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  • Focused Update for Atrial Fibrillation Guideline

    Characterized as a tachyarrhythmia, atrial fibrillation (AF) is the most common type of heart arrhythmia and is the leading cardiac cause of stroke. Its causes can be congenital or as a result of age, other medical conditions, or certain lifestyle practices. The worldwide prevalence of AF has been increasing, with estimates that its incidence could double or even triple over the next thirty years. Helping keep pace with that rise are new guideline updates, released by the American College of Cardiology (ACC), American Heart Association (AHA), and Heart Rhythm Society (HRS) in 2019. The AHA/ACC/HRS guidelines include revisions to sections addressing anticoagulation, catheter ablation, and management of AF complicating acute coronary syndrome (ACS). Additionally, there are new sections that cover device detection of AF and weight loss.

    Due to evidence of being safer options for patients, non-vitamin K oral anticoagulants (NOACs) are now preferred above warfarin for risk reduction of AF-associated stroke, unless patients have moderate-to-severe mitral stenosis or a mechanical heart valve. The list of NOACs includes dabigatran, rivaroxaban, apixaban, and now also edoxaban. Whether the AF is paroxysmal or persistent should have no bearing on the decision to use an anticoagulant. Before an NOAC is initiated, testing should be completed for renal and hepatic function, and should continue to be retested annually. Warfarin or apixaban is acceptable for oral anticoagulation in AF patients who have a CHA2DS2-VASc score ≥2 in men or ≥3 in women and a creatinine clearance <15mL/min or who are on dialysis. The guidelines also recommend anticoagulating in patients with ACS and AF who are at an increased risk of systemic thromboembolism, unless the risk of bleeding exceeds the potential benefit of the therapy. If a patient experiences a life-threatening bleed or requires an urgent procedure, idarucizumab is recommended for the reversal of dabigatran, and andexanet alfa (recombinant factor Xa) for the reversal of rivaroxaban and apixaban.

    Outside of management with pharmacotherapy, the guidelines also detail options for clinical consideration, based on the specific condition. In certain patients with symptomatic AF and HF with reduced left ventricular ejection fraction, an AF catheter ablation may be the chosen treatment. For patients who are undergoing cardiac surgery, a surgical occlusion of the left atrial appendage may be considered. Additionally, if there is an increased risk of stroke and contraindications to long-term anticoagulation, it may be appropriate for a patient to receive a percutaneous left atrial appendage occlusion. Lifestyle modification may also be an approach for AF management, such as weight loss combined with risk factor modification in patients who are overweight or obese.

    The guidelines address two main points regarding device detection of AF. The first encourages further evaluation when high-rate episodes are recorded in patients with pacemakers or implanted cardioverter-defibrillators, in order to identify and better inform treatment of clinically relevant AF. The second focus concentrates on implantation of a loop recorder when external ambulatory monitoring in patients with cryptogenic stroke has been inconclusive.

    The recommendations included in the practice guidelines incorporate new data that has emerged from clinical trials and new indications for thromboembolism protection devices. New data will continue to be reviewed on an ongoing basis.


    American College of Cardiology website. Atrial Fibrillation: Guidelines For Management of Patients With. https://www.acc.org/guidelines/hubs/atrial-fibrillation. Updated January 28, 2019. Accessed January 23, 2020.

    Asmarats L, Rodés-Cabau J. Percutaneous Left Atrial Appendage Closure, Circulation: Cardiovascular Interventions (2017), doi: https://doi.org/10.1161/CIRCINTERVENTIONS.117.005359

    Centers for Disease Control and Prevention website. Atrial Fibrillation https://www.cdc.gov/heartdisease/atrial_fibrillation.htm. Updated December 9, 2019. Accessed January 23, 2020.

    January CT, Wann LS, Calkins H, Chen LY, Cigarroa JE, Cleveland JC Jr, Ellinor PT, Ezekowitz MD, Field ME, Furie KL, Heidenreich PA, Murray KT, Shea JB, Tracy CM, Yancy CW. 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 Jul 9;140(2):e125-e151.

    Nesheiwat Z, Goyal A, Jagtap M. Atrial Fibrillation (A Fib) [Updated 2019 Dec 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: www.ncbi.nlm.nih.gov/books/NBK526072/