Society Guidelines
2014 Focused Update of the Canadian Cardiovascular Society Guidelines for the Management of Atrial Fibrillation

https://doi.org/10.1016/j.cjca.2014.08.001Get rights and content

Abstract

Atrial fibrillation (AF) is an extremely common clinical problem with an important population morbidity and mortality burden. The management of AF is complex and fraught with many uncertain and contentious issues, which are being addressed by extensive ongoing basic and clinical research. The Canadian Cardiovascular Society AF Guidelines Committee produced an extensive set of evidence-based AF management guidelines in 2010 and updated them in the areas of anticoagulation and rate/rhythm control in 2012. In late 2013, the committee judged that sufficient new information regarding AF management had become available since 2012 to warrant an update to the Canadian Cardiovascular Society AF Guidelines. After extensive evaluation of the new evidence, the committee has updated the guidelines for: (1) stroke prevention principles; (2) anticoagulation of AF patients with chronic kidney disease; (3) detection of AF in patients with stroke; (4) investigation and management of subclinical AF; (5) left atrial appendage closure in stroke prevention; (6) emergency department management of AF; (7) periprocedural anticoagulation management; and (8) rate and rhythm control including catheter ablation. This report presents the details of the updated recommendations, along with their background and rationale. In addition, a complete set of presently applicable recommendations, those that have been updated and those that remain in force from previous guideline versions, is provided in the Supplementary Material.

Résumé

La fibrillation auriculaire (FA) est un problème clinique très fréquent représentant un fardeau important de la morbidité et de la mortalité de la population. La prise en charge de la FA est complexe et comporte plusieurs questions incertaines et controversées, qui sont actuellement abordées par la recherche fondamentale et clinique approfondie. En 2010, le comité des lignes directrices sur la FA de la Société canadienne de cardiologie a produit un vaste ensemble de lignes directrices sur la prise en charge de la FA fondées sur des données probantes et les a mises à jour en 2012 dans les domaines de l’anticoagulation du contrôle de la fréquence et du rythme. À la fin de 2013, le comité a estimé que les nouvelles informations sur la prise en charge de la FA qui sont disponibles depuis 2012 étaient suffisantes pour justifier une mise à jour des lignes directrices sur la FA de la Société canadienne de cardiologie. Après l’évaluation approfondie des nouvelles données probantes, le comité a mis à jour les lignes directrices sur : 1) les principes de prévention de l’accident vasculaire cérébral; 2) l’anticoagulation des patients atteints d’une maladie rénale chronique qui ont une FA; 3) la détection de la FA chez les patients qui subissent un accident vasculaire cérébral; 4) l’évaluation et la prise en charge de la FA subclinique; 5) la fermeture de l’appendice auriculaire gauche dans la prévention de l’accident vasculaire cérébral; 6) la prise en charge de la FA par le service des urgences; 7) la prise en charge péri-interventionnelle de l’anticoagulation; 8) le contrôle de la fréquence et du rythme, y compris l’ablation par cathéter. Ce rapport présente de manière détaillée les recommandations mises à jour, ainsi que leur fondement et leurs justifications. De plus, l’ensemble des recommandations actuellement applicables, celles qui ont été mises à jour et celles des versions précédentes des lignes directrices qui demeurent en vigueur, est fourni dans une Liste complète des lignes directrices comme documentation complémentaire.

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.

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