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2014 aha/acc/hrs guideline for the management of patients with atrial fibrillation: executive summary: a report of the american college of cardiology/american heart association task force on practice guidelines and the heart rhythm society

CLINICAL PRACTICE GUIDELINE 2014 AHA/ACC/HRS Guideline forthe Management of Patients WithAtrial Fibrillation: Executive Summary A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society Developed in Collaboration With the Society of Thoracic Surgeons Craig T. January, MD, PHD, FACC, Chair Ralph L. Sacco, MD, FAHAy L. Samuel Wann, MD, MACC, FAHA, Vice Chair* William G. Stevenson, MD, FACC, FAHA, FHRS*{ Patrick J. Tchou, MD, FACCz Joseph S. Alpert, MD, FACC, FAHA*y Cynthia M. Tracy, MD, FACC, FAHAy Hugh Calkins, MD, FACC, FAHA, FHRS*zx Clyde W. Yancy, MD, FACC, FAHAy Joaquin E. Cigarroa, MD, FACCyJoseph C. Cleveland JR, MD, FACCjjJamie B. Conti, MD, FACC, FHRS*y *Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and Patrick T. Ellinor, MD, PHD, FAHAz other entities may apply; see for recusal information. ACC/AHA Michael D. Ezekowitz, MB, CHB, FACC, FAHA*y Representative. Rhythm Society Representative. ACC/AHA Task Michael E. Field, MD, FACC, FHRSy Force on Performance Measures Liaison. Society of Thoracic Surgeons Katherine T. Murray, MD, FACC, FAHA, FHRSy Representative. ACC/AHA Task Force on Practice Guidelines Liaison.
Jeffrey L. Anderson, MD, FACC, FAHA, Chair Richard J. Kovacs, MD, FACC, FAHA Jonathan L. Halperin, MD, FACC, FAHA, Chair-Elect E. Magnus Ohman, MD, FACC Susan J. Pressler, PhD, RN, FAHA Nancy M. Albert, PhD, RN, FAHA Frank W. Sellke, MD, FACC, FAHA Biykem Bozkurt, MD, PhD, FACC, FAHA Win-Kuang Shen, MD, FACC, FAHA Ralph G. Brindis, MD, MPH, MACC William G. Stevenson, MD, FACC, FAHA# Mark A. Creager, MD, FACC, FAHA# Clyde W. Yancy, MD, FACC, FAHA# Lesley H. Curtis, PhD, FAHA David DeMets, PhD# Robert A. Guyton, MD, FACC# #Former Task Force member; current member during the writing effort.
Judith S. Hochman, MD, FACC, FAHA# This document was approved by the American College of Cardiology Board of Trustees, the American Heart Association Science Advisory and Coordinating Committee, and the Heart Rhythm Society Board of Trustees in March 2014.
The American College of Cardiology Foundation requests that this document be cited as follows: January CT, Wann LS, Alpert JS, Calkins H, Cigarroa JE, Cleveland JC Jr, Conti JB, Ellinor PT, Ezekowitz MD, Field ME, Murray KT, Sacco RL, Stevenson WG, Tchou PJ, Tracy CM, Yancy CW. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: executive summary: a report of the American College of Cardiology/AmericanHeart Association Task Force on Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol 2014;64:2246–80.
This article is copublished in Circulation.
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Executive Summary: AHA/ACC/HRS Atrial Fibrillation Guideline TABLE OF CONTENTS 6.5. Wolff-Parkinson-White and Pre-Excitation 1.1. Methodology and Evidence Review . . . . . 2250 6.7. Familial (Genetic) AF . . . . . . . . . . . 2264 1.2. Organization of the Writing Committee . . . . 2250 6.8. Postoperative Cardiac and Thoracic Surgery . . 2265 1.3. Document Review and Approval . . . . . . . 2250 7. EVIDENCE GAPS AND FUTURE RESEARCH 1.4. Scope of the Guideline . . . . . . . . . . . 2250 2. CLINICAL CHARACTERISTICS AND 2.1. AF Classification . . . . . . . . . . . . . 2251 2.2. Mechanisms of AF and Pathophysiology . . . 2251 Author Relationships With Industry and 2.3. Risk Factors and Associated Heart Disease . . . 2251 Other Entities (Relevant) . . . . . . . . . . . . 2271 2.4. Clinical Evaluation: Recommendation . . . . 2251 3. THROMBOEMBOLIC RISK AND TREATMENT . . 2251 Reviewer Relationships With Industry andOther Entities (Relevant) . . . . . . . . . . . . 2273 3.1. Risk-Based Antithrombotic Therapy: Recommendations . . . . . . . . . . . . 2251 3.2. Risk Stratification Schemes Initial Clinical Evaluation in Patients With AF . . . 2280 2 and CHA2DS2-VASc) 3.3. Considerations in Selecting Anticoagulants . . 2254 3.4. Cardiac Surgery—Left Atrial Appendage Occlusion/Excision: Recommendation . . . . 2254 The medical profession should play a central role in evaluating the evidence related to drugs, devices, and 4. RATE CONTROL: RECOMMENDATIONS . . . . . 2254 procedures for the detection, management, and preven- tion of disease. When properly applied, expert analysis of 5. RHYTHM CONTROL: RECOMMENDATIONS . . . 2255 available data on the benefits and risks of these therapies 5.1. Prevention of Thromboembolism . . . . . . 2255 and procedures can improve the quality of care, optimize patient outcomes, and favorably affect costs by focusing 5.2. Direct-Current Cardioversion . . . . . . . . 2256 resources on the most effective strategies. An organized 5.3. Pharmacological Cardioversion . . . . . . . 2256 and directed approach to a thorough review of evidence 5.4. Antiarrhythmic Drugs to Maintain has resulted in the production of clinical practice guide- lines that assist clinicians in selecting the best manage- ment strategy for an individual patient. Moreover, clinical practice guidelines can provide a foundation for other 5.6. AF Catheter Ablation to Maintain applications, such as performance measures, appropriate use criteria, and both quality improvement and clinical 5.7. Surgical Maze Procedures . . . . . . . . . 2261 decision support tools.
The American College of Cardiology (ACC) and the American Heart Association (AHA) have jointly engaged in 6. SPECIFIC PATIENT GROUPS AND AF: the production of guidelines in the area of cardiovascular RECOMMENDATIONS . . . . . . . . . . . . 2261 disease since 1980. The ACC/AHA Task Force on Practice 6.1. Hypertrophic Cardiomyopathy . . . . . . . 2261 Guidelines (Task Force), whose charge is to develop, 6.2. AF Complicating Acute Coronary Syndromes . 2263 update, or revise practice guidelines for cardiovascular diseases and procedures, directs this effort. Writing 6.3. Hyperthyroidism . . . . . . . . . . . . . 2263 committees are charged with the task of performing an 6.4. Pulmonary Disease . . . . . . . . . . . . 2264 assessment of the evidence and acting as an independent Downloaded From: http://content.onlinejacc.org/ on 01/12/2015
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Executive Summary: AHA/ACC/HRS Atrial Fibrillation Guideline group of authors to develop, update, or revise written In view of the advances in medical therapy across recommendations for clinical practice.
the spectrum of cardiovascular diseases, the Task Experts in the subject under consideration are selected Force has designated the term guideline-directed medical from both organizations to examine subject-specific data therapy to represent optimal medical therapy as defined and write guidelines. Writing committees are specifically by ACC/AHA guideline (primarily Class I)–recommended charged to perform a literature review; weigh the strength therapies. This new term, guideline-directed medical ther- of evidence for or against particular tests, treatments, or apy, is used herein and throughout subsequent guidelines.
procedures; and include estimates of expected health Therapies not available in the United States are dis- outcomes where such data exist. Patient-specific modi- cussed in the text without a specific COR. For studies fiers, comorbidities, and issues of patient preference performed in large numbers of subjects outside North that may influence the choice of tests or therapies are America, each writing committee reviews the potential considered, as well as frequency of follow-up and cost- impact of different practice patterns and patient pop- effectiveness. When available, information from studies ulations on the treatment effect and relevance to the ACC/ on cost is considered; however, review of data on efficacy AHA target population to determine whether the findings and outcomes constitutes the primary basis for preparing should inform a specific recommendation.
recommendations in this guideline.
The ACC/AHA practice guidelines are intended to assist In analyzing the data, and developing recommenda- clinicians in clinical decision making by describing a tions and supporting text, the writing committee uses range of generally acceptable approaches to the diagnosis, evidence-based methodologies developed by the Task management, and prevention of specific diseases or con- Force The Classification of Recommendation (COR) is ditions. The guidelines attempt to define practices that an estimate of the size of the treatment effect, with meet the needs of most patients in most circumstances.
consideration given to risks versus benefits, as well as The ultimate judgment about care of a particular patient evidence and/or agreement that a given treatment or must be made by the clinician and patient in light of procedure is or is not useful/effective or in some situa- all the circumstances presented by that patient. As a tions may cause harm; this is defined in The Level result, situations may arise in which deviations from of Evidence (LOE) is an estimate of the certainty or these guidelines may be appropriate. Clinical decision precision of the treatment effect. The writing committee making should involve consideration of the quality and reviews and ranks evidence supporting each recommenda- availability of expertise in the area where care is pro- tion, with the weight of evidence ranked as LOE A, B, or C, vided. When these guidelines are used as the basis for according to specific definitions that are included in regulatory or payer decisions, the goal should be Studies are identified as observational, retro- improvement in quality of care. The Task Force recog- spective, prospective, or randomized, as appropriate. For nizes that situations arise in which additional data are certain conditions for which inadequate data are avail- needed to inform patient care more effectively; these able, recommendations are based on expert consensus areas are identified within each respective guideline and clinical experience and are ranked as LOE C. When when appropriate.
recommendations at LOE C are supported by historical Prescribed courses of treatment in accordance with clinical data, appropriate references (including clinical these recommendations are effective only if followed.
reviews) are cited if available.
Because lack of patient understanding and adherence For issues with sparse available data, a survey of cur- may adversely affect outcomes, clinicians should make rent practice among the clinician members of the writing every effort to engage the patient's active participation in committee is the basis for LOE C recommendations and no prescribed medical regimens and lifestyles. In addition, references are cited.
patients should be informed of the risks, benefits, and The schema for COR and LOE is summarized in , alternatives to a particular treatment and should be which also provides suggested phrases for writing rec- involved in shared decision making whenever feasible, ommendations within each COR.
particularly for COR IIa and IIb, for which the benefit-to- A new addition to this methodology is the separation of risk ratio may be lower.
the Class III recommendations to delineate whether the The Task Force makes every effort to avoid actual, recommendation is determined to be of "no benefit" or is potential, or perceived conflicts of interest that may arise associated with "harm" to the patient. In addition, in view as a result of relationships with industry and other en- of the increasing number of comparative effectiveness tities (RWI) among the members of the writing commit- studies, comparator verbs and suggested phrases for tee. All writing committee members and peer reviewers of writing recommendations for the comparative effective- the guideline are required to disclose all current ness of one treatment or strategy versus another are healthcare-related relationships, including those existing included for COR I and IIa, LOE A or B only.
12 months before initiation of the writing effort.
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Executive Summary: AHA/ACC/HRS Atrial Fibrillation Guideline Applying Classification of Recommendations and Level of Evidence A recommendation with Level of Evidence B or C does not imply that the recommendation is weak. Many important clinical questions addressed in the guidelines do not lendthemselves to clinical trials. Although randomized trials are unavailable, there may be a very clear clinical consensus that a particular test or therapy is useful or effective.
*Data available from clinical trials or registries about the usefulness/efficacy in different subpopulations, such as sex, age, history of diabetes mellitus, history of prior myocardialinfarction, history of heart failure, and prior aspirin use.
†For comparative-effectiveness recommendations (Class I and IIa; Level of Evidence A and B only), studies that support the use of comparator verbs should involve direct comparisonsof the treatments or strategies being evaluated.
In December 2009, the ACC and AHA implemented a in the list of writing committee members, and specific new RWI policy that requires the writing committee section recusals are noted in Authors' and chair plus a minimum of 50% of the writing committee peer reviewers' RWI pertinent to this guideline are dis- to have no relevant RWI includes the ACC/ closed in . In addition, to ensure AHA definition of relevance). The Task Force and all complete transparency, writing committee members' writing committee members review their respective comprehensive disclosure information—including RWI RWI disclosures during each conference call and/or not pertinent to this document—is available as an online meeting of the writing committee, and members provide supplement. Comprehensive disclosure information for updates to their RWI as changes occur. All guideline the Task Force is also available as an recommendations require a confidential vote by the The ACC and AHA exclusively sponsor the work of the writing committee and require approval by a consensus writing committee, without commercial support. Writing of the voting members. Members may not draft or vote committee members volunteered their time for this on any recommendations pertaining to their RWI. Mem- activity. Guidelines are official policy of both the ACC bers who recused themselves from voting are indicated Downloaded From: http://content.onlinejacc.org/ on 01/12/2015
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Executive Summary: AHA/ACC/HRS Atrial Fibrillation Guideline In an effort to maintain relevance at the point of care previously published by the ACC and AHA. References for clinicians, the Task Force continues to oversee an selected and published in this document are representative ongoing process improvement initiative. As a result, in and not all-inclusive.
response to pilot projects, several changes to this guide- line will be apparent, including limited narrative text, a 1.2. Organization of the Writing Committee focus on summary and evidence tables (with references The 2014 AF writing committee was composed of clini- linked to abstracts in PubMed), and more liberal use of cians with broad expertise related to AF and its treatment, summary recommendation tables (with references that including adult cardiology, electrophysiology, cardiotho- support the LOE) to serve as a quick reference.
racic surgery, and heart failure (HF). The writing com- In April 2011, the Institute of Medicine released 2 reports: mittee was assisted by staff from the ACC and AHA. Under Finding What Works in Health Care: Standards for Sys- the guidance of the Task Force, the Heart Rhythm Society tematic Reviews and Clinical Practice Guidelines We Can was invited to be a partner organization and provided Trust It is noteworthy that the Institute of Medicine representation. The writing committee also included a cited ACC/AHA practice guidelines as being compliant representative from the Society of Thoracic Surgeons. The with many of the proposed standards. A thorough review rigorous methodological policies and procedures noted in of these reports and of our current methodology is under the Preamble differentiate ACC/AHA guidelines from way, with further enhancements anticipated.
other published guidelines and statements.
The recommendations in this guideline are considered current until they are superseded by a focused update, 1.3. Document Review and Approval the full-text guideline is revised, or until a published This document was reviewed by 2 official reviewers each addendum declares it out of date and no longer official nominated by the ACC, AHA, and Heart Rhythm Society, ACC/AHA policy. The reader is encouraged to consult the as well as 1 reviewer from the Society of Thoracic Sur- full-text guideline for additional guidance and details geons and 43 individual content reviewers (from the ACC about atrial fibrillation (AF), because the executive sum- Electrophysiology Section Leadership Council, ACC Adult mary contains mainly the recommendations.
Congenital and Pediatric Cardiology Section Leadership Jeffrey L. Anderson, MD, FACC, FAHA Council, ACC Association of International Governors, ACC Chair, ACC/AHA Task Force on Practice Guidelines Heart Failure and Transplant Section Leadership Council, ACC Imaging Section Leadership Council, ACC Interven- tional Section Leadership Council, ACC Surgeons' Coun-cil, and the Heart Rhythm Society Scientific Documents 1.1. Methodology and Evidence Review Committee). All information on reviewers' RWI was The recommendations listed in this document are, distributed to the writing committee and is published in whenever possible, evidence based. An extensive evi- dence review was conducted, focusing on 2006 through This document was approved for publication by the October 2012 and selected other references through March governing bodies of the ACC, AHA, and Heart Rhythm 2014. The relevant data are included in evidence tables in Society and endorsed by the Society of Thoracic Surgeons.
the Searches were extended to studies, reviews, and other evidence conducted in 1.4. Scope of the Guideline human subjects, published in English, and accessible The task of the 2014 writing committee was to establish through PubMed, EMBASE, Cochrane, Agency for Health- revised guidelines for optimum management of AF. The care Research and Quality Reports, and other selected da- new guideline incorporates new and existing knowledge tabases relevant to this guideline. Key search words derived from published clinical trials, basic science, and included but were not limited to the following: age, comprehensive review articles, along with evolving antiarrhythmic, atrial fibrillation, atrial remodeling, atrio- treatment strategies and new drugs. This guideline ventricular conduction, atrioventricular node, cardiover- supersedes the "ACC/AHA/ESC 2006 Guidelines for the sion, classification, clinical trial, complications, concealed Management of Patients With Atrial Fibrillation" and conduction, cost-effectiveness, defibrillator, demographics, the 2 subsequent focused updates from 2011 In epidemiology, experimental, heart failure, hemodynamics, addition, the ACC, AHA, American College of Physicians, human, hyperthyroidism, hypothyroidism, meta-analysis, and American Academy of Family Physicians submitted a myocardial infarction, pharmacology, postoperative, preg- proposal to the Agency for Healthcare Research and nancy, pulmonary disease, quality of life, rate control, Quality to perform a systematic review on specific ques- rhythm control, risks, sinus rhythm, symptoms, and tions related to the treatment of AF. The data from that tachycardia-mediated cardiomyopathy. Additionally, the report were reviewed by the writing committee and writing committee reviewed documents related to AF incorporated where appropriate (8a,8b).
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Executive Summary: AHA/ACC/HRS Atrial Fibrillation Guideline The 2014 AF guideline is organized thematically, with 2. Selection of antithrombotic therapy should be based on the recommendations, where appropriate, provided with risk of thromboembolism irrespective of whether the AF pattern is paroxysmal, persistent, or permanent .
guidelines have been eliminated or updated as warranted (Level of Evidence: B) by new evidence or a better understanding of earlier 3. In patients with nonvalvular AF, the CHA2DS2-VASc* score evidence. In developing the 2014 AF guideline, the is recommended for assessment of stroke risk .
writing committee reviewed prior published guidelines (Level of Evidence: B) and related statements. lists these publications 4. For patients with AF who have mechanical heart valves, and statements deemed pertinent to this effort and is warfarin is recommended, and the target international intended for use as a resource.
normalized ratio (INR) intensity (2.0 to 3.0 or 2.5 to 3.5) 2. CLINICAL CHARACTERISTICS AND should be based on the type and location of the prosthesis (Level of Evidence: B) 5. For patients with nonvalvular AF with prior stroke, transient 2.1. AF Classification ischemic attack (TIA), or a CHA2DS2-VASc score of 2 or greater, AF may be described in terms of the duration of episodes oral anticoagulants are recommended. Options include warfarin (INR 2.0 to 3.0) using a simplified scheme shown in (Level of Evidence: A), dabigatran (Level of Evidence: B), rivaroxaban (Level of Evidence: B), or Implanted loop recorders, pacemakers, and defibrillators apixaban (Level of Evidence: B) offer the possibility of reporting frequency, rate, and dura- tion of abnormal atrial rhythms, including AF Epi- 6. Among patients treated with warfarin, the INR should be sodes often increase in frequency and duration over time.
determined at least weekly during initiation of antith- rombotic therapy and at least monthly when anticoagula- 2.2. Mechanisms of AF and Pathophysiology tion (INR in range) is stable (Level of Evidence: A) AF occurs when structural and/or electrophysiological 7. For patients with nonvalvular AF unable to maintain a abnormalities alter atrial tissue to promote abnormal therapeutic INR level with warfarin, use of a direct impulse formation and/or propagation (). These thrombin or factor Xa inhibitor (dabigatran, rivaroxaban, or abnormalities are caused by diverse pathophysiological apixaban) is recommended. (Level of Evidence: C) mechanisms , such that AF represents a final 8. Reevaluation of the need for and choice of antithrombotic common phenotype for multiple disease pathways and therapy at periodic intervals is recommended to reassess mechanisms that are incompletely understood.
stroke and bleeding risks. (Level of Evidence: C) 9. Bridging therapy with unfractionated heparin or low-molecular- 2.3. Risk Factors and Associated Heart Disease weight heparin (LMWH) is recommended for patients with AF Multiple clinical risk factors, electrocardiographic and and a mechanical heart valve undergoing procedures that require echocardiographic features, and biochemical markers are interruption of warfarin. Decisions on bridging therapy should associated with an increased risk of AF ().
balance the risks of stroke and bleeding. (Level of Evidence: C) 2.4. Clinical Evaluation: Recommendation 10. For patients with AF without mechanical heart valves who require interruption of warfarin or new anticoagulants for See for information on initial clinical evalua- procedures, decisions about bridging therapy (LMWH or tion in patients with AF.
unfractionated heparin) should balance the risks of stroke and bleeding and the duration of time a patient will not be anticoagulated. (Level of Evidence: C) 1. Electrocardiographic documentation is recommended to establish the diagnosis of AF. (Level of Evidence: C) 11. Renal function should be evaluated before initiation of direct thrombin or factor Xa inhibitors and should be 3. THROMBOEMBOLIC RISK AND TREATMENT reevaluated when clinically indicated and at least annually . (Level of Evidence: B) 3.1. Risk-Based Antithrombotic Therapy: Recommendations 12. For patients with atrial flutter, antithrombotic therapy is See for a summary of recommendations from this recommended according to the same risk profile used for AF. (Level of Evidence: C) 1. In patients with AF, antithrombotic therapy should be individ- ualized based on shared decision making after discussion of the *CHA2DS2-VASc indicates Congestive heart failure, Hypertension, Age $75 absolute and relative risks of stroke and bleeding and the years (doubled), Diabetes mellitus, prior Stroke or TIA or thromboembolism patient's values and preferences. (Level of Evidence: C) (doubled), Vascular disease, Age 65 to 74 years, Sex category.
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Executive Summary: AHA/ACC/HRS Atrial Fibrillation Guideline Associated Guidelines and Statements Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) Assessment of Cardiovascular Risk in Asymptomatic Adults Coronary Artery Bypass Graft Surgery Percutaneous Coronary Intervention Secondary Prevention and Risk Reduction Therapy for Patients With Coronary and Other Atherosclerotic Vascular Disease Atrial Fibrillation Stable Ischemic Heart Disease Antithrombotic Therapy Device-Based Therapy ST-Elevation Myocardial Infarction Unstable Angina/Non-ST-Elevation Myocardial Infarction Valvular Heart Disease Assessment of Cardiovascular Risk Lifestyle Management to Reduce Cardiovascular Risk Management of Overweight and Obesity in Adults Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults Treatment of Atrial Fibrillation Oral Antithrombotic Agents for the Prevention of Stroke in Nonvalvular Atrial Fibrillation: A Science Advisory for Healthcare Professionals Expert Consensus Statement on Catheter and Surgical Ablation of Atrial Fibrillation: Recommendations for Patient Selection, Procedural Techniques, PatientManagement and Follow-Up, Definitions, Endpoints, and Research Trial Design *Includes the following sections: Catheter Ablation for AF/Atrial Flutter; Prevention and Treatment of AF Following Cardiac Surgery; Rate and Rhythm Management; Prevention ofStroke and Systemic Thromboembolism in AF and Flutter; Management of Recent-Onset AF and Flutter in the Emergency Department; Surgical Therapy; The Use of AntiplateletTherapy in the Outpatient Setting; and Focused 2012 Update of the CCS AF Guidelines: Recommendations for Stroke Prevention and Rate/Rhythm Control.
AATS indicates American Association for Thoracic Surgery; ACC, American College of Cardiology; ACCP, American College of Chest Physicians; ACP, American College of Physicians; AF, atrial fibrillation; AHA, American Heart Association; AHRQ, Agency for Healthcare Research and Quality; ASA, American Stroke Association; CCS, Canadian Cardiology Society; ECAS,European Cardiac Arrhythmia Society; EHRA, European Heart Rhythm Association; ESC, European Society of Cardiology; HRS, Heart Rhythm Society; JNC, Joint National Committee;NHLBI, National Heart, Lung, and Blood Institute; PCNA, Preventive Cardiovascular Nurses Association; SCAI, Society for Cardiovascular Angiography and Interventions; STS, Society ofThoracic Surgeons; and TOS, The Obesity Society.
2. For patients with nonvalvular AF and moderate-to-severe 1. For patients with nonvalvular AF and a CHA 2DS2-VASc scores of 2 or greater, treatment of 0, it is reasonable to omit antithrombotic therapy with reduced doses of direct thrombin or factor Xa inhibitors (Level of Evidence: B) may be considered (e.g., dabigatran, rivaroxaban, or apix- aban), but safety and efficacy have not been established.
2. For patients with nonvalvular AF with a CHA2DS2-VASc score (Level of Evidence: C) of 2 or greater and who have end-stage chronic kidney disease (CKD) (creatinine clearance <15 mL/min) or are on 3. In patients with AF undergoing percutaneous coronary hemodialysis, it is reasonable to prescribe warfarin (INR 2.0 intervention,y bare-metal stents may be considered to to 3.0) for oral anticoagulation (Level of Evidence: B) minimize the required duration of dual antiplatelet therapy.
Anticoagulation may be interrupted at the time of the 1. For patients with nonvalvular AF and a CHA2DS2-VASc score of 1, no antithrombotic therapy or treatment with an oral anticoagulant or aspirin may be considered. (Level of Evi- the 2011 percutaneous coronary intervention guideline for type of stent and duration of dual antiplatelet therapy recommendations .
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Executive Summary: AHA/ACC/HRS Atrial Fibrillation Guideline Definitions of AF: A Simplified Scheme  AF that terminates spontaneously or with intervention within 7 d of onset.
 Episodes may recur with variable frequency.
 Continuous AF that is sustained >7 d.
Long-standing persistent AF  Continuous AF >12 mo in duration.
 The term "permanent AF" is used when the patient and clinician make a joint decision to stop further attempts to restore and/or maintain sinus rhythm.
 Acceptance of AF represents a therapeutic attitude on the part of the patient and clinician rather than an inherent pathophysiological attribute of AF.
 Acceptance of AF may change as symptoms, efficacy of therapeutic interventions, and patient and clinician preferences evolve.
 AF in the absence of rheumatic mitral stenosis, a mechanical or bioprosthetic heart valve, or mitral valve repair.
AF indicates atrial fibrillation.
procedure to reduce the risk of bleeding at the site of pe- of evidence from clinical trials regarding the balance of risks ripheral arterial puncture. (Level of Evidence: C) and benefits . (Level of Evidence: C) 4. Following coronary revascularization (percutaneous or sur- gical) in patients with AF and a CHA2DS2-VASc score of 2 or 1. The direct thrombin inhibitor dabigatran should not be used greater, it may be reasonable to use clopidogrel (75 mg once in patients with AF and a mechanical heart valve daily) concurrently with oral anticoagulants but without aspirin . (Level of Evidence: B) CLASS III: NO BENEFIT 3.2. Risk Stratification Schemes (CHADS2 and CHA2DS2-VASc) 1. The direct thrombin inhibitor dabigatran and the factor One meta-analysis has stratified ischemic stroke risk Xa inhibitor rivaroxaban are not recommended in patients among patients with nonvalvular AF using the following with AF and end-stage CKD or on dialysis because of the lack scoring systems: AF Investigators CHADS2 (Congestive FIGURE 1 Mechanisms of AF AF indicates atrial fibrillation; Caþþ, ionized calcium; and RAAS, renin-angiotensin-aldosterone system.
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Executive Summary: AHA/ACC/HRS Atrial Fibrillation Guideline 4. RATE CONTROL: RECOMMENDATIONS Selected Risk Factors and Biomarkers for AF Clinical Risk Factors See for a summary of recommendations for this section and for common medication dosages for rate control of AF.
Diabetes mellitus 1. Control of the ventricular rate using a beta blocker or non- dihydropyridine calcium channel antagonist is recommended for patients with paroxysmal, persistent, or permanent AF . (Level of Evidence: B) Obstructive sleep apnea 2. Intravenous administration of a beta blocker or nondi- Cardiothoracic surgery hydropyridine calcium channel blocker is recommended to slow the ventricular heart rate in the acute setting in patients without pre-excitation. In hemodynamically unstable patients, electrical cardioversion is indicated . (Level of Evidence: B) 3. In patients who experience AF-related symptoms during Increased pulse pressure activity, the adequacy of heart rate control should be European ancestry assessed during exertion, adjusting pharmacological treat- ment as necessary to keep the ventricular rate within the physiological range. (Level of Evidence: C) 1. A heart rate control (resting heart rate <80 beats per minute [bpm]) strategy is reasonable for symptomatic management of AF (Level of Evidence: B) Decreased LV fractional shortening 2. Intravenous amiodarone can be useful for rate control in critically Increased LV wall thickness ill patients without pre-excitation (Level of Evidence: B) 3. Atrioventricular (AV) nodal ablation with permanent ven- tricular pacing is reasonable to control heart rate when pharmacological therapy is inadequate and rhythm control is AF indicates atrial fibrillation; BNP, B-type natriuretic peptide; CRP, C-reactive protein; not achievable . (Level of Evidence: B) ECG, electrocardiographic; HF, heart failure; LA, left atrial; LV, left ventricular; LVH, leftventricular hypertrophy; MI, myocardial infarction; and VHD, valvular heart disease.
heart failure, Hypertension, Age $75 years, Diabetes mellitus, 1. A lenient rate-control strategy (resting heart rate <110 bpm) Prior Stroke or TIA or Thromboembolism [doubled]) , may be reasonable as long as patients remain asymptomatic or CHA2DS2-VASc (Congestive heart failure, Hypertension, and left ventricular systolic function is preserved .
Age $75 years [doubled], Diabetes mellitus, Prior Stroke or TIA (Level of Evidence: B) or thromboembolism [doubled], Vascular disease, Age 65 to 74 2. Oral amiodarone may be useful for ventricular rate control years, Sex category) ( when other measures are unsuccessful or contraindicated.
3.3. Considerations in Selecting Anticoagulants (Level of Evidence: C) For patients with CKD, dose modifications of the new agents are available (however, for those with 1. AV nodal ablation with permanent ventricular pacing should not severe or end-stage CKD, warfarin remains the anticoag- be performed to improve rate control without prior attempts to ulant of choice, as there are no or very limited data for achieve rate control with medications. (Level of Evidence: C) these patients. Among patients on hemodialysis, warfarin 2. Nondihydropyridine calcium channel antagonists should not has been used with acceptable risks of hemorrhage .
be used in patients with decompensated HF as these may lead 3.4. Cardiac Surgery—Left Atrial Appendage Occlusion/Excision: to further hemodynamic compromise. (Level of Evidence: C) 3. In patients with pre-excitation and AF, digoxin, non- dihydropyridine calcium channel antagonists, or intravenous 1. Surgical excision of the left atrial appendage may be amiodarone should not be administered as they may increase considered in patients undergoing cardiac surgery. (Level of the ventricular response and may result in ventricular fibrillation (Level of Evidence: B) Downloaded From: http://content.onlinejacc.org/ on 01/12/2015
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Executive Summary: AHA/ACC/HRS Atrial Fibrillation Guideline Summary of Recommendations for Risk-Based Antithrombotic Therapy Antithrombotic therapy based on shared decision making, discussion of risks of stroke and bleeding, and patient's preferences Selection of antithrombotic therapy based on risk of thromboembolism CHA2DS2-VASc score recommended to assess stroke risk Warfarin recommended for mechanical heart valves and target INR intensity based on type and location of prosthesis With prior stroke, TIA, or CHA2DS2-VASc score $2, oral anticoagulants recommended. Options include: Dabigatran, rivaroxaban, or apixaban With warfarin, determine INR at least weekly during initiation of therapy and monthly when stable Direct thrombin or factor Xa inhibitor recommended if unable to maintain therapeutic INR Reevaluate the need for anticoagulation at periodic intervals Bridging therapy with UFH or LMWH recommended with a mechanical heart valve if warfarin is interrupted. Bridging therapy should balance risks of stroke and bleeding For patients without mechanical heart valves, bridging therapy decisions should balance stroke and bleeding risks against duration of time patient will not be anticoagulated Evaluate renal function before initiation of direct thrombin or factor Xa inhibitors, and reevaluate when clinically indicated and at least annually For atrial flutter, antithrombotic therapy is recommended as for AF With nonvalvular AF and CHA2DS2-VASc score of 0, it is reasonable to omit antithrombotic therapy With CHA2DS2-VASc score $2 and end-stage CKD (CrCl <15 mL/min) or on hemodialysis, it is reasonable to prescribe warfarin for oral anticoagulation With nonvalvular AF and a CHA2DS2-VASc score of 1, no antithrombotic therapy or treatment with oral anticoagulant or aspirin may be considered With moderate-to-severe CKD and CHA2DS2-VASc scores $2, reduced doses of direct thrombin or factor Xa inhibitors may be considered For PCI,BMS may be considered to minimize duration of DAPT After coronary revascularization in patients with CHA2DS2-VASc score $2, it may be reasonable to use clopidogrel concurrently with oral anticoagulants but without aspirin Direct thrombin dabigatran and factor Xa inhibitor rivaroxaban are not recommended in patients with AF and end-stage CKD or on dialysis because of a lack of evidence from clinical trialsregarding the balance of risks and benefits Direct thrombin inhibitor dabigatran should not be used with a mechanical heart valve *See the 2011 PCI guideline for type of stent and duration of DAPT recommendations AF indicates atrial fibrillation; BMS, bare-metal stent; CHA2DS2-VASc, Congestive heart failure, Hypertension, Age $75 years (doubled), Diabetes mellitus, Prior Stroke or TIA or thromboembolism (doubled), Vascular disease, Age 65 to 74 years, Sex category; CKD, chronic kidney disease; COR, Class of Recommendation; CrCl, creatinine clearance; DAPT, dualantiplatelet therapy; INR, international normalized ratio; LMWH, low-molecular-weight heparin; LOE, Level of Evidence; N/A, not applicable; PCI, percutaneous coronary intervention;TIA, transient ischemic attack; and UFH, unfractionated heparin.
4. Dronedarone should not be used to control the ventricular anticoagulation with warfarin (INR 2.0 to 3.0) is recom- rate in patients with permanent AF as it increases the risk of mended for at least 3 weeks before and 4 weeks after car- the combined endpoint of stroke, myocardial infarction, dioversion, regardless of the CHA2DS2-VASc score and the systemic embolism, or cardiovascular death method (electrical or pharmacological) used to restore sinus (Level of Evidence: B) rhythm (Level of Evidence: B) 2. For patients with AF or atrial flutter of more than 48 hours' 5. RHYTHM CONTROL: RECOMMENDATIONS duration or unknown duration that requires immediate car- dioversion for hemodynamic instability, anticoagulation See for a summary of recommendations for should be initiated as soon as possible and continued for at rhythm control.
least 4 weeks after cardioversion unless contraindicated.
(Level of Evidence: C) 5.1. Prevention of Thromboembolism 3. For patients with AF or atrial flutter of less than 48 hours' duration and with high risk of stroke, intravenous heparin or 1. For patients with AF or atrial flutter of 48 hours' duration LMWH, or administration of a factor Xa or direct thrombin or longer, or when the duration of AF is unknown, inhibitor, is recommended as soon as possible before or Downloaded From: http://content.onlinejacc.org/ on 01/12/2015
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Executive Summary: AHA/ACC/HRS Atrial Fibrillation Guideline transesophageal echocardiography and maintained after Comparison of the CHADS2 and CHA2DS2-VASc cardioversion for at least 4 weeks Risk Stratification Scores for Subjects With (Level of Evidence: B) 2. For patients with AF or atrial flutter of 48 hours' duration or Stroke Risk Stratification With longer or when duration of AF is unknown, anticoagulation Definition and Scores for the CHADS2 and CHA2DS2-VASc with dabigatran, rivaroxaban, or apixaban is reasonable for CHADS2 and CHA2DS2-VASc at least 3 weeks before and 4 weeks after cardioversion . (Level of Evidence: C) 1. For patients with AF or atrial flutter of less than 48 hours' duration who are at low thromboembolic risk, anticoagulation (intravenous heparin, LMWH, or a new oral anticoagulant) or Diabetes mellitus no antithrombotic therapy may be considered for cardiover- sion, without the need for postcardioversion oral anti- coagulation (Level of Evidence: C) 5.2. Direct-Current Cardioversion 1. In pursuing a rhythm-control strategy, cardioversion is rec- ommended for patients with AF or atrial flutter as a method Diabetes mellitus to restore sinus rhythm. If cardioversion is unsuccessful, repeated attempts at direct-current cardioversion may be made after adjusting the location of the electrodes, applying Vascular disease (prior MI, PAD, or aortic plaque) pressure over the electrodes or following administration of an antiarrhythmic medication . (Level of Evidence: B) Sex category (i.e., female sex) 2. Cardioversion is recommended when a rapid ventricular response to AF or atrial flutter does not respond promptly to pharmacological therapies and contributes to ongoing *These adjusted stroke rates are based on data for hospitalized patients with AF andwere published in 2001 . Because stroke rates are decreasing, actual stroke rates in contemporary nonhospitalized cohorts might vary from these estimates.
†Adjusted stroke rate scores are based on data from Lip and colleagues 3. Cardioversion is recommended for patients with AF or . Actual rates of stroke in contemporary cohorts might vary from these atrial flutter and pre-excitation when tachycardia is associ- ated with hemodynamic instability. (Level of Evidence: C) AF indicates atrial fibrillation; CHADS2, Congestive heart failure, Hypertension, Age $75 years, Diabetes mellitus, Prior Stroke or TIA or Thromboembolism (doubled);CHA2DS2-VASc, Congestive heart failure, Hypertension, Age $75 years (doubled), Diabetes mellitus, Prior Stroke or TIA or thromboembolism (doubled), Vascular disease,Age 65–74 years, Sex category; HF, heart failure; MI, myocardial infarction; PAD, 1. It is reasonable to perform repeated cardioversions in pa- peripheral artery disease; TE, thromboembolism; and TIA, transient ischemic attack tients with persistent AF, provided that sinus rhythm can be maintained for a clinically meaningful period between car- dioversion procedures. Severity of AF symptoms and patient preference should be considered when embarking on a immediately after cardioversion, followed by long-term strategy requiring serial cardioversion procedures. (Level of anticoagulation therapy. (Level of Evidence: C) 4. Following cardioversion for AF of any duration, the decision 5.3. Pharmacological Cardioversion about long-term anticoagulation therapy should be based on the thromboembolic risk profile (). (Level of Evidence: C) 1. Flecainide, dofetilide, propafenone, and intravenous ibutilide are useful for pharmacological cardioversion of AF or atrial 1. For patients with AF or atrial flutter of 48 hours' duration or flutter, provided contraindications to the selected drug are longer or of unknown duration who have not been anti- absent . (Level of Evidence: A) coagulated for the preceding 3 weeks, it is reasonable to perform transesophageal echocardiography before cardio- version and proceed with cardioversion if no left atrial 1. Administration of oral amiodarone is a reasonable option for thrombus is identified, including in the left atrial appen- pharmacological cardioversion of AF . (Level of dage, provided that anticoagulation is achieved before Downloaded From: http://content.onlinejacc.org/ on 01/12/2015
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Executive Summary: AHA/ACC/HRS Atrial Fibrillation Guideline Dose Selection of Oral Anticoagulant Options for Patients With Nonvalvular AF and CKD (Based on Prescribing Information for the United States) Normal/mild impairment Dose adjusted for 20 mg QD with the evening meal 5.0 or 2.5 mg BID (CrCl >30 mL/min) (CrCl >50 mL/min) Moderate impairment Dose adjusted for 15 mg QD with the evening meal 5.0 or 2.5 mg BID (CrCl >30 mL/min) (CrCl 30–50 mL/min) Severe impairment Dose adjusted for 15 mg QD with the evening meal No recommendation.
(CrCl 15–30 mL/min) (CrCl 15–30 mL/min) See Section 4.2.2.2 in the full-text End-stage CKD not Dose adjusted for No recommendation.
(CrCl <15 mL/min) (CrCl <15 mL/min) See Section 4.2.2.2 in the full-text End-stage CKD on dialysis Dose adjusted for No recommendation.
(CrCl <15 mL/min) (CrCl <15 mL/min) See Section 4.2.2.2 in the full-text *Renal function should be evaluated before initiation of direct thrombin or factor Xa inhibitors and should be reevaluated when clinically indicated and at least annually. CrCl should bemeasured using the Cockcroft-Gault method.
†The concomitant use of P-glycoprotein inducers or inhibitors with dabigatran or the concomitant use of dual P-glycoprotein and strong CYP3A4 inducers or inhibitors with eitherrivaroxaban or apixaban, particularly in the setting of CKD, may require dosing adjustment or avoidance of concomitant drug use (see the FDA drug label at , Section 8.6 in the full-text guideline).
‡Use apixaban 2.5 mg BID if any 2 patient characteristics are present: Cr $1.5 mg/dL, $80 y of age, body weight #60 kg . Apixaban is not recommended in patients with severehepatic impairment.
§Dose-adjusted warfarin has been used, but observational data on safety and efficacy are conflicting.
Modeling studies suggest that dabigatran 75 mg BID might be safe for patients with CrCl 15–30 mL/min, but this has not been validated in a prospective cohort. Some countriesoutside the United States use 110 mg BID .
¶No published studies support a dose for this level of renal function.
#In patients with end-stage CKD on stable hemodialysis, prescribing information indicates the use of apixaban 5 mg BID with dose reduction to 2.5 mg BID if the patient is $80 y of ageor body weight is #60 kg.
AF indicates atrial fibrillation; BID, twice daily; CKD, chronic kidney disease; Cr, creatinine; CrCl, creatinine clearance; FDA, Food and Drug Administration; INR, international normalized ratio; and QD, once daily.
2. Propafenone or flecainide ("pill-in-the-pocket") in addition to a beta blocker or nondihydropyridine calcium channel 1. Dofetilide therapy should not be initiated out of hospital antagonist is reasonable to terminate AF outside the hospital because of the risk of excessive QT prolongation that once this treatment has been observed to be safe in a monitored setting for selected patients (Level of Summary of Recommendations for Rate Control Control ventricular rate using a beta blocker or nondihydropyridine calcium channel antagonist for paroxysmal, persistent, or permanent AF IV beta blocker or nondihydropyridine calcium channel blocker is recommended to slow ventricular heart rate in the acute setting in patients without pre-excitation. In hemodynamically unstablepatients, electrical cardioversion is indicated For AF, assess heart rate control during exertion, adjusting pharmacological treatment as necessary A heart rate control (resting heart rate <80 bpm) strategy is reasonable for symptomatic IV amiodarone can be useful for rate control in critically ill patients without pre-excitation AV nodal ablation with permanent ventricular pacing is reasonable when pharmacological therapy is inadequate and rhythm control is not achievable A lenient rate-control strategy (resting heart rate <110 bpm) may be reasonable when patients remain asymptomatic and LV systolic function is preserved Oral amiodarone may be useful for ventricular rate control when other measures are unsuccessful or contraindicated AV nodal ablation should not be performed without prior attempts to achieve rate control Nondihydropyridine calcium channel antagonists should not be used in decompensated HF With pre-excitation and AF, digoxin, nondihydropyridine calcium channel antagonists, or amiodarone should not be administered Dronedarone should not be used to control ventricular rate with permanent AF AF indicates atrial fibrillation; AV, atrioventricular; bpm, beats per minute; COR, Class of Recommendation; HF, heart failure; IV, intravenous; LOE, Level of Evidence; LV, leftventricular; and N/A, not applicable.
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Executive Summary: AHA/ACC/HRS Atrial Fibrillation Guideline Common Medication Dosage for Rate Control of AF Usual Oral Maintenance Dose Metoprolol tartrate 2.5–5.0 mg IV bolus over 2 min; up to 3 doses Metoprolol XL (succinate) 500 mcg/kg IV bolus over 1 min, then 50–300 mcg/kg/min IV 1 mg IV over 1 min, up to 3 doses at 2-min intervals 10–40 mg TID or QID 3.125–25 mg BID Nondihydropyridine calcium channel antagonists 0.0750.15 mg/kg IV bolus over 2 min; may give an additional 10.0 mg 180–480 mg QD (ER) after 30 min if no response, then 0.005 mg/kg/min infusion 0.25 mg/kg IV bolus over 2 min, then 515 mg/h 120–360 mg QD (ER) Digitalis glycosides 0.25 mg IV with repeat dosing to a maximum of 1.5 mg over 24 h 0.125–0.25 mg QD 300 mg IV over 1 h, then 10–50 mg/h over 24 h *Multiple dosing schemes exist for the use of amiodarone.
AF indicates atrial fibrillation; BID, twice daily; ER, extended release; IV, intravenous; N/A, not applicable; QD, once daily; QID, 4 times a day; and TID, 3 times a day.
5.4. Antiarrhythmic Drugs to Maintain Sinus Rhythm summarizes the range of antiarrhythmic drugs useful in the maintenance of sinus rhythm along with therapy can be useful in patients with AF for the treat- toxicity profiles.
ment of tachycardia-induced cardiomyopathy. (Level ofEvidence: C) 1. Before initiating antiarrhythmic drug therapy, treatment of precipitating or reversible causes of AF is recommended.
1. It may be reasonable to continue current antiarrhythmic drug (Level of Evidence: C) therapy in the setting of infrequent, well-tolerated re- currences of AF when the drug has reduced the frequency or 2. The following antiarrhythmic drugs are recommended in symptoms of AF. (Level of Evidence: C) patients with AF to maintain sinus rhythm, depending on underlying heart disease and comorbidities (Level of 1. Antiarrhythmic drugs for rhythm control should not be continued when AF becomes permanent (Level of Evidence: C), including dronedarone . (Level of Evidence: B) 2. Dronedarone should not be used for treatment of AF in pa- tients with New York Heart Association class III and IV HF or patients who have had an episode of decompensated HF in the past 4 weeks . (Level of Evidence: B) 3. The risks of the antiarrhythmic drug, including proar- 5.5. Upstream Therapy rhythmia, should be considered before initiating therapy with each drug. (Level of Evidence: C) 4. Because of its potential toxicities, amiodarone should only angiotensin-receptor blocker (ARB) is reasonable for primary be used after consideration of risks and when other agents prevention of new-onset AF in patients with HF with re- have failed or are contraindicated (Level duced left ventricular ejection fraction . (Level of Downloaded From: http://content.onlinejacc.org/ on 01/12/2015
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Executive Summary: AHA/ACC/HRS Atrial Fibrillation Guideline Summary of Recommendations for Electrical and Pharmacological Cardioversion of AF and Atrial Flutter Prevention of thromboembolism With AF or atrial flutter for $48 h, or unknown duration, anticoagulate with warfarin for at least 3 wk before and 4 wk after cardioversion With AF or atrial flutter for >48 h or unknown duration, requiring immediate cardioversion, anticoagulate as soon as possible and continue for at least 4 wk With AF or atrial flutter <48 h and high stroke risk, IV heparin or LMWH, or factor Xa or direct thrombin inhibitor, is recommended before or immediately after cardioversion,followed by long-term anticoagulation Following cardioversion of AF, long-term anticoagulation should be based on thromboembolic risk With AF or atrial flutter for $48 h or unknown duration and no anticoagulation for preceding 3 wk, it is reasonable to perform TEE before cardioversion and then cardiovert if no LA thrombus is identified,provided anticoagulation is achieved before TEE and maintained after cardioversion for at least 4 wk With AF or atrial flutter $48 h or unknown duration, anticoagulation with dabigatran, rivaroxaban, or apixaban is reasonable for $3 wk before and 4 wk after cardioversion With AF or atrial flutter <48 h and low thromboembolic risk, IV heparin, LMWH, a new oral anticoagulant, or no antithrombotic may be considered for cardioversion Cardioversion is recommended for AF or atrial flutter to restore sinus rhythm. If unsuccessful, cardioversion attempts may be repeated.
Cardioversion is recommended for AF or atrial flutter with RVR, that does not respond to Cardioversion is recommended for AF or atrial flutter and pre-excitation with hemodynamic instability It is reasonable to repeat cardioversion in persistent AF when sinus rhythm can be maintained for a clinically meaningful time period between procedures Flecainide, dofetilide, propafenone, and IV ibutilide are useful for cardioversion of AF or atrial flutter, provided contraindications to the selected drug are absent Amiodarone is reasonable for pharmacological cardioversion of AF Propafenone or flecainide ("pill-in-the-pocket") to terminate AF out of hospital is reasonable once observed to be safe in a monitored setting Dofetilide should not be initiated out of hospital AF indicates atrial fibrillation; COR, Class of Recommendation; IV, intravenous; LA, left atrial; LMWH, low-molecular-weight heparin; LOE, Level of Evidence; N/A, not applicable; RVR,rapid ventricular response; and TEE, transesophageal echocardiography.
antiarrhythmic medication when a rhythm-control strategy 1. Therapy with an ACE inhibitor or ARB may be considered for is desired (Level of Evidence: A) primary prevention of new-onset AF in the setting of hy- 2. Before consideration of AF catheter ablation, assessment of pertension (Level of Evidence: B) the procedural risks and outcomes relevant to the individual 2. Statin therapy may be reasonable for primary prevention of patient is recommended. (Level of Evidence: C) new-onset AF after coronary artery surgery . (Level 1. AF catheter ablation is reasonable for some patients with CLASS III: NO BENEFIT symptomatic persistent AF refractory or intolerant to at 1. Therapy with an ACE inhibitor, ARB, or statin is not beneficial least 1 class I or III antiarrhythmic medication .
for primary prevention of AF in patients without cardiovas- (Level of Evidence: A) cular disease (Level of Evidence: B) AF, catheter ablation is a reasonable initial rhythm-control 5.6. AF Catheter Ablation to Maintain Sinus Rhythm strategy before therapeutic trials of antiarrhythmic drug shows an approach to the integration of antiar- therapy, after weighing the risks and outcomes of drug and rhythmic drugs and catheter ablation of AF in patients ablation therapy . (Level of Evidence: B) without and with structural heart disease.
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Executive Summary: AHA/ACC/HRS Atrial Fibrillation Guideline Dosage and Safety Considerations for Maintenance of Sinus Rhythm in AF Major Pharmacokinetic Exclude/Use With Caution Drug Interactions Vaughan Williams class IA  Immediate release:  Metabolized by CYP3A4: caution with inhibitors 100–200 mg once every 6 h  Prolonged QT interval (e.g., verapamil, diltiazem, ketoconazole,  Extended release: 200–400 mg  Prostatism, glaucoma macrolide antibiotics, protease inhibitors,  Avoid other QT interval grapefruit juice) and inducers (e.g., rifampin,  324–648 mg every 8 h  Prolonged QT interval  Inhibits CYP2D6: [concentrations of tricyclic antidepressants, metoprolol, antipsychotics;Yefficacy of codeine  Inhibits P-glycoprotein: [digoxin concentration Vaughan Williams class IC  50–200 mg once every 12 h  Sinus or AV node dysfunction  Metabolized by CYP2D6 (inhibitors include quinidine, fluoxetine, tricyclics; also genetically absent in 7%–10% of population) and renal  Atrial flutter excretion (dual impairment can [[plasma  Infranodal conduction disease  Brugada syndrome  Renal or liver disease  Immediate release: 150–300 mg  Sinus or AV node dysfunction  Metabolized by CYP2D6 (inhibitors include quinidine, fluoxetine, tricyclics; also genetically  Extended release: 225–425 mg absent in 7%–10% of population)—poor  Atrial flutter metabolizers have [beta blockade  Infranodal conduction disease  Inhibits P-glycoprotein: [digoxin concentration  Brugada syndrome  Inhibits CYP2C9: [warfarin concentration Vaughan Williams class III  Oral: 400–600 mg daily in divided  Sinus or AV node dysfunction  Inhibits most CYPs to cause drug interaction: doses for 2–4 wk; maintenance  Infranodal conduction disease [concentrations of warfarin ([INR 0%–200%), typically 100200 mg QD statins, many other drugs  IV: 150 mg over 10 min; then  Prolonged QT interval  Inhibits P-glycoprotein: [digoxin concentration 1 mg/min for 6 h; then 0.5 mg/minfor 18 h or change to oral dosing;after 24 h, consider decreasingdose to 0.25 mg/min  125–500 mcg once every 12 h  Prolonged QT interval  Primary renal elimination involving glomerular filtration and active tubular secretion: verapamil, HCTZ, cimetidine, ketoconazole, trimethoprim, prochlorperazine, and megestrol are contraindicated;  Diuretic therapy discontinue amiodarone at least 3 mo before  Avoid other QT interval  400 mg once every 12 h  Metabolized by CYP3A: caution with inhibitors (e.g., verapamil, diltiazem, ketoconazole,  Long-standing persistent macrolide antibiotics, protease inhibitors, grapefruit juice) and inducers (e.g., rifampin,  Prolonged QT interval  Inhibits CYP3A, CYP2D6, P-glycoprotein: [concentrations of some statins, sirolimus,tacrolimus, beta blockers, digoxin  40–160 mg once every 12 h  Prolonged QT interval  None (renal excretion)  Diuretic therapy  Avoid other QT interval  Sinus or AV nodal dysfunction AF indicates atrial fibrillation; AV, atrioventricular; CAD, coronary artery disease; HCTZ, hydrochlorothiazide; HF, heart failure; INR, international normalized ratio; IV, intravenous; andQD, once daily.
Adapted with permission from Roden et al.
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Executive Summary: AHA/ACC/HRS Atrial Fibrillation Guideline when a rhythm-control strategy is desired (Level of not well managed with other approaches (Level of 2. AF catheter ablation may be considered before initiation of antiarrhythmic drug therapy with a class I or III anti- 6. SPECIFIC PATIENT GROUPS AND AF: arrhythmic medication for symptomatic persistent AF when a rhythm-control strategy is desired. (Level ofEvidence: C) See for a summary of recommendations for this 1. AF catheter ablation should not be performed in patients 6.1. Hypertrophic Cardiomyopathy who cannot be treated with anticoagulant therapy during and after the procedure. (Level of Evidence: C) 1. Anticoagulation is indicated in patients with hypertrophic 2. AF catheter ablation to restore sinus rhythm should not be performed with the sole intent of obviating the need for CHA2DS2-VASc score (Level of Evidence: B) anticoagulation. (Level of Evidence: C) 5.7. Surgical Maze Procedures 1. Antiarrhythmic medications can be useful to prevent recur- rent AF in patients with HCM. Amiodarone or disopyramide 1. An AF surgical ablation procedure is reasonable for selected combined with a beta blocker or nondihydropyridine calcium patients with AF undergoing cardiac surgery for other in- channel antagonists are reasonable for therapy. (Level of dications. (Level of Evidence: C) 2. AF catheter ablation can be beneficial in patients with HCM in whom a rhythm-control strategy is desired when antiar- 1. A stand-alone AF surgical ablation procedure may be rhythmic drugs fail or are not tolerated . (Level of reasonable for selected patients with highly symptomatic AF FIGURE 2 Strategies for rhythm control in patients with paroxysmal* and persistent AF.† *Catheter ablation is only recommended as first-line therapy for patients with paroxysmal AF (Class IIa recommendation).
†Drugs are listed alphabetically.
‡Depending on patient preference when performed in experienced centers.
§Not recommended with severe LVH (wall thickness >1.5 cm).
Should be used with caution in patients at risk for torsades de pointes ventricular tachycardia.
¶Should be combined with AV nodal blocking agents.
AF indicates atrial fibrillation; AV, atrioventricular; CAD, coronary artery disease; HF, heart failure; and LVH, left ventricular hypertrophy.
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Executive Summary: AHA/ACC/HRS Atrial Fibrillation Guideline Summary of Recommendations for Specific Patient Groups and AF Anticoagulation is indicated in HCM with AF independent of the CHA2DS2-VASc score Antiarrhythmic drugs can be useful to prevent recurrent AF in HCM. Amiodarone or disopyramide combined with a beta blocker or nondihydropyridine calcium channel antagonist are reasonable AF catheter ablation can be beneficial for HCM to facilitate a rhythm-control strategy when antiarrhythmics fail or are not tolerated Sotalol, dofetilide, and dronedarone may be considered for a rhythm-control strategy in HCM AF complicating ACS Urgent cardioversion of new-onset AF in the setting of ACS is recommended for patients with hemodynamic compromise, ongoing ischemia, or inadequate rate control IV beta blockers are recommended to slow RVR with ACS and no HF, hemodynamic instability, With ACS and AF with CHA2DS2-VASc score $2, anticoagulation with warfarin is recommended unless contraindicated Amiodarone or digoxin may be considered to slow RVR with ACS and AF and severe LV dysfunction and HF or hemodynamic instability Nondihydropyridine calcium antagonists might be considered to slow RVR with ACS and AF only in the absence of significant HF or hemodynamic instability Beta blockers are recommended to control ventricular rate with AF complicating thyrotoxicosis unless contraindicated When beta blockers cannot be used, a nondihydropyridine calcium channel antagonist is recommended to control ventricular rate Pulmonary diseases A nondihydropyridine calcium channel antagonist is recommended to control ventricular rate Cardioversion should be attempted for patients with pulmonary disease who become hemodynamically unstable with new-onset AF WPW and pre-excitation syndromes Cardioversion is recommended for patients with AF, WPW syndrome, and RVR who are IV procainamide or ibutilide to restore sinus rhythm or slow ventricular rate is recommended for patients with pre-excited AF and RVR who are not hemodynamically compromised 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 IV amiodarone, adenosine, digoxin, or nondihydropyridine calcium channel antagonists in patients with WPW syndrome who have pre-excited AF is potentially harmful A beta blocker or nondihydropyridine calcium channel antagonist is recommended for persistent or permanent AF in patients with HFpEF In the absence of preexcitation, an IV beta blocker (or a nondihydropyridine calcium channel antagonist with HFpEF) is recommended to slow ventricular response to AF in the acutesetting, with caution in patients with overt congestion, hypotension, or HFrEF In the absence of pre-excitation, IV digoxin or amiodarone is recommended to control heart rate acutely Assess heart rate during exercise and adjust pharmacological treatment in symptomatic patients during activity Digoxin is effective to control resting heart rate with HFrEF A combination of digoxin and beta blocker (or a nondihydropyridine calcium channel antagonist with HFpEF) is reasonable to control resting and exercise heart rate with AF It is reasonable to perform AV node ablation with ventricular pacing to control heart rate when pharmacological therapy is insufficient or not tolerated IV amiodarone can be useful to control heart rate with AF when other measures are unsuccessful or contraindicated With AF and RVR causing or suspected of causing tachycardia-induced cardiomyopathy, it is reasonable to achieve rate control by AV nodal blockade or a rhythm-control strategy Continued on the next page Downloaded From: http://content.onlinejacc.org/ on 01/12/2015
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Executive Summary: AHA/ACC/HRS Atrial Fibrillation Guideline In patients with chronic HF who remain symptomatic from AF despite a rate-control strategy, it is reasonable to use a rhythm-control strategy Amiodarone may be considered when resting and exercise heart rate cannot be controlled with a beta blocker (or a nondihydropyridine calcium channel antagonist with HFpEF) or digoxin, alone or in combination AV node ablation may be considered when rate cannot be controlled and tachycardia-mediated cardiomyopathy is suspected AV node ablation should not be performed without a pharmacological trial to control ventricular rate For rate control, IV nondihydropyridine calcium channel antagonists, IV beta blockers, and dronedarone should not be given with decompensated HF Familial (genetic) AF For patients with AF and multigenerational family members with AF, referral to a tertiary care center for genetic counseling and testing may be considered Postoperative cardiac and thoracic surgery A beta blocker is recommended to treat postoperative AF unless contraindicated A nondihydropyridine calcium channel blocker is recommended when a beta blocker is inadequate to achieve rate control with postoperative AF Preoperative amiodarone reduces AF with cardiac surgery and is reasonable as prophylactic therapy for patients at high risk of postoperative AF It is reasonable to restore sinus rhythm pharmacologically with ibutilide or direct-current cardioversion with postoperative AF It is reasonable to administer antiarrhythmic medications to maintain sinus rhythm with recurrent or refractory postoperative AF It is reasonable to administer antithrombotic medications for postoperative AF It is reasonable to manage new-onset postoperative AF with rate control and anticoagulation with cardioversion if AF does not revert spontaneously to sinus rhythm during follow-up Prophylactic sotalol may be considered for patients with AF risk after cardiac surgery Colchicine may be considered postoperatively to reduce AF after cardiac surgery ACS indicates acute coronary syndromes; AF, atrial fibrillation; AV, atrioventricular; CHA2DS2-VASc, Congestive heart failure, Hypertension, Age $75 years (doubled), Diabetes mellitus,Prior Stroke or TIA or thromboembolism (doubled), Vascular disease, Age 65 to 74 years, Sex category; COPD, chronic obstructive pulmonary disease; COR, Class of Recommendation;HCM, hypertrophic cardiomyopathy; HF, heart failure; HFpEF, heart failure with preserved ejection fraction; HFrEF, heart failure with reduced ejection fraction; IV, intravenous; LOE,Level of Evidence; LV, left ventricular; N/A, not applicable; RVR, rapid ventricular response; and WPW, Wolff-Parkinson-White.
1. Sotalol, dofetilide, and dronedarone may be considered for a 1. Administration of amiodarone or digoxin may be consid- rhythm-control strategy in patients with HCM . (Level of ered to slow a rapid ventricular response in patients with dysfunction and HF or hemodynamic instability. (Level ofEvidence: C) 6.2. AF Complicating Acute Coronary Syndromes 2. Administration of nondihydropyridine calcium antagonists might be considered to slow a rapid ventricular response in 1. Urgent direct-current cardioversion of new-onset AF in the patients with ACS and AF only in the absence of significant setting of acute coronary syndromes (ACS) is recom- HF or hemodynamic instability. (Level of Evidence: C) ongoing ischemia, or inadequate rate control. (Level ofEvidence: C) 6.3. Hyperthyroidism 2. Intravenous beta blockers are recommended to slow a rapid ventricular response to AF in patients with ACS who do not 1. Beta blockers are recommended to control ventricular rate in display HF, hemodynamic instability, or bronchospasm.
patients with AF complicating thyrotoxicosis unless contra- (Level of Evidence: C) indicated. (Level of Evidence: C) 3. For patients with ACS and AF with a CHA2DS2-VASc score of 2. In circumstances in which a beta blocker cannot be used, 2 or greater, anticoagulation with warfarin is recommended a nondihydropyridine calcium channel antagonist is recom- unless contraindicated. (Level of Evidence: C) mended to control the ventricular rate. (Level of Evidence: C) Downloaded From: http://content.onlinejacc.org/ on 01/12/2015
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Executive Summary: AHA/ACC/HRS Atrial Fibrillation Guideline 6.4. Pulmonary Disease 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 1. A nondihydropyridine calcium channel antagonist is recom- during activity. (Level of Evidence: C) mended to control the ventricular rate in patients with AF and chronic obstructive pulmonary disease. (Level of 5. Digoxin is effective to control resting heart rate in patients with HF with reduced ejection fraction. (Level ofEvidence: 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 1. A combination of digoxin and a beta blocker (or a non- dihydropyridine calcium channel antagonist for patients with 6.5. Wolff-Parkinson-White and Pre-Excitation Syndromes HFpEF) is reasonable to control resting and exercise heartrate in patients with AF . (Level of Evidence: B) 1. Prompt direct-current cardioversion is recommended for 2. It is reasonable to perform AV node ablation with ventricular patients with AF, Wolff-Parkinson-White syndrome, and pacing to control heart rate when pharmacological therapy is insufficient or not tolerated . (Level of compromised . (Level of Evidence: C) 2. Intravenous procainamide or ibutilide to restore sinus 3. Intravenous amiodarone can be useful to control heart rate rhythm or slow the ventricular rate is recommended for in patients with AF when other measures are unsuccessful patients with pre-excited AF and rapid ventricular response or contraindicated. (Level of Evidence: C) who are not hemodynamically compromised . (Level of 4. For patients with AF and rapid ventricular response causing or suspected of causing tachycardia-induced cardiomyopa- 3. Catheter ablation of the accessory pathway is recommended thy, it is reasonable to achieve rate control by either AV in symptomatic patients with pre-excited AF, especially nodal blockade or a rhythm-control strategy .
if the accessory pathway has a short refractory period (Level of Evidence: B) that allows rapid antegrade conduction . (Level of 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) 1. Administration digoxin (oral or intravenous), or nondihydropyridine calcium 1. Oral amiodarone may be considered when resting and exer- channel antagonists (oral or intravenous) in patients with cise heart rate cannot be adequately controlled using a beta Wolff-Parkinson-White syndrome who have pre-excited AF is blocker (or a nondihydropyridine calcium channel antagonist potentially harmful because these drugs accelerate the in patients with HFpEF) or digoxin, alone or in combination.
ventricular rate (Level of Evidence: B) (Level of Evidence: C) 2. AV node ablation may be considered when the rate cannot 6.6. Heart Failure be controlled and tachycardia-mediated cardiomyopathy is (Level of Evidence: C) 1. Control of resting heart rate using either a beta blocker or nondihydropyridine calcium channel antagonist is recom- 1. AV node ablation should not be performed without a phar- mended for patients with persistent or permanent AF and macological trial to achieve ventricular rate control. (Level compensated HF with preserved ejection fraction (HFpEF) . (Level of Evidence: B) 2. For rate control, intravenous nondihydropyridine calcium 2. In the absence of pre-excitation, intravenous beta-blocker channel antagonists, intravenous beta blockers, and drone- administration (or a nondihydropyridine calcium channel darone should not be administered to patients with de- antagonist in patients with HFpEF) is recommended to slow compensated HF. (Level of Evidence: C) the ventricular response to AF in the acute setting, with caution needed in patients with overt congestion, hypo- tension, or HF with reduced left ventricular ejection fraction 6.7. Familial (Genetic) AF . (Level of Evidence: B) 3. In the absence of pre-excitation, intravenous digoxin or 1. For patients with AF and multigenerational family members amiodarone is recommended to control heart rate acutely with AF, referral to a tertiary care center for genetic coun- in patients with HF . (Level of Evidence: B) seling and testing may be considered. (Level of Evidence: C) Downloaded From: http://content.onlinejacc.org/ on 01/12/2015
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Executive Summary: AHA/ACC/HRS Atrial Fibrillation Guideline 6.8. Postoperative Cardiac and Thoracic Surgery mechanisms will lead to more defined approaches totreating and abolishing AF. This includes new method- 1. Treating patients who develop AF after cardiac surgery with a beta blocker is recommended unless contraindicated ological approaches for AF ablation that would favor- . (Level of Evidence: A) ably impact survival, thromboembolism, and quality of life across different patient profiles. New pharmacolog- 2. A nondihydropyridine calcium channel blocker is recom- ical therapies are needed, including antiarrhythmic mended when a beta blocker is inadequate to achieve rate drugs that have atrial selectivity and drugs that target control in patients with postoperative AF . (Level of fibrosis, which will hopefully reach clinical evaluation.
The successful introduction of new anticoagulants is investigations will inform clinical practices for optimizing beneficial ap- 1. Preoperative administration of amiodarone reduces the plications and minimizing the risks of these agents, incidence of AF in patients undergoing cardiac surgery particularly in the elderly, in the presence of comor- and is reasonable as prophylactic therapy for patients bidities and in the periprocedural period. Further in- at high risk for postoperative AF (Level of vestigations must be performed to better understand the links between the presence of AF, AF burden, and 2. It is reasonable to restore sinus rhythm pharmacologically stroke risk, and to better define the relationship be- with ibutilide or direct-current cardioversion in patients tween AF and dementia. The roles of emerging surgical who develop postoperative AF, as advised for nonsurgical and procedural therapies to reduce stroke will be patients . (Level of Evidence: B) defined. Great promise lies in prevention. Future stra- 3. It is reasonable to administer antiarrhythmic medications tegies for reversing the growing epidemic of AF will in an attempt to maintain sinus rhythm in patients come from basic science and genetic, epidemiological, with recurrent or refractory postoperative AF, as advised and clinical studies.
for other patients who develop AF . (Level ofEvidence: B) 4. It is reasonable to administer antithrombotic medication in PRESIDENTS AND STAFF patients who develop postoperative AF, as advised for nonsurgical patients . (Level of Evidence: B) American College of Cardiology John Gordon Harold, MD, MACC, President 5. It is reasonable to manage well-tolerated, new-onset post- Shalom Jacobovitz, Chief Executive Officer operative AF with rate control and anticoagulation with William J. Oetgen, MD, MBA, FACC, Executive Vice cardioversion if AF does not revert spontaneously to sinus President, Science, Education, and Quality rhythm during follow-up. (Level of Evidence: C) Charlene May, Senior Director, Science and Clinical Amelia Scholtz, PhD, Publications Manager, Science and 1. Prophylactic administration of sotalol may be considered for patients at risk of developing AF after cardiac surgery American College of Cardiology/American Heart Association (Level of Evidence: B) Lisa Bradfield, CAE, Director, Science and Clinical 2. Administration of colchicine may be considered for patients postoperatively to reduce AF after cardiac surgery Ezaldeen Ramadhan III, Project Management Team (Level of Evidence: B) Leader, Science and Clinical Policy Emily Cottrell, MA, Quality Assurance, Science and 7. EVIDENCE GAPS AND FUTURE RESEARCH DIRECTIONS American Heart Association Mariell Jessup, MD, FACC, FAHA, President The past decade has seen substantial progress in the Nancy Brown, Chief Executive Officer understanding of mechanisms of AF, clinical imple- Rose Marie Robertson, MD, FAHA, Chief Science Officer mentation of ablation for maintaining sinus rhythm, Gayle R. Whitman, PhD, RN, FAHA, FAAN, Senior Vice and new drugs for stroke prevention. Further studies President, Office of Science Operations are needed to better inform clinicians about the risks Marco Di Buono, PhD, Vice President, Science, Research, and benefits of therapeutic options for an individual and Professional Education patient. Continued research is needed into the mecha- Jody Hundley, Production Manager, Scientific Publications, nisms that initiate and sustain AF. It is hoped that Office of Science Operations Downloaded From: http://content.onlinejacc.org/ on 01/12/2015
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Executive Summary: AHA/ACC/HRS Atrial Fibrillation Guideline 1. ACC/AHA Task Force on Practice Guidelines.
Methodology Manual and Policies From the ACCF/ . Accessed August 14, 2014.
AHA Task Force on Practice Guidelines. American College of Cardiology Foundation and American Heart Association. Cardiosource.com and My.ameri- canheart.org. 2010. Available at: Accessed May 9, 2014.
8a. Al-Khatib SM, Allen Lapointe N, Chatterjee R, et al.
Treatment of Atrial Fibrillation. Comparative Effectiveness Review 119. (Prepared by the Duke Evidence-based Practice Center under Contract No.
290-2007-10066-I.) AHRQ Publication No.13- EHC095-EF. Rockville, MD: Agency for Healthcare Research and Quality; June 2013. Available at: Accessed August 14, 2014.
8b. Lopes RD, Crowley MJ, Shah BR, et al. Stroke Prevention in Atrial Fibrillation. Comparative Effec- tiveness Review No. 123. (Prepared by the Duke Evidence-based Practice Center under Contract No.
290-2007-10066-I.) AHRQ Publication No. 13- EHC113-EF. Rockville, MD: Agency for Healthcare Research and Quality; August 2013. Available at: Downloaded From: http://content.onlinejacc.org/ on 01/12/2015
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Executive Summary: AHA/ACC/HRS Atrial Fibrillation Guideline KEY WORDS AHA Scientific Statements, atrial fibrillation, cardio-renal physiology/ pathophysiology, cardiovascular surgery: transplantation, ventricular assistance, cardiomyopathy, epidemiology, full revision, health policy and outcome research, other atrial fibrillation Downloaded From: http://content.onlinejacc.org/ on 01/12/2015
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Executive Summary: AHA/ACC/HRS Atrial Fibrillation Guideline APPENDIX 1. AUTHOR RELATIONSHIPS WITH INDUSTRY AND OTHER ENTITIES (RELEVANT)—2014 AHA/ACC/HRS GUIDELINE FOR THE MANAGEMENT OF PATIENTS WITH ATRIAL FIBRILLATION Speakers Partnership/ University of Wisconsin- Madison—Professor of Medicine, Cardiovascular Medicine Division Columbia St. Mary's Clinical Cardiologist University of Arizona Health  Sanofi-aventis Johns Hopkins Hospital— Professor of Medicine,  Sanofi-aventis Joaquin E. Cigarroa Oregon Health and Science Professor; Clinical Chief Joseph C. Cleveland, Jr University of Colorado— Professor of Surgery; University of Florida— Professor of Medicine; Division of Cardiovascular Patrick T. Ellinor Massachusetts General Hospital Heart Center, Cardiac Arrhythmia Michael D. Ezekowitz Jefferson Medical Continued on the next page Downloaded From: http://content.onlinejacc.org/ on 01/12/2015
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Executive Summary: AHA/ACC/HRS Atrial Fibrillation Guideline APPENDIX 1. CONTINUED Speakers Partnership/ University of Wisconsin School of Medicine and Public Health— Assistant Professor of Medicine, Director of Cardiac Arrhythmia Katherine T. Murray Vanderbilt University School of Medicine, Divisions of Clinical Pharmacology and University of Miami, Miller School of Medicine, William G. Stevenson Brigham and Women's  Biosense  Biosense Hospital, Cardiac Arrhythmia Program— Director; Harvard Medical School— Professor of Medicine Cleveland Clinic Foundation— Section of Cardiac Electrophysiology and Pacing, Department of Cardiovascular Medicine Heart and Vascular George Washington University Director and Professor Northwestern University, Feinberg School of Professor of Medicine; Division of Cardiology— This table represents the relationships of committee members with industry and other entities that were determined to be relevant to this document. These relationships werereviewed and updated in conjunction with all meetings and/or conference calls of the writing committee during the document development process. The table does not necessarilyreflect relationships with industry at the time of publication. A person is deemed to have a significant interest in a business if the interest represents ownership of $5% of the votingstock or share of the business entity, or ownership of $$10,000 of the fair market value of the business entity; or if funds received by the person from the business entity exceed 5% ofthe person's gross income for the previous year. Relationships that exist with no financial benefit are also included for the purpose of transparency. Relationships in this table aremodest unless otherwise noted.
According to the ACC/AHA, a person has a relevant relationship IF: a) the relationship or interest relates to the same or similar subject matter, intellectual property or asset, topic, orissue addressed in the document; or b) the company/entity (with whom the relationship exists) makes a drug, drug class, or device addressed in the document, or makes a competingdrug or device addressed in the document; or c) the person, or a member of the person's household, has a reasonable potential for financial, professional, or other personal gain or loss asa result of the issues/content addressed in the document.
*Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply. Sectionnumbers pertain to those in the full-text guideline.
†No financial benefit.
‡Indicates significant relationship.
§Dr. Sacco's relationship with Boehringer Ingelheim was added just after final balloting of the recommendations and before organizational review, so it was not relevant during thewriting or voting stages of the guideline's development.
ACC indicates American College of Cardiology; AHA, American Heart Association; DSMB, data safety monitoring board; and HRS, Heart Rhythm Society.
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APPENDIX 2. REVIEWER RELATIONSHIPS WITH INDUSTRY AND OTHER ENTITIES (RELEVANT)—2014 AHA/ACC/HRS GUIDELINE FOR THE MANAGEMENT OF PATIENTS WITH ATRIAL FIBRILLATION Official Reviewer—HRS St. George's, University of London—Professor of Clinical Cardiology  Boston Scientific  Sanofi-aventis  St. Jude Medical Official Reviewer—AHA Albert Einstein College of Medicine—Professor of Mt. Sinai Medical Center— Task Force on Practice Professor of Medicine  Boston Scientific  Sanofi-aventis Continued on the next page Downloaded From: http://content.onlinejacc.org/ on 01/12/2015
APPENDIX 2. CONTINUED Official Reviewer—AHA UT Southwestern Medical  St. Jude Medical of Internal Medicine Official Reviewer—HRS Lankenau Medical Office Building—Chief of  GlaxoSmithKline Official Reviewer—ACC Board Premier Healthcare, LLC—Clinical  Plaintiff, ICD, 2012 Cardiac EP; Indiana Professor of Medicine  Sanofi-aventis Official Reviewer—ACC Board Michigan Heart, P. C. Michigan Heart and Vascular Institute— Organizational Reviewer—STS The Heart Hospital Baylor Plano— Cardiologist; University of Texas at Arlington—Adjunct Assistant Clinical Professor Intermountain Medical Center—  The Medicines Task Force on Practice Associate Chief of Cardiology  Sanofi-aventis Content Reviewer—ACC EP Park Nicollet Health Services— Section Leadership Council Content Reviewer—ACC UT Southwestern Medical School—  Boston Scientifi  Abbott Vascular Interventional Section Director, Cardiac Leadership Council Catheterization Laboratory, VA North Texas Healthcare  Sanofi-aventis Continued on the next page Downloaded From: http://content.onlinejacc.org/ on 01/12/2015
APPENDIX 2. CONTINUED Content Reviewer—AHA Mayo Clinic, Division of Professor of Medicine Content Reviewer—ACC Board Queen Elizabeth II Health Departments of Medicine, Community Health, and University of Buffalo—Charles  Biosense Webster and Mary Bauer Professor  Sanofi-aventis  St. Jude Medical Content Reviewer— Duke University School of ACC/AHA Task Force on Practice Guidelines Professor of Medicine  GlaxoSmithKline VCU Medical Center—Director,  Biosense Webster  Biosense Webster Represented hospital, Clinical EP Laboratory  Boston Scientific  Boston Scientific  Boston Scientific CardioNet  Sanofi-aventis  Sanofi-aventis  St. Jude Medical  Sanofi-aventis  St. Jude Medical Tufts University School of  Boston Scientific  Boston Scientific  Boston Scientific Medicine—Professor of  St. Jude Medical  Boston Scientific Cardiomyopathy Center, Division of Cardiology Mount Sinai School of Medicine— Director, Zena and Michael A.
Wiener Cardiovascular Institute Continued on the next page Downloaded From: http://content.onlinejacc.org/ on 01/12/2015
APPENDIX 2. CONTINUED Content Reviewer—HHS HHS Office of the Assistant Secretary for Health and National Center for Chronic Disease Prevention and Health Centers for Disease Control and Content Reviewer— New York University School of  GlaxoSmithKline ACC/AHA Task Force Medicine—Clinical Chief of on Practice Guidelines University of Oklahoma Health  Biosense Webster Bi  Boston Scientifi Sciences Center for Cardiac  Boston Scientific Arrhythmia Research Institute—Professor of Content Reviewer—ACC USUHS—Associate Professor of Board of Governors Content Reviewer—HRS University of Birmingham,  Sanofi-aventis School of Clinical and Experimental Medicine— Chair in Cardiovascular Medicine Northwestern Medical Center  Boston Scientific  Biosense Webster  Catheter Robotics  Plaintiff, pacemaker Division of Cardiology—  Cameron Health Biotronik Director of Clinical Cardiac EP  Boston Scientific Hunterdon Cardiovascular Harvard Medical School,  Boston Scientific  Boston Scientific Brigham and Women's  St. Jude Medical University of Florida,  Medtronic—STOP- Department of Medicine— Content Reviewer—ACC Saint Patrick Hospital— Board of Governors  Sanofi-aventis Continued on the next page Downloaded From: http://content.onlinejacc.org/ on 01/12/2015
APPENDIX 2. CONTINUED Content Reviewer—ACC EP University of Iowa Hospital—  Boston Scientific Section Leadership Professor of Medicine  Boston Scientific  Sanofi-aventis  Sanofi-aventis Content Reviewer—AIG Gazi University School of Medicine—Professor of Mayo Foundation St. Mary's  St. Jude Medica  Biosense Webster  Boston Scientific  Boston Scientific  St. Jude Medical  Sanofi-aventis  St. Jude Medica University of Wisconsin Hospital and Clinics—Chair, Department Content Reviewer—AHA University of Colorado School of Gurusher Panjrath Content Reviewer—ACC HF George Washington University— and Transplant Section Assistant Professor of Medicine Leadership Council Content Reviewer—HRS St. Vincent Hospital and Health Center—Director, Clinical EP Content Reviewer—ACC Oregon Health and Science Surgeons' Council Continued on the next page Downloaded From: http://content.onlinejacc.org/ on 01/12/2015
APPENDIX 2. CONTINUED Content Reviewer— ACC Adult Children's Hospital Boston— Congenital and Pediatric Cardiology SectionLeadership Council Content Reviewer— ACC Adult University of Utah School of Congenital and Pediatric Medicine and Primary Cardiology Section Children's Medical Center— Leadership Council Associate Professor Content Reviewer—HHS National Institute on Aging, Division of Geriatrics and Clinical Gerontology Content Reviewer—HRS  Biosense Webster  St. Jude Medical Cardiovascular Institute, Rhode Task Force on Practice Island Hospital and Lifespan— Chief of Cardiothoracic Surgery Mayo Clinic Arizona—Professor Task Force on Practice of Medicine, Consultant David J. Slotwiner Long Island Jewish Medical  Boston Scientific Center—Associate Director, EP Valley Health System Arrhythmia  Ambucor  Biosense Webster University College of  Boston Scientific  Sanofi-aventis Physicians and Surgeons— Professor of Medicine Content Reviewer—ACC Emory University School of Surgeons' Council of Cardiothoracic Surgery  St. Jude Medical Chief Executive Officer  Sanofi-aventis Continued on the next page Downloaded From: http://content.onlinejacc.org/ on 01/12/2015
APPENDIX 2. CONTINUED Content Reviewer—HRS Case Western Reserve University—  Abbott Vascular The Walter H. Pritchard Professor of Cardiology,  Biosense Webster  Sanofi-avent Professor of Medicine, and  St. Jude Medical Professor of Biomedical  Sanofi-aventis This table represents the relationships of reviewers with industry and other entities that were disclosed at the time of peer review and determined to be relevant to this document. It does not necessarily reflect relationships with industry at the time ofpublication. A person is deemed to have a significant interest in a business if the interest represents ownership of $5% of the voting stock or share of the business entity, or ownership of $$10,000 of the fair market value of the business entity; or if fundsreceived by the person from the business entity exceed 5% of the person's gross income for the previous year. A relationship is considered to be modest if it is less than significant under the preceding definition. Relationships that exist with no financialbenefit are also included for the purpose of transparency. Relationships in this table are modest unless otherwise noted. Names are listed in alphabetical order within each category of review.
According to the ACC/AHA, a person has a relevant relationship IF: a) the relationship or interest relates to the same or similar subject matter, intellectual property or asset, topic, or issue addressed in the document; or b) the company/entity (with whomthe relationship exists) makes a drug, drug class, or device addressed in the document, or makes a competing drug or device addressed in the document; or c) the person, or a member of the person's household, has a reasonable potential for financial,professional, or other personal gain or loss as a result of the issues/content addressed in the document.
*Significant relationship.
†No financial benefit.
ACC indicates American College of Cardiology; AHA, American Heart Association; AIG, Association of International Governors; DSMB, data safety monitoring board; EP, electrophysiology; HF, heart failure; HHS, Health and Human Services; HRS, Heart Rhythm Society; ICD, implantable cardioverter-defibrillator; PI, principal investigator; STOP-AF, Sustained Treatment Of Paroxysmal Atrial Fibrillation; STS, Society of Thoracic Surgeons; UCLA, University of California, Los Angeles; USUHS, UniformedServices University of the Health Sciences; UT, University of Texas; VA, Veterans Affairs; and VCU, Virginia Commonwealth University.
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Executive Summary: AHA/ACC/HRS Atrial Fibrillation Guideline APPENDIX 3. INITIAL CLINICAL EVALUATION IN PATIENTS WITH AF Minimum Evaluation 1. History and physical examination,  Presence and nature of symptoms associated with AF  Clinical type of AF (paroxysmal, persistent, or permanent)  Onset of first symptomatic attack or date of discovery of AF  Frequency, duration, precipitating factors, and modes of initiation or termination of AF  Response to any pharmacological agents that have been administered  Presence of any underlying heart disease or reversible conditions (e.g., hyperthyroidism or alcohol consumption) 2. ECG, to identify  Rhythm (verify AF)  P-wave duration and morphology or fibrillatory waves  Bundle-branch block  Other atrial arrhythmias  To measure and follow R-R, QRS, and QT intervals in conjunction with antiarrhythmic drug therapy 3. TTE, to identify  LV and RV size and function  Peak RV pressure (pulmonary hypertension)  LA thrombus (low sensitivity)  Pericardial disease 4. Blood tests of thyroid, renal, and  For a first episode of AF  When ventricular rate is difficult to control Additional Testing (1 or several tests may be necessary) 1. 6-min walk test  If adequacy of rate control is in question  If adequacy of rate control is in question 2. Exercise testing  To reproduce exercise-induced AF  To exclude ischemia before treatment of selected patients with a type IC antiarrhythmic drug 3. Holter or event monitoring  If diagnosis of type of arrhythmia is in question  As a means of evaluating rate control  To identify LA thrombus (in LAA)  To guide cardioversion 5. Electrophysiological study  To clarify the mechanism of wide-QRS-complex tachycardia  To identify a predisposing arrhythmia such as atrial flutter or paroxysmal supraventricular tachycardia  To seek sites for curative AF ablation or AV conduction block/modification 6. Chest radiograph, to evaluate  Lung parenchyma, when clinical findings suggest an abnormality  Pulmonary vasculature, when clinical findings suggest an abnormality *Type IC refers to the Vaughan Williams classification of antiarrhythmic drugs.
AF indicates atrial fibrillation; AV, atrioventricular; ECG, electrocardiogram; LA, left atrial; LAA, left atrial appendage; LV, left ventricular; LVH, left ventricular hypertrophy; MI, myocardial infarction; RA, right atrial; RV, right ventricular; TEE, transesophageal echocardiography; TTE, transthoracic echocardiogram; and VHD, valvular heart disease.
Adapted with permission from Fuster et al. Downloaded From: http://content.onlinejacc.org/ on 01/12/2015

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