Summary

ACC/AHA and HRS provide revised recommendations for specific sections involved in the management of atrial fibrillation (AF);

• oral anticoagulant selection and NOAC eligibility to lower risk of thromboembolic stroke
• LAA occlusion and catheter ablation
• therapies to lower bleeding risk in AF patients with acute coronary syndrome

In January 2019, the American College of Cardiology/American Heart Association (ACC/AHA) Task Force on Clinical Practice Guidelines and the Heart Rhythm Society (HRS) updated their 2014 guidelines that focus on the management of patients with atrial fibrillation (AF). Here is a summary of those guidelines.

Anticoagulant regimen selection

1. Oral anticoagulants are recommended for patients with AF and an elevated CHA2DS2-VASc score of >2 in men or >3 in women (CHA2DS2-VASc being congestive heart failure, hypertension, age ≥75 years [doubled], diabetes mellitus, prior stroke or transient ischaemic attack or thromboembolism [doubled], vascular disease, age 65-74 years, sex category).
2. Females have a low stroke risk similar to males in the absence of other AF risk factors (CHA2DS2-VASc score of 0 in males and 1 in females). For age >65 years or ≥2 non–sex-related stroke risk factors, the addition of female sex to the CHA2DS2-VASc score does make a difference.
3. In non-vitamin K oral anticoagulants (NOACs)-eligible patients with AF (except those with moderate-to-severe mitral stenosis or a mechanical heart valve), dabigatran, rivaroxaban, apixaban, and edoxaban are recommended over warfarin.
4. A CHA2DS2-VASc score is advised to assess the risk of stroke in patients with AF (except those with moderate-to-severe mitral stenosis or a mechanical heart valve).
5. Warfarin is recommended for patients with AF who have mechanical heart valves.
6. Before the initiation of a NOAC kidney and liver functions should be evaluated with a minimum of yearly re-valuations thereafter.
7. Patients with low CHA2DS2-VASc scores are no longer routinely given aspirin. Clinicians may consider giving an oral anticoagulant to lower the risk of thromboembolic stroke in patients with AF (except those with moderate-to-severe mitral stenosis or a mechanical heart valve) and a CHA2DS2-VASc score of 1 in men, or 2 in women.

Anticoagulation- Interruption and bridging

In cases of life-threatening bleeding or an urgent procedure, idarucizumab is recommended to counteract dabigatran. In cases of life-threatening or uncontrolled bleeding, andexanet alfa can be useful to counteract rivaroxaban and apixaban.

LAA (left atrial appendage) Percutaneous Occlusion

In patients with AF that have contraindications to long-term anticoagulation but have a higher risk of stroke, percutaneous LAA occlusion may be considered.

Thromboembolism prevention

Irrespective of the CHA2DS2-VASc score or the method (electrical or pharmacologic) used to restore sinus rhythm, warfarin anticoagulation (international normalised ratio [INR] 2.0-3.0), a factor Xa inhibitor, or direct thrombin inhibitor is recommended for patients with AF or atrial flutter of at least 48 hours, or when the AF duration is unknown, for a minimum of 3 weeks before and a minimum of 4 weeks after cardioversion.

Catheter ablation in patients with HF

In some patients with symptomatic AF and heart failure (HF) with reduced left ventricular (LV) ejection fraction (HFrEF), AF catheter ablation may be a rational choice for lowering the mortality rate and reducing HF hospitalization.

ACS due to AF complications

To lessen the bleeding risk in AF patients with post percutaneous coronary intervention (PCI) stenting for acute coronary syndrome (ACS) with a higher risk of stroke (based on CHA2DS2-VASc risk score of ≥2), these three options are better than triple therapy (oral anticoagulant, aspirin, and P2Y12 inhibitor):

• Double therapy with clopidogrel or ticagrelor (a P2Y12 inhibitor) and dose-adjusted vitamin K antagonist
• Double therapy with clopidogrel (a P2Y12 inhibitor) and low-dose rivaroxaban 15 mg per day
• Double therapy with clopidogrel (a P2Y12 inhibitor) and dabigatran 150 mg twice per day

A transition to double therapy (oral anticoagulant and P2Y12 inhibitor) can be considered by clinicians at 4-6 weeks if triple therapy is given to patients with AF at a higher risk of stroke (based on CHA2DS2-VASc risk score of ≥2) and who underwent PCI with stenting (drug eluting or bare metal) for ACS.

AF patients and weight loss

Weight loss in combination with other risk factor modification is recommended for overweight and obese patients with AF.