/failed rhythm control, or severely symptomatic w/ >1 hospitalization for HF, consider AVNA w/ pacemaker implantation tx to reduce sx, physical limitations, recurrent HF hospitalizations, and mortality [II][B]. Creates dependence on pacing. - Consider consequences of lifelong pacemaker implantation, esp. w/ respect to age and comorbidities in decision-making regarding benefit.
- Procedure has low complication rate and low long-term mortality risk.
- No evidence supports AVNA as 1st-line tx.
- Implant pacemaker a few weeks before ablation to ensure adequacy of pacing leads prior to ablation.
- Program initial pacemaker lower rate to 70-90 bpm to reduce risk of sudden death.
If CHA2DS2-VASc ≥2 w/ contraindications to oral anticoagulation or high risk of major bleeding, consider percutaneous LAAO [IIb][C] or endoscopic surgical closure of LAA [IIb][C]. - Benefit of LAAO in absence of anticoagulation and risk of stroke/systemic embolism is uncertain.
- Risks: stroke, major bleeding, device-related thrombus, pericardial effusion, vascular complications, and death.
- Percutaneous LAAO requires postprocedure anticoagulation, but surgical LAAO does not.
Footnotes 1 Joglar JA, et al. 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2024 Jan 2;149(1):e1-e156. Full-text ePDF
Without HF, rhythm-control approach desired No anti-coag risk factors Consider a wait-and-see approach for spontaneous conversion to SR w/in 48h [IIa][B]. Either electrical or pharmacological cardioversion is acceptable, safe, and effective. Electrical cardioversion is more effective but involves risk of anesthesia/sedation. Thromboembolic risks and considerations for anticoagulation still apply. Anticoagulate based on CHA2DS2-VASc score. DOACs preferred. Reassess thromboembolic risk at periodic interval to ensure anticoagulation started in appropriate pts [I][B]. - If CHA2DS2-VASc score ≥2, anticoagulate [I][C].
- If CHA2DS2-VASc score ≥1, consider anticoagulation [IIa][C].
- If hypertrophic cardiomyopathy or cardiac amyloidosis, anticoagulate regardless of CHA2DS2-VASc score [I][B].
- Use DOAC vs. VKA unless mech valve/mod-severe mitral stenosis [I][A].
- Avoid reduced-dose DOAC unless pt meets DOAC-specific criteria [III][B].
- If stroke risk <1% per year, no anticoagulation. Aspirin not recommended.
- Aspirin alone or w/ clopidogrel not recommended as alternative to anticoagulation.
- Do not combine antiplatelets w/ anticoagulation [III].
- If mitral stenosis or mech heart valve, warfarin 1st line.
- If post bariatric surgery, warfarin 1st line due to concerns about DOAC absorption.
- If hx/active CA, DOACs 1st line.
- Consider drug interactions when prescribing warfarin and DOACs, esp. CYP3A4 and/or p-glycoprotein inhibitors or inducers. May require altered dosing.
- DOAC options
◦ Direct thrombin inhibitor: dabigatran
◦ Factor Xa inhibitors: rivaroxaban; apixaban; edoxaban
◦ If liver dz (Child-Pugh Class B): Avoid rivaroxaban. - If on VKA, target INR 2-3 [I][B] w/ ≥70% time in therapeutic range [IIa][A] or switch to DOAC [I][B].
- If age ≥75 yo on clinically stable VKA w/ polypharmacy, maintain VKA to avoid excess bleeding risk [IIb][B].
- If ACS or PCI, DOAC + antiplatelet preferred over warfarin. If PCI, d/c aspirin early (1-4wk) and continue DOAC + P2Y12 inhibitor vs. triple tx to reduce bleed risk.
- If CAD/PVD w/ OAC, avoid antiplatelets beyond 12mo.
- If mild-mod CKD (CrCl >30), DOACs preferred vs. VKA, w/ appropriate dosing adjustments.
- If stage 3 or 4 CKD w/ elevated stroke risk, prescribe warfarin, or DOAC dose adjusted for CrCl.
- If ESRD (CrCl <15 mL/min) or dialysis w/ elevated stroke risk, prescribe warfarin or appropriate-dose apixaban. Avoid dabigatran if CrCl <30 mL/min.
- If pregnant, DOACs not recommended. LMWH preferred. Avoid warfarin in 1st trimester, due to risk of miscarriage/teratogenicity, and after 36 wk, due to bleeding risk if early unexpected delivery. If warfarin dose >5 mg/day, use LMWH throughout 1st trimester, then transition to warfarin for remainder of antenatal period until 36h before planned delivery; at this time, start unfractionated heparin.
Prevention of thromboembolism in setting of cardioversion - Prior to cardioversion, anticoagulation x3wk [I][B] or imaging to exclude cardiac thrombus [I][B].
- If AF duration is >24h, or there is scope to wait for spontaneous cardioversion, do NOT cardiovert w/o appropriate anticoagulation or TEE [III][C].
- Begin anticoagulation prior to cardioversion and continue x4wk. Continue long-term in pts w/ stroke risk, regardless of outcome of conversion [I][B].
- If imaging shows LAA thrombus, anticoagulate, then repeat imaging prior to cardioversion [IIa][B].
- If prior LAAO w/o anticoagulation, image to exclude device-related thrombus prior to cardioversion.
- If AF duration <48h and CHA2DS2-VASc score ≥2, consider precardioversion imaging to exclude thrombus.
- If AF duration <12h w/ CHA2DS2-VASc score 0-1, benefit of precardioversion imaging is uncertain.
Considerations for DC cardioversion: - Preferred if pt can tolerate sedation, desires rapid conversion, or if not candidate/failed pharm conversion. Safe in pregnancy.
- Consider a wait-and-see approach for spontaneous conversion to SR w/in 48h of AF onset in pts w/o hemodynamic compromise vs. immediate cardioversion [IIa][B].
- Consider pre-tx w/ amiodarone, flecainide, ibutilide, or propafenone to facilitate success.
- Use synchronized cardioversion to prevent VT.
- Use biphasic 200 J initial energy to improve success of initial shock.
- If initial shock unsuccessful or longer-duration AF, consider anterior-post electrode vector orientation, higher energy, pre-tx w/ AADs.
- If pt has obesity, manual pressure augmentation or escalation of energy may improve success.
If hemodynamically stable or DC can’t be performed, use pharmacologic cardioversion. Multiple medication options: - If recent-onset AF w/o severe LV hypertrophy/HFrEF/CAD, IV flecainide or propafenone recommended [I][A].
- ibutilide (≥60 kg: 1 mg over 10min; <60 kg: 0.01 mg/kg over 10min). If arrhythmia does not terminate w/in 10min after 1st infusion, may administer a 2nd dose. Rapid onset. AEs: nonsustained VT, QT prolongation, TdP. Avoid if LVEF ≤40%.
- If severe LV hypertrophy/HFrEF/CAD, amiodarone (5-7 mg/kg or 300 mg, then 1200-3000 mg IV over 24h) is recommended, accepting delay in cardioversion [I][A]. Slow onset (8-12h). AEs: bradycardia, hypotension, QT prolongation, phlebitis, TdP. May use if LVEF ≤40%.
- procainamide (1 g IV over 30min, then 2 mg/min over 1h). Less effective than ibutilide. AEs: granulocytosis, AV block, HFrEF exacerbation, hypotension, neutropenia, QT prolongation, rash, thrombocytopenia, TdP. Avoid if initially treated w/ amiodarone or ibutilide. Consider only if ibutilide or amiodarone not optimal. Considered safe in pregnancy.
- IV sotalol not recommended.
- Avoid pharm conversion if sick-sinus syndrome, AV conduction disturbances, QTc >500 ms [III][C].
- Consider “pill in the pocket” strategy for select pts [IIa][B]:
◦ Test 1st as inpt trial w/ monitoring.
◦ Give BB/non-DHP CCB PO 30min prior to single PO dose of flecainide or propafenone.
◦ Avoid if severe LV hypertrophy/HFrEF/CAD.
Once converted, consider catheter ablation in appropriate pts. Ablation is more effective than AADs for persistent and paroxysmal AF. Continue uninterrupted oral anticoagulation to prevent periprocedural stroke/thromboembolism [I][A]. - Earlier implementation of rhythm control improves ablation success.
- Useful if antiarrhythmic meds ineffective/contraindicated/not tolerated and in those w/ symptomatic/clinically significant AFL.
- Consider catheter ablation if AF-related bradycardia or sinus pauses [IIa][C].
- 1st-line tx for paroxysmal AF in younger pts w/ few comorbidities, to reduce progression to persistent AF. May consider as 1st line in persistent AF, w/in a shared decision-making strategy.1
- If athlete, consider ablation.
- Complications include LA-esophageal fistula, perforation w/ tamponade, CVA/TIA, PV stenosis, phrenic nerve paralysis, vasc access complications, death, pneumonia.
- Post ablation, continue anticoagulation x3mo, longer if CHA2DS2-VASc ≥2.
- If recurrent AF post ablation, repeat ablation or initiate pharm options for rate or rhythm control.
If not candidate for ablation, prescribe meds for long-term maintenance of SR. Consider medical hx and drug-drug interactions for choice. AAD tx not recommended if pt w/ advanced conduction disturbances, unless antibradycardia pacing provided [III][C]. Options include: - Dronedarone recommended, including if HFmrEF, HFpEF, ischemic heart dz, valve dz [I][A].
- Amiodarone if HFrEF, w/ careful consideration and monitoring for extracardiac toxicity [I][A]
- If no impaired LV systolic function/severe LV hypertrophy/CAD, flecainide or propafenone recommended [I][A].
- If using flecainide or propafenone, consider combo w/ BB/non-DHP CCB to prevent 1:1 conduction if rhythm transforms to AFL [IIa][C].
- If no prolonged QT, hypokalemia, hypomagnesemia, dofetilide is 1st-line option w/ close monitor of QT, K+, Mg, and kidney function. Initiate as inpt for 3-day monitoring.
- Sotalol 3rd-line option if no bradycardia and NL LVEF or CAD. Initiate as inpt for 3-day monitoring. Requires close monitoring of QT, K+ level, renal function, and other proarrhythmic risk factors [IIb][A].
- If pregnant, flecainide and sotalol reasonable options.
- If prior MI/structural heart dz, amiodarone, dofetilide 1st line. Sotalol 2nd line. Flecainide and propafenone contraindicated.
- Ongoing monitoring required:
◦ amiodarone: TSH, AST, ALT (q3-6mo), ECG (q1y), CXR and physical exam for visual abnormalities, skin changes, neuro sx annually.
◦ dofetilide: ECG, K+, Mg, CrCl q3-6mo.
◦ dronedarone: ECG, AST, ALT w/in first 6mo.
◦ procainamide: ECG, BP.
◦ sotalol: ECG, K+, Mg, CrCl q3-6mo.
Footnotes 1 Van Gelder IC, et al. 2024 ESC Guidelines for the management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J. 2024 Sep 29;45(36):3314-3414. Full-text article
Either electrical or pharmacological cardioversion is acceptable, safe, and effective. Electrical cardioversion is more effective but involves risk of anesthesia/sedation. If CHA2DS2-VASc ≥2 w/ contraindications to oral anticoagulation or high risk of major bleeding, consider percutaneous LAAO [IIb][C] or endoscopic surgical closure of LAA [IIb][C]. - Benefit of LAAO in absence of anticoagulation and risk of stroke/systemic embolism is uncertain.
- Risks: stroke, major bleeding, device-related thrombus, pericardial effusion, vascular complications, and death.
- Percutaneous LAAO requires postprocedure anticoagulation, but surgical LAAO does not.
Prevention of thromboembolism in setting of cardioversion - If AF duration ≥48h, image to exclude cardiac thrombus.
- If prior LAAO w/o anticoagulation, image to exclude device-related thrombus prior to cardioversion.
- If AF duration <48h and CHA2DS2-VASc score ≥2, consider precardioversion imaging to exclude thrombus.
- If AF duration <12h w/ CHA2DS2-VASc score 0-1, benefit of precardioversion imaging is uncertain.
Considerations for DC cardioversion: - Preferred if pt can tolerate sedation, desires rapid conversion, or if not candidate/failed pharm conversion. Safe in pregnancy.
- Consider a wait-and-see approach for spontaneous conversion to SR w/in 48h of AF onset in pts w/o hemodynamic compromise vs. immediate cardioversion [IIa][B].
- Consider pre-tx w/ amiodarone, flecainide, ibutilide, or propafenone to facilitate success.
- Use synchronized cardioversion to prevent VT.
- Use biphasic 200 J initial energy to improve success of initial shock.
- If initial shock unsuccessful or longer-duration AF, consider anterior-post electrode vector orientation, higher energy, pre-tx w/ AADs.
- If pt has obesity, manual pressure augmentation or escalation of energy may improve success.
If hemodynamically stable or DC can’t be performed, use pharmacologic cardioversion. Multiple medication options: - If recent-onset AF w/o severe LV hypertrophy/HFrEF/CAD, IV flecainide or propafenone recommended [I][A].
- ibutilide (≥60 kg: 1 mg over 10min; <60 kg: 0.01 mg/kg over 10min). If arrhythmia does not terminate w/in 10min after 1st infusion, may administer a 2nd dose. Rapid onset. AEs: nonsustained VT, QT prolongation, TdP. Avoid if LVEF ≤40%.
- If severe LV hypertrophy/HFrEF/CAD, amiodarone (5-7 mg/kg or 300 mg, then 1200-3000 mg IV over 24h) is recommended, accepting delay in cardioversion [I][A]. Slow onset (8-12h). AEs: bradycardia, hypotension, QT prolongation, phlebitis, TdP. May use if LVEF ≤40%.
- procainamide (1 g IV over 30min, then 2 mg/min over 1h). Less effective than ibutilide. AEs: granulocytosis, AV block, HFrEF exacerbation, hypotension, neutropenia, QT prolongation, rash, thrombocytopenia, TdP. Avoid if initially treated w/ amiodarone or ibutilide. Consider only if ibutilide or amiodarone not optimal. Considered safe in pregnancy.
- IV sotalol not recommended.
- Avoid pharm conversion if sick-sinus syndrome, AV conduction disturbances, QTc >500 ms [III][C].
- Consider “pill in the pocket” strategy for select pts [IIa][B]:
◦ Test 1st as inpt trial w/ monitoring.
◦ Give BB/non-DHP CCB PO 30min prior to single PO dose of flecainide or propafenone.
◦ Avoid if severe LV hypertrophy/HFrEF/CAD.
Once converted, consider catheter ablation in appropriate pts. Ablation is more effective than AADs for persistent and paroxysmal AF. Continue uninterrupted oral anticoagulation to prevent periprocedural stroke/thromboembolism [I][A]. - Earlier implementation of rhythm control improves ablation success.
- Useful if antiarrhythmic meds ineffective/contraindicated/not tolerated and in those w/ symptomatic/clinically significant AFL.
- Consider catheter ablation if AF-related bradycardia or sinus pauses [IIa][C].
- 1st-line tx for paroxysmal AF in younger pts w/ few comorbidities, to reduce progression to persistent AF. May consider as 1st line in persistent AF, w/in a shared decision-making strategy.1
- If athlete, consider ablation.
- Complications include LA-esophageal fistula, perforation w/ tamponade, CVA/TIA, PV stenosis, phrenic nerve paralysis, vasc access complications, death, pneumonia.
- Post ablation, continue anticoagulation x3mo, longer if CHA2DS2-VASc ≥2.
- If recurrent AF post ablation, repeat ablation or initiate pharm options for rate or rhythm control.
If not candidate for ablation, prescribe meds for long-term maintenance of SR. Consider medical hx and drug-drug interactions for choice. AAD tx not recommended if pt w/ advanced conduction disturbances, unless antibradycardia pacing provided [III][C]. Options include: - Dronedarone recommended, including if HFmrEF, HFpEF, ischemic heart dz, valve dz [I][A].
- Amiodarone if HFrEF, w/ careful consideration and monitoring for extracardiac toxicity [I][A]
- If no impaired LV systolic function/severe LV hypertrophy/CAD, flecainide or propafenone recommended [I][A].
- If using flecainide or propafenone, consider combo w/ BB/non-DHP CCB to prevent 1:1 conduction if rhythm transforms to AFL [IIa][C].
- If no prolonged QT, hypokalemia, hypomagnesemia, dofetilide is 1st-line option w/ close monitor of QT, K+, Mg, and kidney function. Initiate as inpt for 3-day monitoring.
- Sotalol 3rd-line option if no bradycardia and NL LVEF or CAD. Initiate as inpt for 3-day monitoring. Requires close monitoring of QT, K+ level, renal function, and other proarrhythmic risk factors [IIb][A].
- If pregnant, flecainide and sotalol reasonable options.
- If prior MI/structural heart dz, amiodarone, dofetilide 1st line. Sotalol 2nd line. Flecainide and propafenone contraindicated.
- Ongoing monitoring required:
◦ amiodarone: TSH, AST, ALT (q3-6mo), ECG (q1y), CXR and physical exam for visual abnormalities, skin changes, neuro sx annually.
◦ dofetilide: ECG, K+, Mg, CrCl q3-6mo.
◦ dronedarone: ECG, AST, ALT w/in first 6mo.
◦ procainamide: ECG, BP.
◦ sotalol: ECG, K+, Mg, CrCl q3-6mo.
Footnotes 1 Van Gelder IC, et al. 2024 ESC Guidelines for the management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J. 2024 Sep 29;45(36):3314-3414. Full-text article
With HF, awaiting decision about rate- or rhythm-control approach Provide guideline-directed medical tx for HF. In all pts, perform basic clinical eval, address modifiable risk factors (obesity, physical inactivity, EtOH consumption, smoking, DM, HTN), and assess stroke risk to determine need for anticoagulation ( CHA2DS2-VASc). If new dx of HFrEF and AF, suspect arrhythmia-induced cardiomyopathy and take early and aggressive approach to rhythm control. Ablation for rhythm control 1st-line tx in many. Basic eval: - Assess sx and AF burden.1
- Confirm rhythm w/ 12-lead ECG.
- CBC, CMP, TSH, HbA1c
- Transthoracic echo when it will guide mgmt [I][C]
- In newly diagnosed AF, routine testing for ischemia, ACS, or PE not indicated unless s/sx suggest these diseases.
- Consider in select pts: ambulatory ECG monitoring to assess burden and rate control; exercise ECG to evaluate rate control/effects of class IC antiarrhythmics; NT-proBNP, troponin to investigate CV dz; TEE to assess for thrombus/valve dz; if ischemia suspected, coronary CT/angiography/imaging; CMR to evaluate for cardiomyopathies/plan interventions; brain imaging and cognitive function tests to evaluate for cerebrovascular dz/dementia risk.
Risk factor modifications: - If overweight/obese, target 10% wt loss to reduce AF sx, burden, recurrence, and progression to persistent [I][B]. If BMI ≥40, consider bariatric surgery [IIb][C].
- Initiate tailored exercise program to improve fitness and reduce AF recurrence [I][B].
- Stop smoking to mitigate increased risk of AF-related CV complications and other adverse outcomes.
- Reduce EtOH use (≤3 drinks/wk, or ≤30 g/wk) to reduce AF recurrence and burden [I][B].
- Caffeine abstention has no benefit in preventing AF but may reduce sx in pts who report caffeine as trigger.
- If HTN, prescribe BP-lowering tx (ACE/ARB preferred) to reduce AF recurrence and AF-related CV events [I][B].
- Manage OSA [IIb][B]. Do not screen for OSA w/ sx-based questionnaires only [II][B].
- Target effective glycemic control [I][C].
- Offer appropriate med tx for HF [I][B]. Prescribe diuretics to alleviate sx and facilitate better AF mgmt [I][C]. Prescribe Na-glucose cotransporter-2 inhibitors regardless of LVEF [I][A].
Risk stratification for thrombosis risk and anticoagulation: - Use validated score (e.g., CHA2DS2-VASc). If male pt w/ CHA2DS2-VASc score of 1 or female pt w/ CHA2DS2-VASc score of 2 remains uncertain about the benefit of anticoagulation, consider other factors that might modify their stroke risk to help inform the decision (e.g., AF burden, BMI ≥30 kg/m^2, HCM, poorly controlled HTN, eGFR <45 mL/h, proteinuria >150 mg/24h, enlarged LA).
- Stroke risk is based on score and risk factors, not AF pattern.
- If congenital heart dz or HCM, anticoagulate regardless of stroke risk score.
- Re-evaluate annually.
- Evaluate for bleeding risks (prior bleeding, anemia, meds). Bleeding risk scores perform poorly. Do not use in isolation. ESC recommends HAS-BLED score.1
- Contraindications to long-term anticoagulation:
◦ Severe bleeding due to a nonreversible cause involving the GI, pulmonary, or GU systems
◦ Spontaneous intracranial/intraspinal bleeding due to a nonreversible cause
◦ Serious bleeding related to recurrent falls when cause of falls is not felt to be treatable - Long-term anticoagulation reasonable if:
◦ Treatable GI, pulmonary, or GU system
◦ Bleeding related to isolated trauma
◦ Bleeding related to procedural complications
Considerations for rhythm vs. rate control: - If HFrEF, consider catheter ablation to improve sx, QOL, and CV outcomes and reduce mortality and HF hospitalizations.
- If reduced LV function, trial of rhythm control recommended to evaluate if AF is contributing to reduced LV function.
- If HFrEF, routine pharm rhythm control no benefit vs. rate control.
- If HFpEF, ablation also an option.
Catheter ablation considerations: - Those likely to benefit: earlier stage of HF, no significant ventricular scar on CMR, no/mild atrial fibrosis, paroxysmal and early persist AF, younger pts w/o comorbidities.
- Less likely to benefit: advanced HF, AF-mediated cardiomyopathies suspected, significant ventricular scar on CMR, severe atrial myopathy/dilation/fibrosis, long-standing persistent AF, prior failed ablations, advanced age or multiple comorbidities.
Footnotes 1 Van Gelder IC, et al. 2024 ESC Guidelines for the management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J. 2024 Sep 29;45(36):3314-3414. Full-text article
With HF, rate control preferred Assess EF. If EF ≤40%, avoid non-DHP CCBs. Long-term rate control w/ BB or digoxin [I]. - If EF >40%, BBs or non-DHP CCBs are 1st line [I][B].
- If BBs contraindicated, not tolerated, or not preferred, digoxin is option. Target digoxin level <1.2 ng/mL. May be used in combo w/ BBs/CCBs.
- Consider combo BB + digoxin [IIa][C].
- If refractory HF sx on rate-control tx, consider target HR <80 bpm at rest and <110 bpm during mod exercise.
- Evaluate for catheter ablation [I].
If refractory to rate-control meds and noncandidate/failed rhythm control, or severely symptomatic w/ >1 hospitalization for HF, consider AVNA w/ pacemaker implantation tx to reduce sx, physical limitations, recurrent HF hospitalizations, and mortality [II][B]. Creates dependence on pacing. - Consider consequences of lifelong pacemaker implantation, esp. w/ respect to age and comorbidities in decision-making regarding benefit.
- Procedure has low complication rate and low long-term mortality risk.
- No evidence supports AVNA as 1st-line tx.
- Implant pacemaker a few weeks before ablation to ensure adequacy of pacing leads prior to ablation.
- Program initial pacemaker lower rate to 70-90 bpm to reduce risk of sudden death.
- If stroke risk <1% per year, no anticoagulation. Aspirin not recommended.
- If stroke risk 1% to 2% per year (CHA2DS2-VASc = 1 in men, 2 in women), anticoagulation is reasonable.
- If stroke risk ≥2% per year (CHA2DS2-VASc ≥2 in men, ≥3 in women), anticoagulate.
- Aspirin alone or w/ clopidogrel not recommended as alternative to anticoagulation.
- If mitral stenosis or mech heart valve, warfarin 1st line. DOACs 1st line for other valve dz.
- If post bariatric surgery, warfarin 1st line due to concerns about DOAC absorption.
- If hx/active CA, DOACs 1st line.
- Consider drug interactions when prescribing warfarin and DOACs, esp. CYP3A4 and/or p-glycoprotein inhibitors or inducers. May require altered dosing.
- DOAC options
◦ Direct thrombin inhibitor: dabigatran
◦ Factor Xa inhibitors: rivaroxaban; apixaban; edoxaban
◦ If liver dz (Child-Pugh Class B): Avoid rivaroxaban. - If using warfarin, target INR = 2-3, consistent vit K dietary intake and routine INR monitoring.
- If ACS or PCI, DOAC + antiplatelet preferred over warfarin. If PCI, d/c aspirin early (1-4wk) and continue DOAC + P2Y12 inhibitor vs. triple tx to reduce bleed risk.
- If ≥1y post PCI or CAD w/o coronary revasc, OAC monotherapy preferred over combo tx w/ aspirin/P2Y12 inhibitors.
- If PAD, anticoagulant monotherapy preferred over combo tx w/ aspirin/P2Y12 inhibitors.
- If stage 3 or 4 CKD w/ elevated stroke risk, prescribe warfarin, or DOAC dose adjusted for CrCl.
- If ESRD (CrCl <15 mL/min) or dialysis w/ elevated stroke risk, prescribe warfarin or appropriate-dose apixaban.
- If pregnant, DOACs not recommended. LMWH preferred. Avoid warfarin in 1st trimester, due to risk of miscarriage/teratogenicity, and after 36 wk, due to bleeding risk if early unexpected delivery. If warfarin dose >5 mg/day, use LMWH throughout 1st trimester, then transition to warfarin for remainder of antenatal period until 36h before planned delivery; at this time, start unfractionated heparin.
With HF, rhythm control preferred Assess EF. Either DC or pharmacological cardioversion is acceptable, safe, and effective. DC cardioversion is more effective but involves risk of anesthesia/sedation. Thromboembolic risks and considerations for anticoagulation still apply. Consider catheter ablation. - If stroke risk <1% per year, no anticoagulation. Aspirin not recommended.
- If stroke risk 1% to 2% per year (CHA2DS2-VASc = 1 in men, 2 in women), anticoagulation is reasonable.
- If stroke risk ≥2% per year (CHA2DS2-VASc ≥2 in men, ≥3 in women), anticoagulate.
- Aspirin alone or w/ clopidogrel not recommended as alternative to anticoagulation.
- If mitral stenosis or mech heart valve, warfarin 1st line. DOACs 1st line for other valve dz.
- If post bariatric surgery, warfarin 1st line due to concerns about DOAC absorption.
- If hx/active CA, DOACs 1st line.
- Consider drug interactions when prescribing warfarin and DOACs, esp. CYP3A4 and/or p-glycoprotein inhibitors or inducers. May require altered dosing.
- DOAC options
◦ Direct thrombin inhibitor: dabigatran
◦ Factor Xa inhibitors: rivaroxaban; apixaban; edoxaban
◦ If liver dz (Child-Pugh Class B): Avoid rivaroxaban. - If using warfarin, target INR = 2-3, consistent vit K dietary intake and routine INR monitoring.
- If ACS or PCI, DOAC + antiplatelet preferred over warfarin. If PCI, d/c aspirin early (1-4wk) and continue DOAC + P2Y12 inhibitor vs. triple tx to reduce bleed risk.
- If ≥1y post PCI or CAD w/o coronary revasc, OAC monotherapy preferred over combo tx w/ aspirin/P2Y12 inhibitors.
- If PAD, anticoagulant monotherapy preferred over combo tx w/ aspirin/P2Y12 inhibitors.
- If stage 3 or 4 CKD w/ elevated stroke risk, prescribe warfarin, or DOAC dose adjusted for CrCl.
- If ESRD (CrCl <15 mL/min) or dialysis w/ elevated stroke risk, prescribe warfarin or appropriate-dose apixaban.
- If pregnant, DOACs not recommended. LMWH preferred. Avoid warfarin in 1st trimester, due to risk of miscarriage/teratogenicity, and after 36 wk, due to bleeding risk if early unexpected delivery. If warfarin dose >5 mg/day, use LMWH throughout 1st trimester, then transition to warfarin for remainder of antenatal period until 36h before planned delivery; at this time, start unfractionated heparin.
Prevention of thromboembolism in setting of cardioversion - If AF duration ≥48h, then anticoagulation x3wk or imaging to exclude cardiac thrombus.
- Begin anticoagulation prior to cardioversion and continue x4wk.
- If imaging shows LAA thrombus, anticoagulate x3-6wk, then repeat imaging prior to cardioversion.
- If prior LAAO w/o anticoagulation, image to exclude device-related thrombus prior to cardioversion.
- If AF duration <48h and CHA2DS2-VASc score ≥2, consider precardioversion imaging to exclude thrombus.
- If AF duration <12h w/ CHA2DS2-VASc score 0-1, benefit of precardioversion imaging is uncertain.
Considerations for DC cardioversion: - Preferred if pt can tolerate sedation, desires rapid conversion, or if not candidate/failed pharm conversion. Safe in pregnancy.
- Consider pre-tx w/ amiodarone, flecainide, ibutilide, or propafenone to facilitate success.
- Use synchronized cardioversion to prevent VT.
- Use biphasic 200 J initial energy to improve success of initial shock.
- If initial shock unsuccessful or longer-duration AF, consider anterior-post electrode vector orientation, higher energy, pre-tx w/ AADs.
- If pt has obesity, manual pressure augmentation or escalation of energy may improve success.
If hemodynamically stable or electric can’t be performed, use pharmacologic cardioversion. Med option varies by EF: - If EF ≤40%, use amiodarone [I] (5-7 mg/kg or 300 mg, then 1200-3000 mg IV over 24h). Slow onset (8-12h). AEs: bradycardia, hypotension, QT prolongation, phlebitis, TdP.
- If stable HFmrEF (LVEF 41%-49%)/CAD/valve dz, use amiodarone or dronedarone [I]. Sotalol 2nd line [IIb].
Once converted, consider catheter ablation in appropriate pts. Recommended if high prob of tachycardia-induced cardiomyopathy to reverse LV dysfunction [I][B]. Ablation is more effective than AADs for persistent and paroxysmal AF. - Earlier implementation of rhythm control improves ablation success.
- Consider cath ablation to reduce HF hospitalizations and prolong survival [IIa][B].
- Useful if antiarrhythmic meds ineffective/contraindicated/not tolerated and in those w/ symptomatic/clinically significant AFL.
- 1st-line tx for paroxysmal AF in younger pts w/ few comorbidities, to reduce progression to persistent AF. May consider as 1st line in persistent AF, w/in a shared decision-making strategy.1
- Complications include LA-esophageal fistula, perforation w/ tamponade, CVA/TIA, PV stenosis, phrenic nerve paralysis, vasc access complications, death, pneumonia.
- Post ablation, continue anticoagulation x3mo, longer if CHA2DS2-VASc ≥2.
- If recurrent AF post ablation, repeat ablation or initiate pharm options for rate or rhythm control.
If not candidate for ablation, prescribe meds for long-term maintenance of SR. Consider medical hx and drug-drug interactions for choice. Options include: - If EF <40%, amiodarone [I][A], dronedarone [I][A], or dofetilide is 1st line.
- If no prolonged QT, hypokalemia, hypomagnesemia, dofetilide is 1st-line option w/ close monitor of QT, K+, Mg, and kidney function. Initiate as inpt for 3-day monitoring.
- Flecainide and propafenone contraindicated.
- Ongoing monitoring required:
◦ amiodarone: TSH, AST, ALT (q3-6mo), ECG (q1y), CXR and physical exam for visual abnormalities, skin changes, neuro sx annually.
◦ dofetilide: ECG, K+, Mg, CrCl q3-6mo.
Footnotes 1 Van Gelder IC, et al. 2024 ESC Guidelines for the management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J. 2024 Sep 29;45(36):3314-3414. Full-text article
-
Device-detected AF/Silent AF
AF may be detected w/ reliable monitoring device (wearable continuous or loop-recording devices, implantable loop recorders, pacemakers/defibrillators) and confirmed by physician review. Smartphones/smartwatches can discriminate AF vs. NSR but are not reliable enough to establish AF dx. Monitoring for AF may be appropriate in pts w/ cryptogenic stroke. - If monitoring device shows AF, perform single-lead or continuous ECG tracing of >30 s or 12-lead ECG.
◦ If no AF, diagnose subclinical AF.
◦ If AF, treat as clinical AF. - Treat modifiable stroke risk factors.
- Provide ongoing monitoring for progression to clinical AF and change in stroke risk.
Consider DOAC if elevated thromboembolic risk [IIb][B]. Decision to anticoagulate is based on length of AF episodes and stroke risk. Device-detected AF is assoc. w/ lower stroke risk than clinical AF. Confirm duration and nature of longest device-detected episode. Assess stroke risk (e.g., CHA2DS2-VASc). - If AF lasts ≥24h w/ CHA2DS2-VASc ≥2 in men, ≥3 in women, reasonable to anticoagulate w/ shared decision-making and based on individual pt risk.
- If AF lasts 5min to 24h w/ CHA2DS2-VASc ≥3, reasonable to anticoagulate w/ shared decision-making and based on individual pt risk.
- If AF episode lasts <5min, no increased stroke risk. Do not anticoagulate.
If anticoagulation is appropriate, DOACs preferred. - Aspirin alone or w/ clopidogrel not recommended as alternative to anticoagulation.
- If mitral stenosis or mech heart valve, warfarin 1st line. DOACs 1st line for other valve dz.
- If post bariatric surgery, warfarin 1st line due to concerns about DOAC absorption.
- If hx/active CA, DOACs 1st line.
- Consider drug interactions when prescribing warfarin and DOACs, esp. CYP3A4 and/or p-glycoprotein inhibitors or inducers. May require altered dosing.
- DOAC options
◦ Direct thrombin inhibitor: dabigatran
◦ Factor Xa inhibitors: rivaroxaban; apixaban; edoxaban
◦ If liver dz (Child-Pugh Class B): Avoid rivaroxaban. - If using warfarin, target INR = 2-3, consistent vit K dietary intake and routine INR monitoring.
- If ACS or PCI, DOAC + antiplatelet preferred over warfarin. If PCI, d/c aspirin early (1-4wk) and continue DOAC + P2Y12 inhibitor vs. triple tx to reduce bleed risk.
- If ≥1y post PCI or CAD w/o coronary revasc, OAC monotherapy preferred over combo tx w/ aspirin/P2Y12 inhibitors.
- If PAD, anticoagulant monotherapy preferred over combo tx w/ aspirin/P2Y12 inhibitors.
- If stage 3 or 4 CKD w/ elevated stroke risk, prescribe warfarin, or DOAC dose adjusted for CrCl.
- If ESRD (CrCl <15 mL/min) or dialysis w/ elevated stroke risk, prescribe warfarin or appropriate-dose apixaban.
- If pregnant, DOACs not recommended. LMWH preferred. Avoid warfarin in 1st trimester, due to risk of miscarriage/teratogenicity, and after 36 wk, due to bleeding risk if early unexpected delivery. If warfarin dose >5 mg/day, use LMWH throughout 1st trimester, then transition to warfarin for remainder of antenatal period until 36h before planned delivery; at this time, start unfractionated heparin.
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