-
Awaiting decision about rate- or rhythm-control approach
RCTs show no superiority of rhythm vs rate control;1 initial rate-control strategy reasonable for many, preferred in pre-excited AF and pregnancy2,3 Consider rhythm control if: - persistent AF sx
- rate-control difficulties
- younger pt age
- tach-mediated CM4
- 1st AF episode
- HCM (preferred)
- acute illness-precipitated AF
- chronic HF w/ sx despite rate control
- pt preference
Footnotes 1 AHA/ACC/HRS 2014 & 2019. Recommendations are regardless of AF/flutter type. Correct underlying causes, if present. Encourage wt loss and risk factor modification as appropriate.
January CT, et al. 2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society in Collaboration With the Society of Thoracic Surgeons. Circulation. 2019. July 9;140(2):e125-151. Free full-text PDF
2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation. J Am Coll Cardiol. 2014. Dec 2;64(21):e1-76. Full-text guideline online
2 ESC 2020. Use antiarrhythmics w/ rate-limiting properties (amiodarone, dronedarone, sotalol, propafenone) only in pts requiring rhythm control. In pts where no attempt to restore sinus rhythm is planned, antiarrhythmics may result in harm.
Hindricks G, et al. 2020 ESC Guidelines for the Diagnosis and Management of Atrial Fibrillation Developed in Collaboration With the European Association of Cardio-Thoracic Surgery (EACTS): The Task Force for the Diagnosis and Management of Atrial Fibrillation of the European Society of Cardiology (ESC) Developed With the Special Contribution of the European Heart Rhythm Association (EHRA) of the ESC. Eur Heart J. 2020. Aug 29;10.1093;1-126. Free full-text PDF
3 ESC 2020. Antiarrhythmic drugs not recommended in pt w/ long QT (>0.5s), or significant SA node or AV node dysfxn, unless functional permanent pacemaker present.
4 AHA/ACC/HRS 2014 & 2019. Do not AV-node ablate before drug rate-control trial. If RVR causing/suspected cause of tach-induced CM, AV-nodal blockade or rhythm control reasonable. If tach-mediated CM suspected w/ rate not controllable: Consider AV node ablation.
-
Rate-control approach desired
Control rest/exercise heart rate1 w/ 1st-line agent,2 no anticoagulant tx (unless HCM)3 - BB or non-DHP CCB (diltiazem/verapamil);2 digoxin an option, per ESC. If LVEF <40%, avoid non-DHP CCB;4 if COPD, CCB; if hyperthyroid, BB preferred (if can’t be used, then CCB)
- Resting goal HR ≤80 per AHA/ACC, ≤110 per ESC (if asymptomatic w/ preserved LV systolic fxn, target HR ≤110 per AHA/ACC). Adjust to control rate during exertion
If BB/CCB failure/intolerance, use non-1st-line rate control - Digoxin/combos:2 Combine BB w/ other drugs, including digoxin; titrate to avoid bradycardia. Digoxin may be used alone or in combo w/ BB/CCB
- Don’t use antiarrhythmics that limit rate in pts where no attempt to restore sinus rhythm is planned, per ESC5
- If drug rate control inadequate/sx persist, use rhythm control6
- If drug tx inadequate and rhythm control not achievable: AV node ablation6 + pacing
Footnotes 1 AHA/ACC/HRS 2014 & 2019. RCTs show no superiority of rhythm vs rate control. Initial rate-control strategy reasonable for many; consider rhythm control if persistent AF sx, rate control difficulties, younger pt age, tach-mediated CM, 1st AF episode, acute illness-precipitated AF, chronic HF w/ sx despite rate control, or pt preference; rhythm control preferred for HCM. Recommendations are regardless of AF/flutter type. Correct underlying causes.
January CT, et al. 2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society in Collaboration With the Society of Thoracic Surgeons. Circulation. 2019. July 9;140(2):e125-151. Free full-text PDF
2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation. J Am Coll Cardiol. 2014. Dec 2;64(21):e1-76. Full-text guideline online
2 AHA/ACC/HRS 2014 & 2019. Drugs alpha-listed. Non-DHP-CCB (diltiazem, verapamil): Do not use CCB if LV dysfxn/↓EF/pre-excitation or if decompensated HF. BB choice (cardioselective, etc) depends on pt condition; consider CCB if COPD. If decompensated HF, start BB after stabilization. Digoxin: Avoid in HCM or pre-excitation. Amiodarone may be used for rate control when other measures fail/contraindicated; do not use in pre-excitation. If HCM, rhythm control preferred; if rate control used, BB/CCB or combine both; amiodarone or disopyramide reasonable w/ BB/CCB; avoid digoxin.
3 AHA/ACC/HRS 2014 & 2019. Reasonable to omit anticoagulant tx if CHA 2DS 2-VASc 0; except HCM requires anticoagulation regardless of score. CHA 2DS 2-VASc (stroke risk): 0 (0%), 1 (1.3%), 2 (2.2%), 3
(3.2%), 4 (4%), 5 (6.7%), 6 (9.8%), 7 (9.6%), 8 (6.7%), 9 (15.2%).
4 ESC 2020. Non-DHP CCBs should be avoided in pts w/ LVEF <40% due to negative inotropic effects.
Hindricks G, et al. 2020 ESC Guidelines for the Diagnosis and Management of Atrial Fibrillation Developed in Collaboration With the European Association of Cardio-Thoracic Surgery (EACTS): The Task Force for the Diagnosis and Management of Atrial Fibrillation of the European Society of Cardiology (ESC) Developed With the Special Contribution of the European Heart Rhythm Association (EHRA) of the ESC. Eur Heart J. 2020. Aug 29;10.1093;1-126. Free full-text PDF
5 ESC 2020. Use antiarrhythmics w/ rate-limiting properties (amiodarone, dronedarone, sotalol, propafenone) only in pts requiring rhythm control. In pts where no attempt to restore sinus rhythm is planned, antiarrhythmics may result in harm.
6 AHA/ACC/HRS 2014 & 2019. Do not AV-node ablate before drug rate control trial. If RVR causing/suspected cause of tach-induced CM, AV-nodal blockade or rhythm control reasonable. If tach-mediated CM suspected w/ rate not controllable: Consider AV-node ablation.
Rate control1 +/- anticoagulant tx2,3 Consider anticoagulant options2,3 based on stroke/bleed risks, renal fxn, pt preference - No anticoagulant tx (unless HCM)2
- Direct oral anticoagulant (apixaban, dabigatran, rivaroxaban, edoxaban recommended over warfarin, in absence of mod-severe MS or mechanical valve)3
- Aspirin3
- Women w/ AF are at increased stroke risk vs men; a study concluded that women <65 yo w/o other risk factors (ie, CHA2DS2-VASc=1 solely d/t gender) are at low stroke risk and don’t require anticoagulation
Control heart rate;1 adjust to control rate during exertion - BB or non-DHP CCB (diltiazem/verapamil);2 digoxin an option, per ESC. If LVEF <40%, avoid non-DHP CCB;4 if COPD, CCB; if hyperthyroid, BB preferred (if can’t be used, then CCB)
- Resting goal HR ≤80 per AHA/ACC, ≤110 per ESC (if asymptomatic w/ preserved LV systolic fxn, target HR ≤110 per AHA/ACC). Adjust to control rate during exertion
- If BB/CCB failure/intolerance, use digoxin/combos:5 Digoxin controls resting HR in HFrEF. Combine BB w/ other drugs, incl digoxin; titrate to avoid bradycardia. Digoxin may be combined w/ BB or CCB, incl for HF pts (avoid CCB if HFrEF)
- If HF and rest/exercise HR not controlled w/ BB, CCB (in HFpEF) or digoxin (alone or combined): consider amiodarone4,5
- If drug rate control inadequate/sx persist, use rhythm control.6 If drug tx inadequate and rhythm control not achievable: AV node ablation6 + pacing
Footnotes 1 AHA/ACC/HRS 2014 & 2019. RCTs show no superiority of rhythm vs rate control. Initial rate-control strategy reasonable for many; consider rhythm control if persistent AF sx, rate control difficulties, younger pt age, tach-mediated CM, 1st AF episode, acute illness-precipitated AF, chronic HF w/ sx despite rate control, or pt preference; rhythm control preferred for HCM. Recommendations are regardless of AF/flutter type. Correct underlying causes.
January CT, et al. 2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society in Collaboration With the Society of Thoracic Surgeons. Circulation. 2019. July 9;140(2):e125-151. Free full-text PDF
2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation. J Am Coll Cardiol. 2014. Dec 2;64(21):e1-76. Full-text guideline online
2 AHA/ACC/HRS 2014 & 2019. HCM requires anticoagulation regardless of score. If pt undergoing cardiac surgery, may consider LAA surgical excision. CHA 2DS 2-VASc (stroke risk): 0 (0%), 1 (1.3%), 2 (2.2%), 3 (3.2%), 4 (4%), 5 (6.7%), 6 (9.8%), 7 (9.6%), 8 (6.7%), 9 (15.2%).
3 AHA/ACC/HRS 2014 & 2019.
• Anticoagulants: Re-eval needs/choices periodically. DOACs are 1st line in absence of mod-severe MS or mechanical valve.
• Warfarin: INR goal 2-3, unless mitral stenosis or mitral mechanical valve (INR goal 2.5-3.5 in those cases); ✓INR weekly during tx start, monthly when stable.
• Renal: DOAC: ✓renal fxn pre-tx, when clinically indicated, and at least annually. If severe/end-stage CKD, warfarin or apixaban are options. If postcoronary revasc (PCI/surg): reasonable to add clopidogrel 75 mg/day or ticagrelor (not aspirin) to anticoagulant.
4 ESC 2020. Use antiarrhythmics w/ rate-limiting properties (amiodarone, dronedarone, sotalol, propafenone) only in pts requiring rhythm control. In pts where no attempt to restore sinus rhythm is planned, antiarrhythmics may result in harm.
Hindricks G, et al. 2020 ESC Guidelines for the Diagnosis and Management of Atrial Fibrillation Developed in Collaboration With the European Association of Cardio-Thoracic Surgery (EACTS): The Task Force for the Diagnosis and Management of Atrial Fibrillation of the European Society of Cardiology (ESC) Developed With the Special Contribution of the European Heart Rhythm Association (EHRA) of the ESC. Eur Heart J. 2020. Aug 29;10.1093;1-126. Free full-text PDF
5 AHA/ACC/HRS 2014 & 2019. Drugs alpha-listed. Non-DHP-CCB (diltiazem, verapamil): Do not use CCB if LV dysfxn/↓EF/pre-excitation or if decompensated HF, but may be used alone or w/ digoxin if HFpEF; BB choice (cardioselective, etc) depends on pt condition; consider CCB if COPD; if decompensated HF, start BB after stabilization. IV BB recommended to slow RVR in pts w/ ACS if no HF, bronchospasm, or hemodynamic instability. Digoxin: Avoid in HCM or pre-excitation. Amiodarone may be used for rate control when other measures failed/contraindicated; do not use in pre-excitation. If HCM, rhythm control preferred; if rate control used, BB/CCB or combine both; amiodarone or disopyramide reasonable w/ BB/CCB.
6 AHA/ACC/HRS 2014 & 2019. Do not AV-node ablate before drug rate control trial. If RVR causing/suspected cause of tach-induced CM, AV-nodal blockade or rhythm control reasonable. If tach-mediated CM suspected w/ rate not controllable: Consider AV-node ablation.
CHA2DS2-VASc ≥2 (including hx of stroke/TIA) Combine anticoagulation1 + rate control2 Anticoagulate1,3 based on stroke/bleed risks, renal fxn, pt preference - DOACs recommended over warfarin (unless mod to severe mitral stenosis or mechanical valve) per ACC/AHA and ESC
- DOAC: dabigatran, rivaroxaban, apixaban, edoxaban3
- Warfarin w/ INR 2-33
- If PCI w/ stenting: reasonable to add clopidogrel 75 mg/day or ticagrelor (not aspirin) to anticoagulant;3 rivaroxaban 15 mg/day preferred to ↓bleed risk, per AHA/ACC
- May consider LAA occlusion/exclusion if contraindication to long-term anticoagulation
Control heart rate;2 adjust to control rate during exertion - BB or non-DHP CCB (diltiazem/verapamil);4 digoxin an option, per ESC. If LVEF <40%, avoid non-DHP CCB;5 if COPD, CCB; if hyperthyroid, BB preferred (if can’t be used, then CCB)
- Resting goal HR ≤80 per AHA/ACC, ≤110 per ESC (if asymptomatic w/ preserved LV systolic fxn, target HR ≤110 per AHA/ACC). Adjust to control rate during exertion
- If BB/CCB failure/intolerance, use digoxin/combos:4 Digoxin controls resting HR in HFrEF. Combine BB w/ other drugs, incl digoxin; titrate to avoid bradycardia. Digoxin may be combined w/ BB or CCB incl for HF pts (avoid CCB if HFrEF)
- If HF and rest/exercise HR not controlled w/ BB, CCB (in HFpEF) or digoxin (alone or combined): Consider amiodarone4
- If drug rate control inadequate/sx persist, use rhythm control.6 If drug tx inadequate and rhythm control not achievable: AV node ablation6 + pacing
Footnotes 1 AHA/ACC/HRS 2014 & 2019. HCM requires anticoagulation regardless of score. If pt undergoing cardiac surgery, may consider LAA surgical excision. CHA 2DS 2-VASc (stroke risk): 0 (0%), 1 (1.3%), 2 (2.2%), 3 (3.2%), 4 (4%), 5 (6.7%), 6 (9.8%), 7 (9.6%), 8 (6.7%), 9 (15.2%).
January CT, et al. 2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society in Collaboration With the Society of Thoracic Surgeons. Circulation. 2019. July 9;140(2):e125-151. Free full-text PDF
2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation. J Am Coll Cardiol. 2014. Dec 2;64(21):e1-76. Full-text guideline online
2 AHA/ACC/HRS 2014 & 2019. RCTs show no superiority of rhythm vs rate control. Initial rate-control strategy reasonable for many; consider rhythm control if persistent AF sx, rate control difficulties, younger pt age, tach-mediated CM, 1st AF episode, acute illness-precipitated AF, chronic HF w/ sx despite rate control, or pt preference; rhythm control preferred for HCM. Recommendations are regardless of AF/flutter type. Correct underlying causes.
3 AHA/ACC/HRS 2014 & 2019.
• Anticoagulants: Re-eval needs/choices periodically. DOACs are 1st line in absence of mod-severe MS or mechanical valve.
• Warfarin: INR goal 2-3, unless mitral stenosis or mitral mechanical valve (INR goal 2.5-3.5 in those cases); ✓INR weekly during tx start, monthly when stable.
• Renal: DOAC: ✓renal fxn pre-tx, when clinically indicated, and at least annually. If severe/end-stage CKD, warfarin or apixaban are options. If postcoronary revasc (PCI/surg): reasonable to add clopidogrel 75 mg/day or ticagrelor (not aspirin) to anticoagulant. If mod to severe CKD w/ CHA 2DS 2-VASc ≥2: Consider reduced DOAC doses.
4 AHA/ACC/HRS 2014 & 2019. Drugs alpha-listed. Non-DHP-CCB (diltiazem, verapamil): do not use CCB if LV dysfxn/↓EF/pre-excitation or if decompensated HF, but may be used alone or w/ digoxin if HFpEF; BB choice (cardioselective, etc) depends on pt condition; consider CCB if COPD; if decompensated HF, start BB after stabilization. Digoxin: Avoid in HCM or pre-excitation. Amiodarone may be used for rate control when other measures failed/contraindicated; do not use in pre-excitation. If HCM, rhythm control preferred; if rate control used, BB/CCB or combine both; amiodarone or disopyramide reasonable w/ BB/CCB.
5 ESC 2020. Use antiarrhythmics w/ rate-limiting properties (amiodarone, dronedarone, sotalol, propafenone) only in pts requiring rhythm control. In pts where no attempt to restore sinus rhythm is planned, antiarrhythmics may result in harm.
Hindricks G, et al. 2020 ESC Guidelines for the Diagnosis and Management of Atrial Fibrillation Developed in Collaboration With the European Association of Cardio-Thoracic Surgery (EACTS): The Task Force for the Diagnosis and Management of Atrial Fibrillation of the European Society of Cardiology (ESC) Developed With the Special Contribution of the European Heart Rhythm Association (EHRA) of the ESC. Eur Heart J. 2020. Aug 29;10.1093;1-126. Free full-text PDF
6 AHA/ACC/HRS 2014 & 2019. Do not AV-node ablate before drug rate control trial. If RVR causing/suspected cause of tach-induced CM, AV-nodal blockade or rhythm control reasonable. If tach-mediated CM suspected w/ rate not controllable: Consider AV-node ablation.
-
Rhythm-control approach desired
Restore sinus rhythm1 via DC cardioversion, antiarrhythmic drug, or RF cath ablation; +/- rate control. No long-term anticoagulant tx (unless HCM).2 Correct underlying causes - DC cardiovert + periprocedural anticoagulation.3,4 Repeat/serial attempts3,4 based on sinus rhythm duration, sx, pt preference3,4 +/- rate-control tx
- Pharmacologic cardioversion5 + peri-procedural anticoagulation3,4 + rate-control tx: flecainide, dofetilide, propafenone, IV ibutilide or amiodarone;5 amiodarone preferred if ICVD or structural heart dz, per ESC
- Postconversion pill-in-pocket prn option: propafenone/flecainide + BB/non-DHP-CCB (diltiazem/verapamil), once proven safe in monitored setting, reasonable to terminate out-pt AF
- Postconversion drug maintenance options6,7 based on CAD/LVH/HF, comorbidities, drug risks, +/- rate-control tx. OK to continue antiarrhythmic despite infrequent well-tolerated recurrences; stop if AF becomes permanent
Cath ablation6,7 + periablation anticoagulation3,4 is an option; factor risk/benefit, pt preference - Cath ablation6 for paroxysmal AF w/ sx: useful if refractory/intolerant to ≥1 class I/III drug; reasonable as initial strategy before class I/III drug trial for recurrent paroxysmal AF w/ sx
- Cath ablation6 for persistent AF w/ sx reasonable if refractory/intolerant to ≥1 class I/III drug, consider for long-standing (>12mo) persistent AF w/ sx; consider as initial strategy before class I/III drug trial
- Cath ablation for AF w/ sx reasonable if HFrEF present
- Cath ablation for AF recommended as 1st line for rhythm control to reverse LV dysfunction in tachycardia-induced cardiomyopathy7
- Cath ablation of accessory pathway recommended for pre-excited AF6
- If undergoing cardiac surgery for other reasons: maze procedure reasonable for select pts6
Footnotes 1 AHA/ACC/HRS 2014 & 2019. RCTs show no superiority of rhythm vs rate control. Initial rate-control strategy reasonable for many; consider rhythm control if persistent AF sx, rate control difficulties, younger pt age, tach-mediated CM, 1st AF episode, acute illness-precipitated AF, chronic HF w/ sx despite rate control, or pt preference; rhythm control preferred for HCM. Recommendations are regardless of AF/flutter type. Correct underlying causes.
January CT, et al. 2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society in Collaboration With the Society of Thoracic Surgeons. Circulation. 2019. July 9;140(2):e125-151. Free full-text PDF
2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation. J Am Coll Cardiol. 2014. Dec 2;64(21):e1-76. Full-text guideline online
2 AHA/ACC/HRS 2014 & 2019. Reasonable to omit anticoagulant tx if CHA 2DS 2-VASc 0; except HCM requires anticoagulation regardless of score. CHA 2DS 2-VASc (stroke risk): 0 (0%), 1 (1.3%), 2 (2.2%), 3 (3.2%), 4 (4%), 5 (6.7%), 6 (9.8%), 7 (9.6%), 8 (6.7%), 9 (15.2%).
3 AHA/ACC/HRS 2014 & 2019. Anticoagulate w/ warfarin or DOAC ≥3wk pre/4wk post. If no anticoagulation for preceding 3wk, reasonable to ✓TEE precardioversion for LA thrombus, cardiovert if anticoagulation achieved pre-TEE and maintained ≥4wk postcardioversion. DC cardioversion: on repeat attempts, consider location adjustment/pressure application on electrodes, or pre-tx w/ antiarrhythmic drug. Pharmacologic cardioversion most likely effective when initiated w/in 7 days after AF episode onset.
4 ESC 2020. Anticoagulate w/ warfarin or DOAC ≥3wk pre/4wk post. If no anticoagulation for preceding 3wk, reasonable to √TEE pre-cardioversion for LA thrombus, cardiovert if anticoagulation achieved pre-TEE and maintained ≥4wk postcardioversion. DC cardioversion: on repeat attempts, consider location adjustment/pressure application on electrodes, or pre-tx w/ antiarrhythmic drug. Pharmacologic cardioversion most likely effective when initiated w/in 7 days after AF episode onset. Pharmacologic cardioversion only in hemodynamically stable patient.
Hindricks G, et al. 2020 ESC Guidelines for the Diagnosis and Management of Atrial Fibrillation Developed in Collaboration With the European Association of Cardio-Thoracic Surgery (EACTS): The Task Force for the Diagnosis and Management of Atrial Fibrillation of the European Society of Cardiology (ESC) Developed With the Special Contribution of the European Heart Rhythm Association (EHRA) of the ESC. Eur Heart J. 2020. Aug 29;10.1093;1-126. Free full-text PDF
5 AHA/ACC/HRS 2014 & 2019. Drugs alpha-listed. Class I: flecainide, propafenone. Class III: amiodarone, dofetilide, dronedarone, sotalol. Consider amiodarone only if other agents failed/contraindicated. If HF: amiodarone or dofetilide. If HCM: dofetilide, dronedarone, sotalol. In-pt vs out-pt initiation: Data on out-pt best established for amiodarone, dronedarone; do not initiate dofetilide out-pt.
6 ESC 2020. Pharmacologic cardioversion only in hemodynamically stable patient.
For pts tx with sotalol: close monitoring of QT interval, serum potassium, CrCl, and other proarrhythmia risk factors (e.g., medication interactions).
7 AHA/ACC/HRS 2014 & 2019. Cath ablation to restore sinus rhythm should not be done w/ sole intent of obviating anticoagulation. Cath ablation may be reasonable in selected symptomatic pts w/ significant LV dysfxn w/ HF. Cath ablation of accessory pathway recommended in pre-excited AF w/ sx, esp if short refractory period. Maze procedure may be used as stand-alone for highly select sx pts not well managed w/ other approaches.
8 ESC 2020. Cath ablation to restore sinus rhythm is recommended as 1st-line tx for rhythm control to reverse LV dysfxn when tachycardia-induced cardiomyopathy highly probable, independent of sx status.
Rhythm control1 +/- anticoagulant tx2,3 Consider anticoagulant options2,3 based on stroke/bleed risks, renal fxn, pt preference - No anticoagulant tx (unless HCM)2
- Direct oral anticoagulant (apixaban, dabigatran, rivaroxaban, edoxaban are recommended over warfarin, in absence of mod-severe MS or mech valve)3
- Aspirin3
- Women w/ AF are at increased stroke risk vs men; a study concluded that women <65 yo w/o other risk factors (ie, CHA2DS2-VASc=1 solely d/t gender) are at low stroke risk and don’t require anticoagulation
Restore sinus rhythm1 via DC cardioversion, antiarrhythmic drug, or RF cath ablation; +/- rate control. Correct underlying causes - DC cardiovert + periprocedural anticoagulation.4 Repeat/serial attempts based on sinus rhythm duration, sx, pt preference4 +/- rate-control tx
- Pharmacologic cardioversion5,6 + periprocedural anticoagulation4 + rate-control tx: flecainide, dofetilide, propafenone, IV ibutilide or amiodarone;5 amiodarone preferred if ICVD or structural heart dz, per ESC6
- Postconversion pill-in-pocket prn option: propafenone/flecainide + BB/non-DHP-CCB (diltiazem/verapamil), once proven safe in monitored setting, reasonable to terminate out-pt AF
- Postconversion maintenance drug options5 based on CAD/LVH/HF, comorbidities, drug risks, +/- rate-control tx. OK to continue antiarrhythmic despite infrequent well-tolerated recurrences; stop if AF becomes permanent
Cath ablation7 + periablation anticoagulation4 is an option; factor risk/benefit, pt preference - Cath ablation7 for paroxysmal AF w/ sx: useful if refractory/intolerant to ≥1 class I/III drug; reasonable as initial strategy before class I/III drug trial for recurrent paroxysmal AF w/ sx
- Cath ablation7 for persistent AF w/ sx reasonable if refractory/intolerant to ≥1 class I/III drug, consider for long-standing (>12mo) persistent AF w/ sx; consider as initial strategy before class I/III drug trial
- Cath ablation for AF w/ sx reasonable if HFrEF present
- Cath ablation for AF recommended as 1st line for rhythm control to reverse LV dysfunction in tachycardia-induced cardiomyopathy8
- Cath ablation of accessory pathway recommended for pre-excited AF7
- If undergoing cardiac surgery for other reasons: maze procedure reasonable for select pts7
Footnotes 1 AHA/ACC/HRS 2014 & 2019. RCTs show no superiority of rhythm vs rate control. Initial rate-control strategy reasonable for many; consider rhythm control if persistent AF sx, rate control difficulties, younger pt age, tach-mediated CM, 1st AF episode, acute illness-precipitated AF, chronic HF w/ sx despite rate control, or pt preference; rhythm control preferred for HCM. Recommendations are regardless of AF/flutter type. Correct underlying causes.
January CT, et al. 2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society in Collaboration With the Society of Thoracic Surgeons. Circulation. 2019. July 9;140(2):e125-151. Free full-text PDF
2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation. J Am Coll Cardiol. 2014. Dec 2;64(21):e1-76. Full-text guideline online
2 AHA/ACC/HRS 2014 & 2019. HCM requires anticoagulation regardless of score. CHA 2DS 2-VASc (stroke risk): 0 (0%), 1 (1.3%), 2 (2.2%), 3 (3.2%), 4 (4%), 5 (6.7%), 6 (9.8%), 7 (9.6%), 8 (6.7%), 9 (15.2%).
3 AHA/ACC/HRS 2014 & 2019.
• Anticoagulants: Re-eval needs/choices periodically. DOACs are 1st line in absence of mod-severe MS or mechanical valve.
• Warfarin: INR goal 2-3, unless mitral stenosis or mitral mechanical valve (INR goal 2.5-3.5 in those cases); ✓INR weekly during tx start, monthly when stable.
• Renal: DOAC: ✓renal fxn pre-tx, when clinically indicated, and at least annually. If severe/end-stage CKD, warfarin or apixaban are options. If postcoronary revasc (PCI/surg): reasonable to add clopidogrel 75 mg/day or ticagrelor (not aspirin) to anticoagulant.
4 AHA/ACC/HRS 2014 & 2019. Anticoagulate w/ warfarin or DOAC ≥3wk pre/4wk post. If no anticoagulation for preceding 3wk, reasonable to ✓TEE precardioversion for LA thrombus, cardiovert if anticoagulation achieved pre-TEE and maintained ≥4wk postcardioversion. DC cardioversion: on repeat attempts, consider location adjustment/pressure application on electrodes, or pre-tx w/ antiarrhythmic drug. Pharmacologic cardioversion most likely effective when initiated w/in 7 days after AF episode onset.
5 AHA/ACC/HRS 2014 & 2019. Drugs alpha-listed. Class I: flecainide, propafenone. Class III: amiodarone, dofetilide, dronedarone, sotalol. Consider amiodarone only if other agents failed/contraindicated. If HF: amiodarone or dofetilide. If HCM: dofetilide, dronedarone, sotalol. In-pt vs out-pt initiation: Data on out-pt best established for amiodarone, dronedarone; do not initiate dofetilide out-pt.
6 ESC 2020. Pharmacologic cardioversion only in hemodynamically stable patient.
For pts tx with sotalol: close monitoring of QT interval, serum potassium, CrCl, and other proarrhythmia risk factors (eg, medication interactions).
Hindricks G, et al. 2020 ESC Guidelines for the Diagnosis and Management of Atrial Fibrillation Developed in Collaboration With the European Association of Cardio-Thoracic Surgery (EACTS): The Task Force for the Diagnosis and Management of Atrial Fibrillation of the European Society of Cardiology (ESC) Developed With the Special Contribution of the European Heart Rhythm Association (EHRA) of the ESC. Eur Heart J. 2020. Aug 29;10.1093;1-126. Free full-text PDF
7 AHA/ACC/HRS 2014 & 2019. Cath ablation to restore sinus rhythm should not be done w/ sole intent of obviating anticoagulation. Cath ablation may be reasonable in selected symptomatic pts w/ significant LV dysfxn w/ HF. Cath ablation of accessory pathway recommended in pre-excited AF w/ sx, esp if short refractory period. Maze procedure may be used as stand-alone for highly select sx pts not well managed w/ other approaches.
8 ESC 2020. Cath ablation to restore sinus rhythm is recommended as 1st-line tx for rhythm control to reverse LV dysfxn when tachycardia-induced cardiomyopathy highly probable, independent of sx status.
CHA2DS2-VASc ≥2 (including hx of stroke/TIA) Combine anticoagulation + rhythm control1 Anticoagulate2,3 based on stroke/bleed risks, renal fxn, pt preference - DOACs recommended over warfarin (unless mod to severe mitral stenosis or mechanical valve) per ACC/AHA and ESC
- DOACs: dabigatran, rivaroxaban, apixaban, edoxaban4
- Warfarin w/ INR 2-34
- If PCI w/ stenting: reasonable to add clopidogrel 75 mg/day or ticagrelor (not aspirin) to anticoagulant
- May consider LAA occlusion/exclusion if contraindication to long-term anticoagulation
Restore sinus rhythm1 via DC cardioversion, antiarrhythmic drug, or RF cath ablation; +/- rate control. Correct underlying causes - DC cardiovert + periprocedural anticoagulation.4 Repeat/serial attempts based on sinus rhythm duration, sx, pt preference4 +/- rate-control tx
- Pharmacologic cardioversion5,6 + periprocedural anticoagulation4 + rate-control tx: flecainide, dofetilide, propafenone, IV ibutilide or amiodarone;7 amiodarone preferred if ICVD or structural heart dz, per ESC6
- Postconversion pill-in-pocket prn option: propafenone/flecainide + BB/non-DHB-CCB (diltiazem/verapamil), once proven safe in monitored setting, reasonable to terminate out-pt AF
- Postconversion maintenance drug options5 based on CAD/LVH/HF, comorbidities, drug risks, +/- rate-control tx. OK to continue antiarrhythmic despite infrequent, well-tolerated, recurrences8; stop if AF becomes permanent
Cath ablation7 + periablation anticoagulation4 is an option; factor risk/benefit, pt preference - Cath ablation7 for paroxysmal AF w/ sx: useful if refractory/intolerant to ≥1 class I/III drug; reasonable as initial strategy before class I/III drug trial for recurrent paroxysmal AF w/ sx
- Cath ablation7 for persistent AF w/ sx reasonable if refractory/intolerant to ≥1 class I/III drug, consider for long-standing (>12mo) persistent AF w/ sx; consider as initial strategy before class I/III drug trial
- Cath ablation for AF w/ sx reasonable if HFrEF present
- Cath ablation for AF recommended as 1st line for rhythm control to reverse LV dysfunction in tachycardia-induced cardiomyopathy9
- Cath ablation of accessory pathway recommended for pre-excited AF7
- If undergoing cardiac surgery for other reasons: maze procedure reasonable for select pts7
Footnotes 1 AHA/ACC/HRS 2014 & 2019. RCTs show no superiority of rhythm vs rate control. Initial rate-control strategy reasonable for many; consider rhythm control if persistent AF sx, rate control difficulties, younger pt age, tach-mediated CM, 1st AF episode, acute illness-precipitated AF, chronic HF w/sx despite rate control, or pt preference; rhythm control preferred for HCM. Recommendations are regardless of AF/flutter type. Correct underlying causes.
January CT, et al. 2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society in Collaboration With the Society of Thoracic Surgeons. Circulation. 2019. July 9;140(2):e125-151. Free full-text PDF
2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation. J Am Coll Cardiol. 2014. Dec 2;64(21):e1-76. Full-text guideline online
2 AHA/ACC/HRS 2014 & 2019. HCM requires anticoagulation regardless of score. If pt undergoing cardiac surgery, may consider LAA surgical excision. CHA 2DS 2-VASc (stroke risk): 0 (0%), 1 (1.3%), 2 (2.2%), 3 (3.2%), 4 (4%), 5 (6.7%), 6 (9.8%), 7 (9.6%), 8 (6.7%), 9 (15.2%).
3 AHA/ACC/HRS 2014 & 2019.
• Anticoagulants: Re-eval needs/choices periodically. DOACs are 1st line in absence of mod-severe MS or mechanical valve.
• Warfarin: INR goal 2-3, unless mitral stenosis or mitral mechanical valve (INR goal 2.5-3.5 in those cases); ✓INR weekly during tx start, monthly when stable.
• Renal: DOAC: ✓renal fxn pre-tx, when clinically indicated, and at least annually. If severe/end-stage CKD, warfarin or apixaban are options. If postcoronary revasc (PCI/surg): reasonable to add clopidogrel 75 mg/day or ticagrelor (not aspirin) to anticoagulant. If mod to severe CKD w/ CHA 2DS 2-VASc ≥2, consider reduced DOAC doses.
4 AHA/ACC/HRS 2014 & 2019. Anticoagulate w/ warfarin or DOAC ≥3wk pre/4wk post. If no anticoagulation for preceding 3wk, reasonable to ✓TEE precardioversion for LA thrombus, cardiovert if anticoagulation achieved pre-TEE and maintained ≥4wk postcardioversion. DC cardioversion: on repeat attempts, consider location adjustment/pressure application on electrodes, or pre-tx w/ antiarrhythmic drug. Pharmacologic conversion most likely effective when initiated w/in 7 days after AF episode onset.
5 AHA/ACC/HRS 2014 & 2019. Drugs alpha-listed. Class I: flecainide, propafenone. Class III: amiodarone, dofetilide, dronedarone, sotalol. Consider amiodarone only if other agents failed/contraindicated. If HF: amiodarone or dofetilide. If HCM: dofetilide, dronedarone, sotalol. In-pt vs out-pt initiation: Data on out-pt best established for amiodarone, dronedarone; do not initiate dofetilide out-pt.
6 ESC 2020. Pharmacologic cardioversion only in hemodynamically stable patient. Pharmacologic cardioversion most likely effective when initiated w/in 7 days after AF episode onset.
Hindricks G, et al. 2020 ESC Guidelines for the Diagnosis and Management of Atrial Fibrillation Developed in Collaboration With the European Association of Cardio-Thoracic Surgery (EACTS): The Task Force for the Diagnosis and Management of Atrial Fibrillation of the European Society of Cardiology (ESC) Developed With the Special Contribution of the European Heart Rhythm Association (EHRA) of the ESC. Eur Heart J. 2020. Aug 29;10.1093;1-126. Free full-text PDF
7 AHA/ACC/HRS 2014 & 2019. Cath ablation to restore sinus rhythm should not be done w/ sole intent of obviating anticoagulation. Cath ablation may be reasonable in selected symptomatic pts w/ significant LV dysfxn w/ HF. Cath ablation of accessory pathway recommended in pre-excited AF w/ sx, esp if short refractory period. Maze procedure may be used as stand-alone for highly select sx pts not well managed w/ other approaches.
8 ESC 2020. For pts tx with sotalol: close monitoring of QT interval, serum potassium, CrCl, and other proarrhythmia risk factors (eg, medication interactions).
9 ESC 2020. Cath ablation to restore sinus rhythm is recommended as 1st-line tx for rhythm control to reverse LV dysfxn when tachycardia-induced cardiomyopathy highly probable, independent of sx status.
|
