Atrial fibrillation specific patient groups

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Special Groups Postoperative AF Acute Myocardial Infarction Wolff-Parkinson-White Preexcitation Syndrome Hypertrophic Cardiomyopathy Hyperthyroidism Pulmonary Diseases Pregnancy ACS and/or PCI or valve intervention Heart failure
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Cafer Zorkun, M.D., Ph.D. [2]

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

Recommendations for AF Complicating ACS Referenced studies that support new or modified recommendations are summarized in Online Data Supplement 8

Class I

1.   For patients with ACS and AF at increased risk of systemic thromboembolism (based on CHA2DS2-VASc risk score of 2 or greater), anticoagulation is recommended unless the bleeding risk exceeds the expected benefit.S7.4-1–S7.4-3MODIFIED: New published data are available. LOE was updated from C in the 2014 AF Guideline to B-R. Anticoagulation options are described in supportive text.(Level of Evidence: B-R) 2.   Urgent direct-current cardioversion of new-onset AF in the setting of ACS is recommended for patients with hemodynamic compromise, ongoing ischemia, or inadequate rate control (Level of Evidence: C)3.   Intravenous beta blockers are recommended to slow a rapid ventricular response to AF in patients with ACS who do not display HF, hemodynamic instability, or bronchospasm(Level of Evidence: C)

Class IIa

4.   If triple therapy (oral anticoagulant, aspirin, and P2Y12 inhibitor) is prescribed for patients with AF at increased risk of stroke (based on CHA2DS2-VASc risk score of 2 or greater) who have undergone percutaneous coronary intervention (PCI) with stenting for ACS, it is reasonable to choose clopidogrel in preference to prasugrel.S7.4-4,S7.4-5NEW: New published data are available(Level of Evidence: B-R) 5.   In patients with AF at increased risk of stroke (based on CHA2DS2-VASc risk score of 2 or greater) who have undergone PCI with stenting for ACS, double therapy with a P2Y12 inhibitor (clopidogrel or ticagrelor) and dose-adjusted vitamin K antagonist is reasonable to reduce the risk of bleeding as compared with triple therapy.S7.4-3,S7.4-6–S7.4-8NEW: New RCT data and data from 2 registries and a retrospective cohort study are available.(Level of Evidence: B-R) 6.   In patients with AF at increased risk of stroke (based on CHA2DS2-VASc risk score of 2 or greater) who have undergone PCI with stenting for ACS, double therapy with P2Y12 inhibitors (clopidogrel) and low-dose rivaroxaban 15 mg daily is reasonable to reduce the risk of bleeding as compared with triple therapy.S7.4-2NEW: New published data are available (Level of Evidence: B-R) 7.   In patients with AF at increased risk of stroke (based on CHA2DS2-VASc risk score of 2 or greater) who have undergone PCI with stenting for ACS, double therapy with a P2Y12 inhibitor (clopidogrel) and dabigatran 150 mg twice daily is reasonable to reduce the risk of bleeding as compared with triple therapy.S7.4-1NEW: New published data are available(Level of Evidence: B-R)

Class IIb

8.   If triple therapy (oral anticoagulant, aspirin, and P2Y12 inhibitor) is prescribed for patients with AF who are at increased risk of stroke (based on CHA2DS2-VASc risk score of 2 or greater) and who have undergone PCI with stenting (drug eluting or bare metal) for ACS, a transition to double therapy (oral anticoagulant and P2Y12 inhibitor) at 4 to 6 weeks may be considered.S7.4-9,S7.4-10NEW: New published data are available.(Level of Evidence: B-R) 9.   Administration of amiodarone or digoxin may be considered to slow a rapid ventricular response in patients with ACS and AF associated with severe LV dysfunction and HF or hemodynamic instability(Level of Evidence: C) 0.   Administration of nondihydropyridine calcium antagonists may be considered to slow a rapid ventricular response in patients with ACS and AF only in the absence of significant HF or hemodynamic instability.(Level of Evidence: C)

2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation (DO NOT EDIT)

Specific Patient Groups and AF

Hypertrophic Cardiomyopathy

Class I

"1. Anticoagulation is indicated in patients with HCM with AF independent of the CHA2DS2-VASc score. (Level of Evidence: B)"

Class IIa

"1. Antiarrhythmic medications can be useful to prevent recurrent AF in patients with HCM. Amiodarone, or disopyramide combined with a beta blocker or nondihydropyridine calcium channel antagonists are reasonable therapies. (Level of Evidence: C)"

"2. AF catheter ablation can be beneficial in patients with HCM in whom a rhythm-control strategy is desired when antiarrhythmic drugs fail or are not tolerated. (Level of Evidence: B)"

Class IIb

"1. Sotalol, dofetilide, and dronedarone may be considered for a rhythm-control strategy in patients with HCM. (Level of Evidence: C)"

AF Complicating Acute Coronary Syndrome

Class I

"1. Urgent direct-current cardioversion of new-onset AF in the setting of ACS is recommended for patients with hemodynamic compromise, ongoing ischemia, or inadequate rate control. (Level of Evidence: C)"

"2. Intravenous beta blockers are recommended to slow a rapid ventricular response to AF in patients with ACS who do not display HF, hemodynamic instability, or bronchospasm. (Level of Evidence: C)"

"3. For patients with ACS and AF with CHA2DS2-VASc score of 2 or greater, anticoagulation with warfarin is recommended unless contraindicated. (Level of Evidence: C)"

Class IIb

"1. Administration of amiodarone or digoxin may be considered to slow a rapid ventricular response in patients with ACS and AF associated with severe LV dysfunction and HF or hemodynamic instability. (Level of Evidence: C)"

"2. Administration of nondihydropyridine calcium antagonists might be considered to slow a rapid ventricular response in patients with ACS and AF only in the absence of significant HF or hemodynamic instability. (Level of Evidence: C)"

Hyperthyroidism

Class I

"1. Beta blockers are recommended to control ventricular rate in patients with AF complicating thyrotoxicosis unless contraindicated. (Level of Evidence: C)"

"2. In circumstances in which a beta blocker cannot be used, a nondihydropyridine calcium antagonist is recommended to control the ventricular rate. (Level of Evidence: C)"

Pulmonary Disease

Class I

"1. A nondihydropyridine calcium antagonist is recommended to control the ventricular rate in patients with AF and chronic obstructive pulmonary disease. (Level of Evidence: C)"

"2. Direct-current cardioversion should be attempted in patients with pulmonary disease who become hemodynamically unstable as a consequence of new onset AF. (Level of Evidence: C)"

Wolff-Parkinson-White and Pre-Excitation Syndromes

Class I

"1. Prompt direct-current cardioversion is recommended for patients with AF, WPW, and rapid ventricular response who are hemodynamically compromised. (Level of Evidence: C)"

"2. Intravenous procainamide or ibutilide to restore sinus rhythm or slow the ventricular rate is recommended for patients with pre-excited AF and rapid ventricular response who are not hemodynamically compromised. (Level of Evidence: C)"

"3. Catheter ablation of the accessory pathway is recommended in symptomatic patients with pre-excited AF, especially if the accessory pathway has a short refractory period that allows rapid antegrade conduction. (Level of Evidence: C)"

Class III: No Benefit

"1. Administration of intravenous amiodarone, adenosine, digoxin (oral or intravenous), or nondihydropyridine calcium antagonists (oral or intravenous) in patients with WPW syndrome who have pre-excited AF is potentially harmful as these treatments accelerate the ventricular rate. (Level of Evidence: B)"

Heart Failure

Class I

"1. Control of resting heart rate using either a beta blocker or a nondihydropyridine calcium antagonist is recommended for patients with persistent or permanent AF and compensated HF with preserved EF. (Level of Evidence: B)"

"2. In the absence of pre-excitation, intravenous beta blocker administration (or a nondihydropyridine calcium antagonist in patients with HFpEF) is recommended to slow the ventricular response to AF in the acute setting, with caution needed in patients with overt congestion, hypotension, or HF with reduced LVEF. (Level of Evidence: B)"

"3. In the absence of pre-excitation, intravenous digoxin or amiodarone is recommended to control heart rate acutely in patients with HF. (Level of Evidence: B)"

"4. Assessment of heart rate control during exercise and adjustment of pharmacological treatment to keep the rate in the physiological range is useful in symptomatic patients during activity. (Level of Evidence: C)"

"5. Digoxin is effective to control resting heart rate in patients with HF with reduced EF. (Level of Evidence: C)"

Class III: Harm

"1. AV node ablation should not be performed without a pharmacological trial to achieve ventricular rate control. (Level of Evidence: B)"

"2. For rate control, intravenous nondihydropyridine calcium antagonists, intravenous beta blockers, and dronedarone should not be administered to patients with decompensated HF. (Level of Evidence: B)"

Class IIa

"1. A combination of digoxin and a beta blocker (or a nondihydropyridine calcium antagonist for patients with HFpEF), is reasonable to control resting and exercise heart rate in patients with AF. (Level of Evidence: B)"

"2. It is reasonable to perform AV node ablation with ventricular pacing to control heart rate when pharmacological therapy is insufficient or not tolerated. (Level of Evidence: B)"

"3. Intravenous amiodarone can be useful to control the heart rate in patients with AF when other measures are unsuccessful or contraindicated. (Level of Evidence: C)"

"4. For patients with AF and rapid ventricular response causing or suspected of causing tachycardia-induced cardiomyopathy, it is reasonable to achieve rate control by either AV nodal blockade or a rhythm-control strategy. (Level of Evidence: B)"

"5. For patients with chronic HF who remain symptomatic from AF despite a rate-control strategy, it is reasonable to use a rhythm-control strategy. (Level of Evidence: C)"

Class IIb

"1. Oral amiodarone may be considered when resting and exercise heart rate cannot be adequately controlled using a beta blocker (or a nondihydropyridine calcium antagonist in patients with HFpEF) or digoxin, alone or in combination. (Level of Evidence: C)"

"2. AV node ablation may be considered when the rate cannot be controlled and tachycardia-mediated cardiomyopathy is suspected. (Level of Evidence: C)"

Familial (Genetic) AF

Class IIb

"1. For patients with AF and multigenerational family members with AF, referral to a tertiary care center for genetic counseling and testing may be considered. (Level of Evidence: C)"

Postoperative Cardiac and Thoracic Surgery

Class I

"1. Treating patients who develop AF after cardiac surgery with a beta blocker is recommended unless contraindicated. (Level of Evidence: A)"

"2. A nondihydropyridine calcium antagonist is recommended when a beta blocker is inadequate to achieve rate control in patients with postoperative AF. (Level of Evidence: B)"

Class IIa

"1. Preoperative administration of amiodarone reduces the incidence of AF in patients undergoing cardiac surgery and is reasonable as prophylactic therapy for patients at high risk for postoperative AF. (Level of Evidence: A)"

"2. It is reasonable to restore sinus rhythm pharmacologically with ibutilide or direct-current cardioversion in patients who develop postoperative AF, as advised for nonsurgical patients. (Level of Evidence: B)"

"3. It is reasonable to administer antiarrhythmic medications in an attempt to maintain sinus rhythm in patients with recurrent or refractory postoperative AF, as advised for other patients who develop AF. (Level of Evidence: B)"

"4. It is reasonable to administer antithrombotic medication in patients who develop postoperative AF, as advised for nonsurgical patients. (Level of Evidence: B)"

"5. It is reasonable to manage well-tolerated, new-onset postoperative AF with rate control and anticoagulation with cardioversion if AF does not revert spontaneously to sinus rhythm during follow-up. (Level of Evidence: C)"

Class IIb

"1. Prophylactic administration of sotalol may be considered for patients at risk of developing AF following cardiac surgery. (Level of Evidence: B)"

"2. Administration of colchicine may be considered for patients postoperatively to reduce AF following cardiac surgery. (Level of Evidence: B)"

Sources

• 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation

References

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