C-CHANGE 2022 recommendations for people with atrial fibrillation, stroke or dementia
| Source guideline | Recommendation | Grade or strength of recommendation and category or level of evidence*† |
|---|---|---|
| Atrial fibrillation | ||
| Screening and diagnostic strategies | ||
| CCS/CHRS AF19 | We recommend that the initial evaluation of a patient with newly diagnosed AF include a complete history and physical examination, a 12-lead ECG, a transthoracic echocardiogram, and basic laboratory investigations (complete blood count, coagulation profile, serum electrolytes including calcium and magnesium, renal function, liver function, thyroid function, fasting lipid profile, fasting glucose and HbA1c)‡. (New recommendation) | Evidence: low-quality |
| Treatment targets and thresholds | ||
| CCS/CHRS AF19 | When rate control of persistent AF is pursued, we recommend titrating rate- controlling agents to achieve a resting heart rate of < 100 beats/min during AF. (New recommendation) | Evidence: moderate-quality |
| Pharmacologic and procedural therapy for risk reduction | ||
| CCS/CHRS AF19 | We recommend that the “CCS Algorithm”§ (CHAD-65) be used to guide the choice of antithrombotic therapy for the purpose of stroke or systemic embolism prevention in patients with NVAF. (New recommendation) | Evidence: high-quality |
| CCS/CHRS AF19 | We recommend that OAC be prescribed for most patients with AF and age 65 yr or older or CHADS2 score ≥ 1. (New recommendation) | Evidence: moderate-quality |
| CCS/CHRS AF19 | We recommend that most patients should receive a DOAC (apixaban, dabigatran, edoxaban or rivaroxaban) in preference to warfarin when OAC therapy is indicated for patients with NVAF. (New recommendation) | Evidence: high-quality |
| CCS/CHRS AF19 | We recommend that warfarin be used for patients with a mechanical prosthetic valve and those with AF and moderate to severe mitral stenosis. (New recommendation) | Evidence: moderate-quality |
| CCS/CHRS AF19 | We recommend that patients with AF who are receiving OAC should have their renal function assessed at baseline and at least annually to detect latent kidney disease, determine OAC eligibility and to support drug dosing. (New recommendation) | Evidence: moderate-quality |
| CCS/CHRS AF19 | We recommend that antithrombotic therapy in patients with AF and CKD be provided according to their risk of stroke or systemic embolism and the severity of renal dysfunction with selection of agent according to Appendix 7 (new recommendation):¶
| Evidence: high-quality |
| CCS/CHRS AF19 | We recommend OAC alone for patients with AF aged 65 yr or older or with a CHADS2 score ≥ 1 and stable coronary or arterial vascular disease. (New recommendation) | Evidence: moderate-quality |
| CCS/CHRS AF19 | We recommend that OAC be prescribed for most frail elderly patients with AF. (New recommendation) | Evidence: moderate-quality |
| CCS/CHRS AF19 | In patients with a gastrointestinal or genitourinary bleed after OAC initiation: We recommend that anticoagulant therapy be recommenced in patients at high risk of stroke as soon as possible after the cause of bleeding has been identified and corrected. (New recommendation) | Evidence: moderate-quality |
| CCS/CHRS AF19 | We recommend that either β-blockers or ND-CCBs (diltiazem or verapamil) be first-line agents for AF rate control in patients without significant left ventricular dysfunction (e.g., patients with an LVEF > 40%). (New recommendation) | Evidence: moderate-quality |
| CCS/CHRS AF19 | We recommend evidence-based β-blockers (bisoprolol, carvedilol, metoprolol) be first-line agents for rate control of hemodynamically stable AF in the acute care setting in patients with significant left ventricular dysfunction (LVEF ≤ 40%) | Evidence: moderate-quality |
| Stroke | ||
| Screening and diagnostic strategies | ||
| Stroke10 | BP should be assessed and managed in all people with stroke or transient ischemic attack. | Evidence: level A |
| Stroke10 | For patients being investigated for an embolic ischemic stroke or transient ischemic episode of undetermined source whose initial short-term ECG monitoring does not reveal AF but a cardioembolic mechanism is suspected, prolonged ECG monitoring for at least 2 wk is recommended to improve detection of paroxysmal AF in selected patients aged ≥ 55 yr who are not already receiving anticoagulant therapy but would be potential anticoagulant candidates. (New recommendation) | Evidence: level A |
| Treatment targets and thresholds | ||
| Hypertension9/stroke10 | For patients who have had an ischemic stroke or transient ischemic attack, BP- lowering treatment is recommended to achieve a target of consistently lower than 140/90 mm Hg. | Evidence: level B |
| Pharmacologic and procedural therapy for risk reduction | ||
| Stroke10 | Individuals presenting within 48 h of symptoms consistent with a new acute stroke or transient ischemic attack event (especially transient focal motor or speech symptoms, or persistent stroke symptoms) are at the highest risk for recurrent stroke and should be immediately sent to an emergency department with capacity for stroke care (including on-site brain imaging and, ideally, access to acute stroke treatments). (New recommendation) | Evidence: level B |
| Stroke10 | For patients with ischemic stroke or transient ischemic attack, antiplatelet therapy is recommended for long-term secondary stroke prevention to reduce the risk of recurrent stroke and other vascular events unless there is an indication for anticoagulant therapy. (New recommendation) | Evidence: level A |
| Stroke10 | For long-term secondary stroke prevention, either ASA (80–325 mg daily), or clopidogrel (75 mg/d), or combined ASA and extended-release dipyridamole (25 mg/200 mg twice per day) are all appropriate treatment options, and selection depends on patient factors or clinical circumstances. | Evidence: level A |
| Stroke10 | For patients with an ischemic stroke or transient ischemic attack and atrial fibrillation, oral anticoagulant therapy is strongly recommended. It is recommended over ASA and dual antiplatelet therapy. | ASA: evidence: level A Dual antiplatelet therapy: evidence: level B |
| Dementia | ||
| Screening and diagnostic strategies | ||
| Dementia20 | An objective assessment of the patient’s cognitive function could be achieved by using rapid psychometric screening tools such as the memory impairment screen and clock drawing test, the Mini-Cog, the AD8, the 4-item version of the MoCA (clock drawing, tap at letter A, orientation and delayed recall) and the GP Assessment of Cognition. (New recommendation) | Evidence: level 2B |
Note: AF = atrial fibrillation, ASA = acetylsalicylic acid, CCB = calcium channel blocker, CCS/CHRS AF = Canadian Cardiovascular Society/Canadian Heart Rhythm Society Guidelines for the Management of Atrial Fibrillation, CHADS = congestive heart failure; hypertension; age ≥ 75 years; diabetes mellitus; and a previous history of stroke or transient ischemic attack, CKD = chronic kidney disease, Dementia = Canadian Consensus Conference on Diagnosis and Treatment of Dementia guideline, DOAC = direct oral anticoagulants, ECG = electrocardiogram, HbA1C = glycated hemoglobin, Hypertension = Hypertension Canada guideline, LVEF = left ventricular ejection fraction, ND-CCB = non-dihydropyridine calcium channel blocker, NVAF = nonvalvular atrial fibrillation, OAC = oral anticoagulant, Stroke = Canadian Stroke Best Practice Recommendations, Heart and Stroke Foundation.
↵* Unless otherwise indicated.
↵† See Appendix 2a (available at www.cmaj.ca/lookup/doi/10.1503/cmaj.220138/tab-related-content) for summary of grading for each included guideline, and Appendix 2b for comparison of grading schemes.
↵‡ See Appendix 6 (available at www.cmaj.ca/lookup/doi/10.1503/cmaj.220138/tab-related-content) for evaluation of patients with AF.
↵§ Algorithm available at https://ccs.ca/app/uploads/2022/05/CCS_Top_10_Info_v5.pdf.
↵¶ See Appendix 7 (available at www.cmaj.ca/lookup/doi/10.1503/cmaj.220138/tab-related-content) for recommendations on dosage of oral anticoagulants.