Updated U.S. Guideline for management of atrial fibrillation
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.
The American College of Cardiology (ACC)/American Heart Association (AHA) Task Force on Clinical Practice Guidelines and the Heart Rhythm Society have published an update to the ‘2014 Atrial Fibrillation (AF) Guideline’, because new evidence has become available since its publication. The current document is a focused update that includes revisions to the sections on anticoagulation, on catheter ablation of AF, and on management of AF complicating acute coronary syndrome (ACS). New sections have been added on when to use devices for detection AF and atrial flutter, and on the beneficial effects of weight loss and risk factor modification on controlling AF.
All of the updated sections are based on new data from clinical trials that has emerged, as well as on new US Food and Drug Administration (FDA) indications for thromboembolism protection devices, which have been published up to August 2018. Modified recommendations are clearly indicated in updated tables, along with the accompanying class (strength) of recommendation (COR) and level (quality) of evidence (LOE).
Specifically, the section on anticoagulation has been updated to reflect the approval of new medications and thromboembolism protection devices. A new advice states that non–vitamin K oral anticoagulants (NOACs) are recommended over the vitamin K antagonist warfarin, except in case of moderate-to-severe mitral stenosis or a mechanical heart valve (COR: I, LOE: A). NOAC’s, also referred to as direct OACs (DOACs) include dabigatran (a direct thrombin inhibitor) and rivaroxaban, apixaban, and edoxaban (factor Xa inhibitors).
Other new recommendations relate to reversal of NOAC action. Use of idarucizumab is recommended for the reversal of dabigatran in the event of life-threatening bleeding or an urgent procedure (COR: I, LOE: B-NR [non-randomized]). Use of andexanet alfa can be useful for the reversal of rivaroxaban and apixaban in the event of life-threatening or uncontrolled bleeding (COR: IIa, LOE: B-NR).
With regard to nonpharmacological stroke prevention, it is now recommended that percutaneous Left Atrial Appendage (LAA) occlusion may be considered in patients with AF at increased risk of stroke who have contraindications to long-term anticoagulation (COR: IIb, LOE: B-NR). Moreover, 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 (COR: IIb, LOE: B-NR).
The recommendation on AF catheter ablation to maintain sinus rhythm has been updated, such that 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 (COR: IIb, LOE: B-R [randomized]).
Several new recommendations have been formulated on AF complicating ACS, on which therapy is preferred in different clinical scenarios, based on new published trial data.