Society Guidelines2014 Focused Update of the Canadian Cardiovascular Society Guidelines for the Management of Atrial Fibrillation
Section snippets
Stroke Prevention Principles
In the 2010 and 2012 CCS guidelines1, 2 it was recommended that the Congestive Heart Failure, Hypertension, Age, Diabetes, Stroke/Transient Ischemic Attack (CHADS2) schema3 be used to estimate stroke risk, because of its simplicity, familiarity, and extensive validation. However, in the 2012 guidelines, elements of the Congestive Heart Failure, Hypertension, Age (≥ 75 years), Diabetes, Stroke/Transient Ischemic Attack, Vascular Disease, Age (65-74 years), Sex (Female) (CHA2DS2-VASc) schema4
Patients With Chronic Kidney Disease
In the Rivaroxaban Once Daily Oral Direct Factor Xa Inhibition Compared With Vitamin K Antagonist for Prevention of Stroke and Embolism Trial in Atrial Fibrillation (ROCKET AF) trial (n = 14,264) and the Anticoagulation and Risk Factors in Atrial Fibrillation (ATRIA) cohort (n = 13,559) chronic kidney disease (CKD) with a creatinine clearance < 60 mL/min was independently associated with risk for stroke after adjusting for CHADS2 or CHA2DS2-VASc parameters.24 Similar results were obtained in
Detection of AF in Patients With Stroke
Identification of AF has particular importance in patients with acute ischemic stroke or TIA because of the treatment implications for secondary stroke prevention. Without AF, the usual secondary stroke prevention treatment is antiplatelet therapy. However, when AF is documented in stroke/TIA patients (whether paroxysmal or persistent/permanent), OAC therapy is superior to antiplatelet therapy and strongly recommended for recurrent stroke prevention.
Diagnostic evaluation of patients with
Investigation and Management of SCAF
The Asymptomatic Atrial Fibrillation and Stroke Evaluation in Pacemaker Patients and the Atrial Fibrillation Reduction Atrial Pacing Trial (ASSERT) and A Prospective Study of the Clinical Significance of Atrial Arrhythmias Detected by Implanted Device Diagnostics (TRENDS) studies demonstrated that episodes of SCAF as short as 5-6 minutes are common among patients with implanted devices and that SCAF is associated with a 2- to 2.5-fold increased risk of stroke.42, 43 Clinical risk factors
Left Atrial Appendage Closure in Stroke Prevention
The concept of left atrial appendage (LAA) removal or occlusion to prevent ischemic stroke in AF has existed for many years. This can be achieved surgically at the time of another cardiac surgical procedure or as a stand-alone surgery. It can also be achieved through a transvenous LAA occlusion device. Such devices are approved in Europe, but not in Canada. There are no major trials of surgical removal and there is only one reported randomized trial of a LAA occlusion device, Watchman Left
Emergency Department Management
This section focuses on stroke prevention for patients with symptomatic, recent-onset AF/AFL, the most common arrhythmia in the Emergency Department (ED). There are 2 competing strategies for ED management; rate-control and rhythm control treatment.50, 51 The rate control approach consists of ventricular rate control, OAC, and delayed cardioversion after 4 weeks if indicated. With the rhythm control approach, attempts are made to cardiovert patients to sinus rhythm in the ED, either
Periprocedural Anticoagulation Management
When a patient receiving an OAC or an antiplatelet agent is to undergo a surgical or diagnostic procedure that has a risk of major bleeding, the risk of a thromboembolic event while the antithrombotic agent is reduced or stopped must be weighed against the risk of bleeding during or after the procedure.60, 61 The major patient factors that suggest a greater risk of a thromboembolic event are captured by a higher CHADS2 score, recent (< 3 months) stroke or TIA, mechanical prosthetic heart valve,
Rate and Rhythm Control
Since the publication of the 2012 focused update of CCS AF guidelines,2 there have been some new data that reinforce the rate and rhythm control recommendations in the 2010 guidelines and the focused update.74
AF ablation as first-line therapy
Recent studies examined the value of AF ablation as first-line therapy. The Medical Antiarrhythmic Treatment or Radiofrequency Ablation in Paroxysmal Atrial Fibrillation (MANTRA-PAF) study randomized 294 patients with paroxysmal AF and no history of AAD use to an initial strategy of catheter ablation (n = 146) or AADs (n = 148). After 24 months, AF burden was not different but significantly more patients in the ablation group were AF-free.80 The Radiofrequency Ablation vs Antiarrhythmic Drugs
Acknowledgements
For a full list of Guideline Committee Members, see the Canadian Cardiovascular Society Atrial Fibrillation Guidelines – Primary Panel and Canadian Cardiovascular Society Atrial Fibrillation Guidelines – Secondary Panel sections of the Supplementary Material.
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The disclosure information of the authors and reviewers is available from the CCS on their guidelines library at www.ccs.ca.
This statement was developed following a thorough consideration of medical literature and the best available evidence and clinical experience. It represents the consensus of a Canadian panel comprised of multidisciplinary experts on this topic with a mandate to formulate disease-specific recommendations. These recommendations are aimed to provide a reasonable and practical approach to care for specialists and allied health professionals obliged with the duty of bestowing optimal care to patients and families, and can be subject to change as scientific knowledge and technology advance and as practice patterns evolve. The statement is not intended to be a substitute for physicians using their individual judgment in managing clinical care in consultation with the patient, with appropriate regard to all the individual circumstances of the patient, diagnostic and treatment options available and available resources. Adherence to these recommendations will not necessarily produce successful outcomes in every case.