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CCS Atrial Fibrillation Guidelines: Management Of AF In 2014: Putting The New Guidelines Into PracticeOctober 2014

Atrial Fibrillation Guidelineswww.ccs.ca

About this Slide SetThis slide set is a quick-reference tool that features essential diagnostic and treatment recommendations based on the 2010 CCS Atrial Fibrillation Guidelines, the 2012 CCS Atrial Fibrillation Guidelines Update and the 2014 Focused Update of the CCS guidelines for the management of AF. 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 guideline 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. For the complete CCS Atrial Fibrillation Guidelines, or for additional resources, please visit our guidelines website at www.ccs.ca.


The 2014 Focused Update of the Canadian Cardiovascular SocietyGuidelines for the Management of Atrial Fibrillation

Co-chairs and AuthorsJeff S. Healey and Atul Verma

AuthorsJohn A. Cairns, Stuart Connolly, Jafna L. Cox, Paul Dorian, David Gladstone, Gordon J. Gubitz, Noah Ivers, Kori Leblanc, Laurent Macle, Michael Sean McMurtry, L. Brent Mitchell, Stanley Nattel, Pierre Pag, Ratika Parkash, P. Timothy Pollak, Allan C. Skanes, Ian G. Stiell, Mario Talajic, Teresa S. M. Tsang and Carl Van Walraven.

Publication date: October 2014


FacultyJeff Healey, MD, FRCPCMcMaster UniversityJohn A Cairns, MD, FRCPC, FACCProfessor of MedicineDivision of Cardiology University of British ColumbiaAtul Verma, MD FRCPC FHRSDirector of Electrophysiology Research & LabsSouthlake Regional Health CentreAssistant Professor, University of TorontoAdjunct Professor, McGill UniversityAllan C. Skanes, MD FRCPCAssociate Professor, Department of Medicine, Division of Cardiology Cardiologist, London Health Sciences Centre Director, Electrophysiology LabLondon Health Sciences CentrePaul Dorian, MD, FRCPCDepartment Director, Division of Cardiology University of TorontoStaff Cardiac ElectrophysiologistSt. Michael's HospitalProfessor of MedicineDivision of Cardiology and Clinical PharmacologyUniversity of TorontoStaff Scientist at the Li Ka Shing Knowledge Institute.L. Brent Mitchell, MD, FRCPCProfessor of Medicine and Cardiac SciencesLibin Cardiovascular Institute of AlbertaAlberta Health Services and University of Calgary


Overview of the 2014 Update

2014 publication is meant as an update to prior update in 2012 and original major guideline re-write in 2010

Includes an executive summary of ALL guidelines from 2010 onwards (updated) which can be downloaded online at the CJC website


Overview of the 2014 UpdateKey new elements of the 2014 Update:

New, simplified stroke risk stratification scheme: The CCS AlgorithmDetection of AF in patients with strokeInvestigation and management of subclinical AFCommentary on left atrial appendage closureRe-write on cardioversion guidelines in EDNew section on peri-procedural management of oral anticoagulationNew rate/rhythm control algorithm


New CCS Algorithm


Detection of AF in Stroke Patients


Management of SCAF


Perioperative Management of OAC

What constitutes low, intermediate and high risk procedures for perioperative bleeding

When interruption of OAC is required and when it is not

How to stop new direct oral anticoagulants around the time of surgery

When and how to bridge for cessation of warfarin therapy

When to restart OAC after surgery


New Rate/Rhythm Algorithm

Case 1 : Dr. YDAF in Emergency Departmentby John A. Cairns, MD FRCPC FACC

October 2014


DisclosuresDSMBs Chair: AVERROES (apixaban), SHIELD-2 (azimilide), ARTESIA (apixaban) Member: ACTIVE Trials (aspirin, clopidogrel, warfarin), PALLAS (dronedarone), COMPASS (rivaroxaban),

Advisory Boards Boehringer Ingelheim Canada (Since Nov 2010), St Jude Medical (since Jan 2012), Bayer (intermittent), BMS (intermittent)

Research trial funding Medtronic, Sanofi Aventis, Astrazeneca, Bayer, Boston Scientific

Speaker honoraria Boehringer Ingelheim Canada, Lilly, Pfizer/BMS, Bayer


Dr. YD, Age 42, Family PractitionerLast evening he was out celebrating the marriage of his receptionist and consumed about 12 ounces of Johnny Walker Black label.

He went home by taxi, slept poorly and realized this morning about 6:00 am that his heart rate was rapid and pulse irregular.

He has a mild bitemporal headache and is driven to the ED by his wife.

He has been well, no known hypertension, DM, heart disease, TIA/stroke and no known arrhythmias although he does have mild palpitations from time to time. No COPD or asthma.

In ED: no chest pain, mild SOB, slightly sweaty. HR 140, irregularly irregular, BP 140/90, JVD 4 cm, Chest clear. ECG shows AF, rate 140.


Overview of AF ManagementAssessment of Thromboembolic Risk (CHADS2)


Dr. YD, Age 42, Family PractitionerHow will you manage his rhythm?

Electrical cardioversion (150-200 j) in ED as soon as it can be done.

IV metoprolol 5 mg, repeated Q 5 min up to 3 times if rate remains above 110. Home on po metoprolol 50-100 mg bid if AF persists.

IV metoprolol 5 mg, repeated Q 5 min up to 3 times if rate remains above 110. Add propofenone 450 mg po about 10-15 minutes after first dose of metoprolol if AF persists.

IV metoprolol 5 mg, repeated Q 5 min up to 3 times if rate remains above 110. Electrical cardioversion if AF persists.

Digoxin 0.25 mg IV, repeat at 1 hour intervals up to 4 doses if AF persists.


Dr. YD, Age 42, Family PractitionerHow will you manage his rhythm?

Electrical cardioversion (150-200 j) in ED as soon as it can be done.

IV metoprolol 5 mg, repeated Q 5 min up to 3 times if rate remains above 110. Home on po metoprolol 50-100 mg bid if AF persists.

IV metoprolol 5 mg, repeated Q 5 min up to 3 times if rate remains above 110. Add propofenone 450 mg po about 10-15 minutes after first dose of metoprolol if AF persists.

IV metoprolol 5 mg, repeated Q 5 min up to 3 times if rate remains above 110. Electrical cardioversion if AF persists. Best answer! *

Digoxin 0.25 mg IV, repeat at 1 hour intervals up to 4 doses if AF persists.*This is a young man with no stroke risk factors. His AF has been present for only a few hours. It is likely the AF was precipitated by his alcohol indiscretion and he is likely to return to NSR with cardioversion and likely to remain in sinus rhythm. Accordingly, electrical cardioversion is a good option. It makes sense to give IV metoprolol to slow his rate before cardioversion. The cardioversion may be done without prior anticoagulation. He requires no ongoing OAC or ASA.Hence, the best answer is #4. #3 would be acceptable if there is some reason not to do electrical cardioversion, or if there is any expectation that he may have recurrent episodes of AF and might be suitable for a pill in the pocket regimen, but this does not appear indicted in this first presentation of AF. #2 is OK, but in a young person with acute onset, electrical (or pharmacological) cardioversion has a high likelihood of resolving the AF. #1 is not advised since there is no rush to cardiovert him and giving metoprolol will be likely to decrease symptoms prior to cardioversion. #5 would not be a good choice.


Dr. YD, Age 42, Family PractitionerHow will you reduce his risk of stroke if you decide to cardiovert him?

IV LMWH or a NOAC po about 1 hour prior to any cardioversion attempt.

IV LMWH or a NOAC po about 1 hour prior to electrical cardioversion, but not required for pharmacologic cardioversion.

No anticoagulant required pre cardioversion attempt.

Start dabigatran 150 mg bid and have him return for cardioversion after 3 weeks of dabigatran.


Dr. YD, Age 42, Family PractitionerHow will you reduce his risk of stroke if you decide to cardiovert him?

IV LMWH or a NOAC po about 1 hour prior to any cardioversion attempt.

IV LMWH or a NOAC po about 1 hour prior to electrical cardioversion, but not required for pharmacologic cardioversion.

No anticoagulant required pre cardioversion attempt. Best answer! He is young, has no risk factors for stroke, and the duration of AF has been short. The risk of a stroke with cardioversion and no anticoagulation is very low. He requires no anticoagulation pre cardioversion.

Start dabigatran 150 mg bid and have him return for cardioversion after 3 weeks of dabigatran.

Atrial Fibrillation Guidelineswww.ccs.caEmergency Management of AF

* Immediate OAC = a dose of OAC should be given just prior to cardioversion - either a novel direct oral anticoagulant (NOAC) or a dose of heparin or low molecular weight heparin with bridging to warfarin if a NOAC is contraindicated.

YESNO Management of AF in the ED Recommendations


Supporting DataPost CV TE 0.8% vs 5.3% with oral anticoagulation. Prospective cohort study (Bjerkelund et al 1969).

90% of TE occur within 10 d of CV. Meta-analysis (Berger 1998)

TE < 1% for CV < 48 hrs with no OAC (case series 1997, 2002)

CV > 48 hrs, TE occurs following CV even with OAC (< 1% by 30 days). Rate with NOACs similar to with VKA (NOAC RCTs 2012-14)


Supporting DataFinnish Study 2014 (Nuotio I et al. JAMA 2014;312:647) Rates of TE with duration of AF:

Case 2 : Mrs. BBRate and Rhythm Control by Paul Dorian, MD FRCPC

October 2014


DisclosuresPaul Dorian has received grant support and honoraria from

Bayer, Boehringer-Ingleheim, BMS, Pfizer, Sanofi


A guidelines based approach to AF management Mrs. BB, a 77 year old lady has hypertension, otherwise well

Lives alone, has a dog

On Ramipril 10 mg and bisoprolol 5 mg a day for hypertension

5 ft 5 in, 190lbs.

Comes to the office for routine BP follow-up


Pulse rate 85/min, irregular

BP 145/95 , repeated X 3

No murmurs , no signs CHF

Says she feels well

On closer questioning, she walks the dog around the block; she used to walk to the park, 2-3 kms away, but no longer feels like it

EKG shows AF, otherwise normal, rate 88/min


What next?Why does she have AF?

Thyroid

Hypertension

Sleep apnea

Ethanol


What next?

What are the risks and benefits of rhythm control?


HistoryEstablish Severity (including impact on QOL)Identify EtiologyIdentify reversible causes (hyperthyroidism, ventricular pacing, SVT, exercise)Identify factors whose treatment could reduce recurrent AF or improve overall prognosis (i.e. hypertension, sleep apnea, left ventricular dysfunction)Identify potential triggers (i.e. alcohol, intensive aerobic training)Identify potentially heritable causes of AF (particularly in lone AF)Determine thromboembolic risk (e.g. CHADS2 Score)Determine bleeding risk to guide appropriate antithrombotic therapyReview prior pharmacologic therapy for AF, for efficacy and adverse effects


Establish AF Severity Use to Guide Therapeutic ApproachDorian et al Can J Cardiol 2006;22:383-386

CCSSAF ScoreImpact on QOL 0Asymptomatic1Minimal effect on QOL2Minor effect of QOL3Moderate effect on QOL4Severe effect on QOL


SAF class 2-3 on detailed discussion Choices: increase beta blockerattempt to restore sinus rhythm

CHADS = 2 (CHADSVaSC 4)

OAC for 3-4 weeks

Electrical Cardioversion


Rhythm Management


Rhythm Management


How likely is cardioversion to be successful? ( distinguish success with IRAF from failure)

If sinus rhythm restored , how likely is AF to recur?

What can be done to prevent recurrence?

HT control, ETOH reduction if excessive, sleep apnea treatment if appropriate


How do we tell if rhythm control is justified?

Assess QOL without knowing the rhythm or doing an EKG

eg QOL improves post CV, and worsens again with recurrence, vs

No better, or better, but AF recurs without symptoms

Atrial Fibrillation Guidelines

Major Goals of AF/AFL Arrhythmia Management Identify and treat underlying structural heart disease and other predisposing conditionsRelieve symptoms Improve functional capacity/quality of life Reduce morbidity/mortality associated with AF/AFL Prevent tachycardia-induced cardiomyopathy Reduce/prevent emergency room visits or hospitalizations secondary to AF/AFLPrevent stroke or systemic thromboembolism


Pill in pocket antiarrhythmic therapyParoxysmal AFCONTINUE RATE CONTROLLow burden recurrenceObserve. If AF recurs, determine if symptomaticSymptoms improve, and patient maintains sinus rhythmMODIFY RATE CONTROL - CONSIDER RHYTHM CONTROLSYMPTOMS RESOLVECatheter ablationMaintenance antiarrhythmic therapySymptoms dont change in sinus rhythm and AF recursSymptoms improve, but AF recurs Rate vs Rhythm Control for Patients with Symptomatic AFHigh burden recurrenceATTEMPT RATE CONTROLBeta-blockerCalcium channel blockerNOYESSpecial circumstances in which to consider early rhythm control:Highly symptomaticMultiple recurrencesExtreme impairment in QOLArrhythmia-induced cardiomyopathySYMPTOMATIC AFConsider cardioversionPersistent AF


Overview of Rhythm ManagementDrugs are listed in alphabetical order

+Dronedarone should be used with caution in combination with digoxin Class I agents should be AVOIDED in CAD and should be COMBINED with AV-nodal blocking agents#Sotalol should be used with caution in those at risk for torsades de pointes VT (e.g. female, age > 65 yr, taking diuretics)** Sotalol should be used with caution with EF 35-40% and those at risk for torsades de pointes VT (e.g. female, age > 65 yr, taking diuretics)


When, if at all, should antiarrhythmic drugs be used?

Prophylactically ?

If AF recurs?


If an antiarrhythmic is required, which one?

If no CAD or LV dysfunction

Consider flecainide, propafenone , dronedarone ( cost), sotalol ( fatigue)

Amiodarone usually second line, but in older patients often effective at low doses note: efficacy assessed as:

Patient feels better and has no adverse effects, NOT A fib is completely suppressed


Established Patterns and Severity of Atrial FibrillationPatterns of Atrial Fibrillation SAF Score* NewlyDiagnosed AF Persistent:Sustained 7dPermanent:Decision to continuein AFParoxysmal:Self-terminating65 years taking diuretics or those with renal insufficiencyQT interval should be monitored 1 week after starting Use cautiously when EF

Case 3 : Mr. MBStroke Preventionby John A. Cairns, MD FRCPC FACC

October 2014


Dr. Fred Brown, a GP colleague, asks for your advice about Mr. MB, Age 67Previously well, active, no significant limitationsNo hypertension, DM, CHF, no medsHR 100 irreg, BP 135/85HS normal, no murmurs or gallops, JVP just visible at 45

Heart skipping beats and racing, especially on exertion 2 weeks prior to GP visit


Dr. Fred Brown, a GP colleague, asks for your advice about Mr. MB, Age 67 (contd)Hgb 145, Glucose 5.4, Cr 1.0 (eGFR 110)EKG AF 95/minEcho unremarkable (LA 4.0, LV 5.0, EF 55%, no LVH)

Dr. Brown started him on atenolol 50 mg qam and symptoms are much improved

Mr. MB, Age 67 yr, 1 week post atenolol 50 mg qam


How would you treat him to reduce his risk of stroke?No antithrombotic therapy ?

ASA 81 mg/day ?

OAC ?



ASA 81 mg/day ?

OAC ? Best answer! This 67 year old man fits the CCS algorithm for use of OAC. The new algorithm looks first at age and if the person is age 65 years, OAC is indicated, provided the risk of major bleeding is not excessive.


What is Mr. MBs CHADS2 score? 1 2 0 3

What is his annual risk of stroke? 0.5% ? 1.0% ? 2.0% ? 5.0% ?


What is Mr. MBs CHADS2 score? 1 2 0 Best answer! His CHADS2 score is 0. Note in CHADS2 no points are given for age until the patient is 75 years. 3

What is his annual risk of stroke? 0.5% ? 1.0% ? 2.0% ? Best answer! His annual risk of stroke at age 67 is about 2.13 % (mean risk for CHADS2 score of 0 is 1.9%, but his risk at age 67 is higher than the mean in this category). 5.0% ?


Stroke rate/ 100 patient yrCHADS21.9%

Risk FactorScoreCongestive Heart Failure1Hypertension1Age 751Diabetes Mellitus1Stroke/TIA/Thromboembolism2Maximum Score6

Chart1

1.8

3

4

6

9

12

18.5

Stroke Rate

Sheet1

Stroke Rate

01.8

13

24

36

49

512

618.5


Mr. MB, Age 67Data from Danish epidemiological studies indicate the following annual risk of stroke:Age 65-74: 2.13%Vascular disease: 1.40%Age < 65, no vascular disease:0.7%

BUT, within the group of patients with CHADS2 = 0 (annual stroke risk 1.9%):


YES* We suggest that a NOAC be used in preference to warfarin for non-valvular AF.



ASA 81 mg/day ?

OAC ?


How would you treat him to reduce his risk of stroke?No antithrombotic therapy ? Incorrect. Given his 2.1% annual risk of stroke it would be wise to prescribe antithrombotic therapy.

ASA 81 mg/day ? Incorrect. Probably inadequate protection. His stroke risk would be reduced by about 20%, with an annual risk of major bleeding of about 0.5%.

OAC ? Correct! Best choice. OAC recommended by CCS Guidelines.


What about bleeding risk?

What would be his annual risk of bleeding on OAC?0.5%?

1%?

3%

5%


What about bleeding risk?

What would be his annual risk of bleeding on OAC?0.5%?

1%? Best answer! This comes from the HAS-BLED score, which gives him 1 point for being over age 65.

3%

5%



YES* We suggest that a NOAC be used in preference to warfarin for non-valvular AF.


Prevention of Stroke in AF/AFL Stratification of patients using a predictive index for stroke risk


Prevention of Stroke in AF/AFL OAC therapy for patients 65 year or CHADS2 1


For Mr. MB, age 67, the GP is asking: If I prescribe an OAC, which should I choose?Warfarin to achieve INR 2-3 ?

Rivaroxaban 20 mg daily ?

Dabigatran 150 mg bid or Dabigatran 110 mg bid?

Apixaban 5 mg bid ?

Any of 2, 3 or 4, although not all are equivalent?

Stroke or systemic embolic events in large NOAC trials, vs warfarinRuff et al., The Lancet, 2013Dabi 150 mgEdox 60 mgRivaroxabanApixaban

Ruff et al., The Lancet, 2013Major bleeding events in large NOAC trials, vs warfarinRE-LY150 mg60 mg

Ruff et al., The Lancet, 2013Secondary efficacy and safety outcomes in large NOAC trials, vs. warfarinEfficacy


Prevention of Stroke in AF/AFL Most patients should receive a NOAC


For Mr. MB, age 67, the GP is asking: If I prescribe an OAC, which should I choose?Warfarin to achieve INR 2-3 ? Correct! An acceptable therapy since OAC is indicated. Warfarin will reduce risk by 2/3, but complex to use.

Rivaroxaban 20 mg daily ? Correct! A preferred therapy. Non-inferior to warfarin and easier to use.

Dabigatran 150 mg bid or Dabigatran 110 mg bid? Correct! A preferred therapy. Superior to warfarin and easier to use. Dabigatran 110 mg bid Correct! An acceptable therapy. Non-inferior to warfarin. Easier to use.

Apixaban 5 mg bid ? Correct! A preferred therapy. Superior to warfarin and easier to use.

Any of 2, 3 or 4, Best answer. All are acceptable therapies, but the NOACs are preferred over warfarin, and the features of the individual NOACs vary.


Case 4: the pediatrician and Case 5 : the young patientCatheter Ablationby Allan C. Skanes, MD FRCPC

October 2014


Disclosures

Knowledge Translation work with:Boehringer-IngelheimBayerPfizer

Research Grants with:Boehringer-IngelheimBiosense Webster


Case 466 year-old pediatrician with intermittent palpitations for last 6-8 months

Strong palpitations, SOB, mild CPLong episodes he finds it hard to finish clinic

To ED once where rapid AF documentedUnderwent DC cardioversion

Put on Bisoprolol 2.5mg daily and titrated to 5mg daily


Case 4Has had high blood pressure readings recorded intermittently but is not hypertensiveAgitated he had to wait.

PMHx: NoneOn ASA and BisoprololAvid cyclist

Overweight but denies snoring / apneic breathingStates I do not have sleep apnea HR 80bpmBP 165/90Otherwise exam is normalEcho: essentially normal LA slightly enlarged 42mmLV function normal, EF 60%, no WMA, no LVH


Case 4

Has read about ablation and wants cryoballoon ablation he has read that this is the newest breakthrough

Doesnt want drugs because they will cloud his sensorium and effect his ability to do clinic.


Your advice for Case 4?

Discuss PV isolation in detail refer for PVI

Strongly suggest add flecainide to bisoprolol

Refer him to EP for further discussion

Suggest he take amiodarone and if fails - ablation


Your advice for Case 4?

Discuss PV isolation in detail refer for PVIStrongly suggest add flecainide to bisoprolol Best answer! The latest CCS AF Guidelines suggest that anti-arrhythmic drugs be given an opportunity for rhythm control prior to AF ablation. Although there is evidence that AF ablation as a first line therapy is effective, the data are mixed and the complication rate is, in most operators opinion too large to do this on a routine basis. There may be rare exceptions where AF ablation is considered prior to trials of anti-arrhythmic drugs, but these should be rare and individualized with full patient informed consent. The choice of anti-arrhythmic drugs as first line could be either flecainide or amiodarone, although amiodarone is not usually first line. Flecainide would probably be my choice over amiodarone, as long as there is no evidence of coronary disease and it would be acceptable to the patient to take it as well as a AV node blocking agent such as a beta blocker or diltiazem. Sotalol and amiodarone are reasonable monotherapies for AF.

Refer him to EP for further discussion Probably, most popular answer!

Suggest he take amiodarone and if fails - ablation


MAANTRA PAF StudyBaseline3 mths18 mths24 mths6 mths12 mthsp=0.007N Eng J Med 2012;367:1587-95 N=294AF Ablation as first line therapy


Time to First recurrence of symptomatic/asymptomatic AF/AT/AFl72.%55%HR: 0.56 (0.35 0.90) p= 0.02n=127RAAFT 2 Study: 1st line AF AblationMorillo C et al. JAMA. 2014 Feb 19;311(7):692-700


Cappato R et al. Circ Arrhythm Electrophysiol. 2010;3:32-8Type of Complication (n=14,218)No of Pts Rate%Femoral pseudoaneurysm 152 0.93AV fistulae 88 0.54Pneumothorax 15 0.09

Valve damage/requiring surgery 11/7 0.07

Tamponade 213 1.31Transient ischaemic attack 115 0.71PV stenosis requiring intervention 48 0.29Stroke 37 0.23Permanent diaphragmatic paralysis 28 0.17Death 25 0.15Atrium-esophageal fistulae 3 0.02TOTAL 741 4.54%Worldwide AF Ablation (03-06)


Ablation RecommendationsWe recommend catheter ablation of AF in patients who remain symptomatic following adequate trials of anti-arrhythmic drug therapy and in whom a rhythm control strategy remains desired. (Strong Recommendation, Moderate Quality Evidence)We suggest catheter ablation to maintain sinus rhythm as first-line therapy for relief of symptoms in highly selected patients with symptomatic, paroxysmal AF. (Conditional Recommendation, Low Quality Evidence)Values and Preferences:These recommendations recognize that the balance of risk with ablation and benefit in symptom relief and improvement in quality of life must be individualized. They also recognize that patients may have relative or absolute cardiac or non-cardiac contra-indications to specific medications.


* Applies to patients with symptomatic AF and failed at least one anti-arrhythmic drug. Dictates ablation performed in experienced centre in patient with minimal heart disease -- Not directly addressed. Often this group is incorporated into other recommendations

Comparison of North American and European Guidelines

CCS GuidelinesESC GuidelinesACCF/AHA/HRSStrengthLevel of EvidenceClassLevel of EvidenceClassLevel of EvidenceParoxysmal* ConditionalModerateIIa (Conditional)A (High)I (Strong)A (High)Persistent* ConditionalModerateIIa (Conditional)B (Moderate)IIa (Conditional)A (High)Failed 1 drugConditionalModerate----I (Strong)A (High)Failed 2 drugsStrongModerate--------1st LineConditionalLowIIb (Conditional)B (Moderate)----PAF / sign. structural heart disease--------IIb (Conditional)A (High)


Case 4Agrees to add flecainide 50mg bid to bisoprolol

Recurrent episodes of AF but shorter

Flecainide increased to 100mg bid

Episodes on average 1 / month lasting 45-90 minutes

Very bothered by spells although does not limit work or personal activities


Wilber DJ et al JAMA 2010;303:333Thermacool study: Freedom from PAF


AblationControlOR95% CI 28/32 13/3511.853.4-41.4

12/15 6/156.01.2-30.7

46/53 13/5923.38.5-63.6

85/99 24/9919.09.2-39.3

38/68 6/6913.35.1-34.9

266/344102/34615.810.1-24.7Piccini JP et al. Circ Arrhythm 2009;2:6269 RCTs / 3 systematic reviews in 1274 patients who have failed 1 druguniformly demonstrate large differences in recurrence of AF (OR 9.74 95% CI, 3.98 to 23.87) in favour of ablation vs AAD Systematic Review of RCTs of Ablation vs RxSystematic Review of RCTs of Ablation vs Rx


Contact Force / CryoablationTechnological AdvancesImproved outcomesImproved sustainabilityImproved safety


Contact Force / CryoablationReddy VY et al. Heart Rhythm 2012; 9:1789 1795Technological AdvancesImproved outcomesImproved sustainabilityImproved safety


Posterior LA as source ofTriggering beats and Circular activity


Tachycardia in Right VeinsCSECG Lead IIRight Veins


AF Ablation lesion set


Tachycardia in Right Veins: Behind FenceIICSRLPVPV TachycardiaPV Isolation


Why do patient need a repeat procedure?


Case 4Doing well 3 months after ablationNo recurrent symptomsLoop recorder shows occ. PACs but no AF

66 year old man with hypertension despite his assurances (CHADS2=1)


What would you recommend for Case 4 at this point?

Continue OAC (dabigatran 150mg bid)

Stop dabigatran


What would you recommend for Case 4 at this point?

Continue OAC (dabigatran 150mg bid) Refer to practical tips in next slide.

Stop dabigatran

This is an area of intense debate and there is no correct answer!Studies of long-term monitoring have consistently shown asymptomatic episodes of AF both prior to and following ablation. Symptoms are therefore not a good guide for the presence or absence of AF. It is the standard of practice in many centers internationally to stop the OAC at this stage. However, the need for OAC after a successful ablation has not been rigourously tested in large randomized trials. These trials have been proposed. Obviously, repeat monitoring would be required to document the absence of asymptomatic AF, although documentation of complete elimination of AF may be impossible. At this stage, I would leave this decision to the electrophysiologist involved. He or she may choose to continue the OAC for a period of time in the absence of clear data. Most would agree that if the CHADS-VASc score was 0 (1 in female) OAC should be discontinued. It would not be recommended if AF were present. If the CHADS score was 2 or greater, most would continue the OAC indefinitely. A range of opinions would be expressed for intermediate scores.


Practical Tips AF ablation should not be considered as an alternative to oral anticoagulation.

If a patient has a high thromboembolic risk profile, then the patient should continue oral anticoagulation even after successful AF ablation.

Studies of long-term monitoring have consistently shown asymptomatic episodes of AF both prior to and following ablation

Initiation of oral anticoagulation should also not be delayed when indicated in patients pending referral for AF ablation.


Case 546 year-old referred because pre-op ECG shows AFHaving ACL/MCL fixed

Completely unaware of his heartGood exercise tolerance

PMHx: Hypertension on perindopril and bisoprolol

Obese BMI 36


Case 5HR in office is 89, BP 145/85

Exam normal

Echo LV normal size function EF 55-60%LA 45mm mild MR

HbA1C 8.6%


What do you recommend for Case 5?

Holter to assess rate control

OAC of your choice (__ban / __tran)

ASA


What do you recommend for Case 5?

Holter to assess rate control

OAC of your choice (__ban / __tran) Best answer!

ASAThe patients heart rate in the office at rest is adequate, ie < 100bpm, and he is without symptoms. He meets guideline recommendations for rate control. A Holter monitor to assess his rate control is not necessary, but not unreasonable to document adequate rate control throughout his daily activities. It is also reassuring that his LV function is normal or near normal and he has no evidence of tachycardia-induced cardiomyopathy. The patient has hypertension. Despite his young age, he should be on an OAC either warfarin or one of the new OACs.. ASA is insufficient protection from stroke.


Case 5Returns to see you in 3 months

Holter AF throughoutmean rate 89 (48 126)3 runs of NSVT or aberrancy

Wants to discuss ablation with you to get:1. back in shape2. off OAC


What options do you offer Case 5 at this point?

1. Refer for ablation

2. Counsel about diet and arrange F/U 6 mos

3. Refer for cardioversion and ablation

4. Arrange for sleep study first


What options do you offer Case 5 at this point?

Refer for ablation

Counsel about diet and arrange F/U 6 mos Best answer!The patients goal to get in shape and off OAC is best met with ongoing lifestyle management. It is important to point out that catheter ablation is not a verified approach to replace OAC in someone who would otherwise need it. Although it makes intuitive sense to patients that is fix the fib then I dont need to take the blood thinner this is not evidence based. Catheter ablation is a symptom-driven procedure that has little to offer a truly asymptomatic patient. Consideration of obstructive sleep apnea (OSA) is important. Usually prior to a full sleep study, screening for sleep apnea is worthwhile. There are occasions when patients symptoms are hard to attribute to AF. Under these circumstances, we have performed DC cardioversion to determine if patients feel better in sinus rhythm and are aware if they return to AF. If so, there may be some benefit to catheter ablation. In this mans case, he is completely asymptomatic. As such, catheter ablation is not indicated.

Refer for cardioversion and ablation

Arrange for sleep study first


Practical Tips AF ablation should not be considered as an alternative to oral anticoagulation.

If a patient has a high thromboembolic risk profile, then the patient should continue oral anticoagulation even after successful AF ablation.

Studies of long-term monitoring have consistently shown asymptomatic episodes of AF both prior to and following ablation

Initiation of oral anticoagulation should also not be delayed when indicated in patients pending referral for AF ablation.


Results Persistent AFp=0.15Documented AF > 30 seconds after one procedure with or without AAD59%48%44%Verma et al presented ESC 2014


Case 6 Mr. OPPeri-Procedureby L. Brent Mitchell, MD FRCPC

October 2014


DisclosuresDr. L. Brent Mitchell has received grant support and/ or honoraria from:

BayerBoehringer-IngelheimBristol-Myers SquibbPfizer


A guidelines based approach to AF management 67 year old male is scheduled for surgeryPre-op consult regarding OAC managementPast history includes 2 years of auto-rate- controlled persistent AF, controlled HT, controlled type II diabetes, prior MI, NYHA class II CHF, no angina, otherwise wellOn irbesartan / HCTZ 300 mg / 25 mg OD, insulin, warfarin (INR 2.0-3.0)Cannot take a beta blocker as heart rate slow


A guidelines based approach to AF management HR 48 bpm, irreg/irreg; BP 150/85 mm HgJVP 2 cm ASA, +ve HJR, S4, II/VI MR murmurlungs clear, no pedal edemaECG: rate-controlled AF, old inferior MIL. Brent Mitchell CCS 2014


Peri-Procedure/Anticoagulation Management


A guidelines based approach to AF management Stroke risk considerations:CHADS2 score = 3; CHA2DS2-VASc = 5no mechanical heart valveno rheumatic heart diseaseBleeding risk considerations:HASBLED score = 1No AT-Rx: stroke = 10.5%/yr: major bleed = 3.1%/yrOn warfarin: stroke = 3.8%/yr: major bleed = 6.7%/yrLaHaye SA et al: Eur J Cardiol 33:2164-71, 2012 (www.afib.ca)


For peri-procedural bleeding risk, procedure matters:For this patient, preparing for a PPM implant, I would:

stop warfarin; no heparin bridging

stop warfarin; heparin bridging

continue warfarin


For peri-procedural bleeding risk, procedure matters:For this patient, preparing for a PPM implant, I would:

stop warfarin; no heparin bridging

stop warfarin; heparin bridging

continue warfarin Correct! the data to support that contention are provided by the trial BRUISE CONTROL given on the next slide


A guidelines based approach to AF management BRUISE CONTROL: A RCT comparing continued warfarin versus discontinued warfarin with heparin bridging in patients undergoing PPM/ICD surgery. N = 681Birnie DH et al. N Engl J Med 368:2084-93, 2013significanthematomaother AEs

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ATRIAL FIBRILLATION GUIDELINESATRIAL FIBRILLATION GUIDELINESATRIAL FIBRILLATIONGUIDELINESThe Canadian Cardiovascular Societys

About this Slide SetThis slide set is a quick-reference tool that features essential diagnostic and treatment recommendations based on the 2010 CCS Atrial Fibrillation Guidelines, the 2012 CCS Atrial Fibrillation Guidelines Update and the 2014 Focused Update of the CCS guidelines for the management of AF. 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 guideline 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. For the complete CCS Atrial Fibrillation Guidelines, or for additional resources, please visit our guidelines website at www.ccs.ca.

The 2014 Focused Update of the Canadian Cardiovascular SocietyGuidelines for the Management of Atrial Fibrillation

Co-chairs and AuthorsJeff S. Healey and Atul Verma

AuthorsJohn A. Cairns, Stuart Connolly, Jafna L. Cox, Paul Dorian, David Gladstone, Gordon J. Gubitz, Noah Ivers, Kori Leblanc, Laurent Macle, Michael Sean McMurtry, L. Brent Mitchell, Stanley Nattel, Pierre Pag, Ratika Parkash, P. Timothy Pollak, Allan C. Skanes, Ian G. Stiell, Mario Talajic, Teresa S. M. Tsang and Carl Van Walraven.

Publication date: October 2014

Baseline Evaluation for All Patients

History and Physical Exam Establish Pattern (New Onset, Paroxysmal, Persistent or Permanent) Establish Severity (including impact on quality of life)Identify EtiologyIdentify reversible causes (hyperthyroidism, ventricular pacing, supra-ventricular tachycardia, exercise, etc)Identify risk factors whose treatment could reduce recurrent AF or improve overall prognosis (i.e. hypertension, sleep apnea, left ventricular dysfunction, etc)Take social history to identify potential triggers (i.e. alcohol, intensive aerobic training, etc)Elicit family history to identify potentially heritable causes of AF (particularly lone AF)Determine thromboembolic risksDetermine bleeding risk to guide appropriate antiplatelet or antithrombotic therapyReview prior pharmacologic therapy for AF, both for efficacy and adverse effectsMeasure blood pressure and heart rateDetermine patient height and weightComprehensive precordial cardiac examination and assessment of jugular venous pressure, carotid and peripheral pulses to detect evidence of structural heart disease12-Lead ElectrocardiogramDocument presence of AFAssess for structural heart disease (myocardial infarction, ventricular hypertrophy, atrial enlargement, congenital heart disease) or electrical heart disease (ventricular pre-excitation, Brugada syndrome)Identify risk factors for complications of therapy for AF (conduction disturbance, sinus node dysfunction or abnormal repolarization)Document baseline PR, QT and QRS intervals.EchocardiogramDocument ventricular size, wall thickness and functionEvaluate left atrial size (if possible, left atrial volume)Exclude significant valvular or congenital heart disease (particularly atrial septal defects)Estimate ventricular filling pressures and pulmonary arterial pressureOtherComplete blood countCoagulation profileRenal functionThyroid and liver functionFasting lipid profileFasting glucose

Additional Investigations for Selected Patients

Investigation Potential Role Chest radiography Exclude concomitant lung disease, heart failure, baseline in patients receiving amiodaroneAmbulatory electrocardiography (Holter monitor, event monitor, loop monitor)Document AF, exclude alternative diagnosis (atrial tachycardia, atrial flutter, AVNRT/AVRT, ventricular tachycardia), symptom-rhythm correlation, assess ventricular rate controlTreadmill exercise test Investigation of patients with symptoms of coronary artery disease, assessment of rate controlTrans-esophageal echocardiography Rule out left atrial appendage thrombus, facilitate cardioversion in patients not receiving oral anti-coagulation, more precise characterization of structural heart disease (mitral valve disease, atrial septal defects, cor triatriatum, etc)Electrophysiologic Study Patients with documented regular supra-ventricular tachycardia (i.e. atrial tachycardia, AVNRT/AVRT, atrial flutter) that is amenable to catheter ablationSerum calcium and magnesium In cases of suspected deficiency (i.e. diuretic use, gastro-intestinal losses) which could influence therapy (i.e. sotalol)Sleep Study (ambulatory oximetry or poly-somnography)In patients with symptoms of obstructive sleep apnea or in select patients with advanced symptomatic heart failureAmbulatory blood pressure monitoringIn cases of borderline hypertension or to assess blood pressure controlGeneric testingIn rare cases of apparent familial AF (particularly with onset at a young age) with additional features of conduction disease, Brugada syndrome or cardiomyopathy

Established Patterns and Severity of Atrial FibrillationPatterns of Atrial Fibrillation SAF Score* Persistent:Sustained7d Permanent:Decision to continuein AF* Dorian P, Cvitkovic SS, Kerr CR; et al. Can J Cardiol. 2006; 22(5): 383-386 ** QOL = quality of lifeParoxysmal:Self-terminating

Overview of AF Management

Major Goals of AF/AFL Arrhythmia Management Identify and treat underlying structural heart disease and other predisposing conditionsRelieve symptoms Improve functional capacity/quality of life Reduce morbidity/mortality associated with AF/AFL Prevent tachycardia-induced cardiomyopathy Reduce/prevent emergency room visits or hospitalizations secondary to AF/AFLPrevent stroke or systemic thromboembolism

Pill in pocket antiarrhythmic therapyParoxysmal AFCONTINUE RATE CONTROLLow burden recurrenceObserve. If AF recurs, determine if symptomaticSymptoms improve, and patient maintains sinus rhythmMODIFY RATE CONTROL - CONSIDER RHYTHM CONTROLSYMPTOMS RESOLVECatheter ablationMaintenance antiarrhythmic therapySymptoms dont change in sinus rhythm and AF recursSymptoms improve, but AF recursRate vs Rhythm Control for Patients with Symptomatic AFHigh burden recurrenceATTEMPT RATE CONTROLBeta-blockerCalcium channel blockerNOYESSpecial circumstances in which to consider early rhythm control:Highly symptomaticMultiple recurrencesExtreme impairment in QOLArrhythmia-induced cardiomyopathySYMPTOMATIC AFConsider cardioversionPersistent AF

Rate Management We suggest that digoxin not be used as initial therapy for active patients and be reserved for rate control in patients who are sedentary or who have left ventricular systolic dysfunction. (Conditional Recommendation, Moderate Quality Evidence)

We suggest that digoxin be added to therapy with beta-blockers or calcium channel blockers in patients whose heart rate remains uncontrolled. (Conditional Recommendation, Moderate Quality Evidence)

We suggest that amiodarone for rate control should be reserved for exceptional cases in which other means are not feasible or are insufficient (Conditional Recommendation, Low Quality Evidence).

Overview of Rate ManagementRate Control Drug Choices Heart FailureCADNo Heart Failureor CAD-blockers Digoxin-blockers*Calcium Channel Blockers#Combination Rx-blockers*Calcium Channel Blockers#DigoxinCombination RxDrugs are listed in alphabetical order*-blockers preferred in CAD# Non-dihydropyridine calcium channel blockers (diltiazem, verapamil)Digoxin may be considered as monotherapy only in particularly sedentary individuals

Managing Rate Control - Recommended Drugs -BlockersCalcium Channel Blockers and Digoxin

DrugDoseAdverse EffectsAtenolol50 - 150 mg p.o. dailybradycardia, hypotension, fatigue, depressionBisoprolol2.5 - 10 mg p.o. dailyas per atenololMetoprolol25 mg - 200 mg p.o. bidas per atenololNadolol20 - 160 mg p.o daily - bidas per atenololPropranolol80 - 240 mg p.o. tidas per atenolol

DrugDoseAdverse EffectsVerapamil120 - 480 mg p.o. daily120 - 240 mg p.o. bidbradycardia, hypotension, constipationDiltiazem120 - 480 mg p.o. daily120 - 240 mg p.o. bidbradycardia, hypotension, ankle swellingDigoxin0.0625 mg - 0.25 mg p.o. dailybradycardia, nausea, vomiting,visual disturbance

Rhythm Management

Rhythm Management We suggest that patients requiring pacing for the treatment of symptomatic bradycardia secondary to sinus node dysfunction, atrial or dual-chamber pacing be generally used for the prevention of AF (Conditional Recommendation, High Quality Evidence).

We suggest that, in patients with intact AV conduction, pacemakers be programmed to minimize ventricular pacing for prevention of AF (Conditional Recommendation, Moderate Quality Evidence).

Rhythm Management We suggest dronedarone be used with caution in patients taking digoxin (Conditional Recommendation, Moderate Quality Evidence). Practical TipDronedarone is a reasonable choice for rhythm control in selected patients with AF. Typically, these would be patients with nonpermanent (predominantly paroxysmal) AF with minimal structural heart disease. Consideration should be given to monitoring for liver enzyme elevations within 6 months of initiating therapy with dronedarone.

Overview of Rhythm ManagementDrugs are listed in alphabetical order

+Dronedarone should be used with caution in combination with digoxin Class I agents should be AVOIDED in CAD and should be COMBINED with AV-nodal blocking agents#Sotalol should be used with caution in those at risk for torsades de pointes VT (e.g. female, age > 65 yr, taking diuretics)** Sotalol should be used with caution with EF 35-40% and those at risk for torsades de pointes VT (e.g. female, age > 65 yr, taking diuretics)

Managing Rhythm Control - Recommended Drugs

Drug/DoseEfficacyToxicityCommentsFlecainide50-150 mg BID30-50%Ventricular tachycardiaBradycardiaRapid ventricular response to AF or atrial flutter (1:1 conduction)Contraindicated in patients with CAD or LV dysfunctionShould be combined with an AV nodal blocking agentPropafenone150-300 mg TID30-50%Ventricular tachycardiaBradycardiaRapid ventricular response to AF or atrial flutter (1:1 conduction)Abnormal tasteContraindicated in patients with CAD or LV dysfunctionShould be combined with an AV nodal blocking agentAmiodarone100-200 mg OD (after 10g loading)60-70%Photosensitivity, Bradycardia,GI upset, Thyroid dysfunction,Hepatic toxicity, Neuropathy, Tremor, Pulmonary toxicity,Torsades de pointes (rare)Low risk of proarrhythmiaLimited by systemic side effectsMost side effects are dose & duration relatedDronedarone400 mg BID40%GI upsetBradycardiaHepatic toxicityShould not be used for rate control or for rhythm control in patients with a history of CHF or LV EF < 40%.Should be used with caution when added to digoxin.Liver enzyme monitoring required.New agent limited experience outside clinical trials. Sotalol80-160 mg BID30-50%Torsades de pointesBradycardiaBeta-blocker side effectsShould be avoided in patients at high risk of torsades de pointes VT especially women >65 years taking diuretics or those with renal insufficiencyQT interval should be monitored 1 week after starting Use cautiously when EF

Catheter AblationWe suggest catheter ablation to maintain sinus rhythm as first-line therapy for relief of symptoms in highly selected patients with symptomatic, paroxysmal atrial fibrillation. (Conditional Recommendation, Moderate Quality Evidence)We recommend curative catheter ablation for symptomatic patients with typical atrial flutter as first line therapy or as a reasonable alternative to pharmacologic rhythm or rate control therapy (Strong Recommendation, Moderate Quality Evidence).In patients with evidence of ventricular preexcitation during AF, we recommend catheter ablation of the accessory pathway, especially if AF is associated with rapid ventricular rates, syncope, or a pathway with a short refractory period (Strong Recommendation, Low Quality Evidence).In young patients with lone, paroxysmal AF, we suggest an electrophysiological study to exclude a re-entrant tachycardia as a cause of AF; if present, we suggest curative ablation of the tachycardia (Conditional Recommendation, Very Low Quality Evidence).

Catheter Ablation+ Balance of risk and benefit in favor of catheter ablation Ongoing symptomatic AF 1 yearRisk/Benefit Ratio for Ablation in Patients with Symptomatic AF Practical Tip AF ablation should not be considered as an alternative to oral anticoagulation. If a patient has a high thromboembolic risk profile, then the patient should continue oral anticoagulation even after successful AF ablation. Studies of long-term monitoring have consistently shown asymptomatic episodes of AF both prior to and following ablation. Initiation of oral anticoagulation should also not be delayed when indicated in patients pending referral for AF ablation.

Practical Tip The following represents a typical, but not exclusive, profile of a patient who is referred for consideration of AF ablation today:Age less than 80Patients who are symptomatic with their AFPatients who have tried but failed or are intolerant of antiarrhythmic drug therapyParoxysmal AF or short-standing persistent AFMinimal to moderate structural heart disease (such as LV dysfunction or valvular disease)

LongstandingPersistentParoxysmal1st line----+Failed 1st drug--++ + Failed 2nd drug++ + + + +Failed multiple drugs+ + + + ++ + +

Prevention of Stroke in AF/AFLCHADS2 Score

CHA2DS2-VASc Score

Risk FactorScore Congestive Heart Failure 1 Hypertension1 Age 751Diabetes Mellitus 1 Stroke/TIA/Thromboembolism2Maximum Score6

Risk FactorScore Congestive Heart Failure 1 Hypertension1 Age 752Diabetes Mellitus1 Stroke/TIA/Thromboembolism2Vascular Disease 1 Age 65-74 1 Female 1 Maximum Score9

Prevention of Stroke in AF/AFL We suggest that ASA (81 mg/day) be prescribed for patients with none of the risks outlined in the CCS algorithm (age < 65 years and no CHADS2 risk factors) who have arterial vascular disease (coronary, aortic, or peripheral). (Conditional Recommendation, Moderate Quality Evidence)

We suggest no antithrombotic therapy for patients with none of the risks outlined in the CCS algorithm (age < 65 years and no CHADS2 risk factors) and free of arterial vascular disease (coronary, aortic, peripheral). (Conditional Recommendation, Low Quality Evidence)

ASANo AntithromboticCAD or Arterial vascular disease(aortic, peripheral)OAC*OAC*YESYESNOPrior Stroke/TIA/SEorHypertension orHeart failure orDiabetes Mellitus(CHADS2 risk factors)The CCS Algorithm for OAC Therapy in AFConsider and modify (if possible) all factors influencing risk of bleeding on OAC (hypertension, antiplatelet drugs, NSAIDSs, excessive alcohol, labile INRs) and specifically bleeding risks for NOACs (low CrCl, age 75, low body weight)**

** may require lower dosingYES* We suggest that a NOAC be used in preference to warfarin for non-valvular AF.NONOAge 65

Prevention of Stroke in Patients with Chronic Kidney Disease (CKD) For antithrombotic therapy of CKD patients, therapy should relate to CrCl as follows:

CrCl >30 mL/min: We recommend that such patients receive antithrombotic therapy according to their risk as determined by the CCS algorithm as detailed in recommendations for patients with normal renal function (Strong Recommendation, High Quality Evidence).CrCl 15-30 mL/min and not on dialysis: We suggest that such patients receive antithrombotic therapy according to their risk as determined by the CCS algorithm as for patients with normal renal function. The preferred agent for these patients is warfarin (Conditional Recommendation, Low Quality Evidence).

CrCl

Consider Apixaban 2.5 mg po bid if age 80 and body weight 60 kg. Dose adjusted warfarin has been used, but observational data regarding safety and efficacy is conflicting. Modelling studies suggest that dabigatran 75 mg bid might be safe for patients with GFR 15-29 mL/min, but this has not been validated in a prospective cohort. No published studies support a dose for this level of renal function; product monographs suggest the drug is contraindicated for this level of renal function.Therapeutic Choices in Patients with Chronic Kidney Disease and Stroke Risk Factors (CHADS2 1)Prevention of Stroke in Patients with Chronic Kidney Disease (CKD) Therapeutic Choices2

GFRWarfarinDabigatranRivaroxabanApixabanGFR 60 mL/minDose adjusted for INR 2.0-3.0150 mg bid or 110 mg bid20 mg daily5 mg bidGFR 50-59 mL/minDose adjusted for INR 2.0-3.0150 mg bid or 110 mg bid20 mg daily5 mg bidGFR 30-49 mL/minDose adjusted for INR 2.0-3.0150 mg bid or 110 mg bid15 mg daily5 mg bidConsider 2.5 mg bidGFR 15-29 mL/min (not on dialysis)No RCT DataNo RCT DataNo RCT Data5 mg bid (for GFR > 25 mL/min only) Consider 2.5 mg bid GFR < 15 mL/min (on dialysis)No RCT DataNo RCT DataNo RCT DataNo RCT Data

Antithrombotic Management of AF/AFL in CAD - RecommendationsASAOACASA + clopidogrelASA + clopidogrel +OACASA + clopidogrelASA + clopidogrel +OACChoose antithrombotic based on stroke riskChoose antithromboticbased on balance of risks and benefitsChoose antithromboticbased on balance of risks and benefitsCHADS2 = 0CHADS2 1CHADS2 1CHADS2 2CHADS2 1CHADS2 2Stable CAD Recent ACS PCI We suggest that patients with AF or AFL who have experienced ACS or who have undergone PCI, should receive antithrombotic therapy selected based on a balanced assessment of their risks of stroke, of recurrent coronary artery events and of hemorrhage associated with the use of combinations of antithrombotic therapies, which in patients at higher risk of stroke may include aspirin plus clopidogrel plus OAC. (Conditional Recommendation, Low Quality Evidence).

Management of AF in the ED We suggest that patients at high risk of stroke* during or after cardioversion may undergo cardioversion guided by transesophageal echocardiography. Anticoagulation should be initiated immediately using intravenous heparin or low molecular weight heparin prior to cardioversion. OAC therapy should then be initiated and maintained for at least 4 weeks post cardioversion. Patients should also be referred for early expert follow-up to review ongoing antithrombotic therapy, based upon stroke risk factors. (Conditional Recommendation, Moderate Quality Evidence)We suggest that after conversion to sinus rhythm has been achieved, whether antiarrhythmic drug therapy is indicated should be based on the estimated probability of recurrence and the symptoms during AF. Long-term therapy will need to be determined by an appropriate outpatient consultation (Conditional Recommendation, Low Quality Evidence).

Emergency Management of AF

YESNO Management of AF in the ED Recommendations * Immediate OAC = a dose of OAC should be given just prior to cardioversion either a novel direct oral anticoagulant (NOAC) or a dose of heparin or low molecular weight heparin with bridging to warfarin if a NOAC is contraindicated.

*Calcium-channel blockers should not be used in patients with heart failure or left ventricular dysfunction *Class IC drugs should be used in combination with AV nodal blocking agents (beta-blockers or calcium-channel inhibitors). Class IC agents should also be avoided in patients with structural heart disease.

Recommended Drugs for Pharmacological ConversionRecommended IV Drugs for Rate Control Management of AF in the ED Recommendations

DrugDoseRisksDiltiazem*0.25 mg/kg IV bolus over 10 min; repeat at 0.35 mg/kg IVHypotension, bradycardiaMetoprolol2.5-5mg IV bolus over 2 min; up to 3 dosesHypotension, bradycardiaVerapamil*0.075-0.15mg/kg over 2 minHypotension, bradycardiaDigoxin0.25 mg IV each 2 h; up to 1.5mgBradycardia, Digitalis toxicity

DrugDoseEfficacyRisksClass 1 A Procainamide15-17 mg/kg IV over 60 min++5% hypotensionClass IC*PropafenoneFlecainide450-600 mg PO300-400 mg PO++++++Hypotension, 1:1 flutter,bradycardia Class IIIIbutilide1-2 mg IV over 10-20 minPre-treat with MgSO4 1-2 gm IV++2-3% Torsades de pointes

Peri-Procedure / Antithrombotic Management We suggest that interruption of antithrombotic therapy in a patient with AF or AFL is not necessary for most procedures with a very low risk of bleeding and many procedures with a low risk of bleeding including cardiac device implantation (pacemaker or implantable defibrillator)(see Table) (Conditional Recommendation, Low Quality Evidence, High Quality Evidence for cardiac device implantation).We recommend that interruption of antithrombotic therapy in a patient with AF or AFL will be necessary for most procedures with an intermediate or high risk of major bleeding (see Table) (Strong Recommendation, Low Quality Evidence).

Bleeding Risks for Various Invasive / Surgical Procedures* Selected ophthalmic procedures may be high risk such as those with retrobulbar block**Based on results from BRUISE CONTROL trial (Birnie et al, N Engl J Med 2013; 368:2084-2093)

HighRiskIntermediate RiskLowRiskVery LowRiskneurosurgery (intracranial or spinal surgery)cardiac surgery (coronary artery bypass or heart valve replacement)major vascular surgery (abdominal aortic aneurysm repair, aortofemoral bypass)major urologic surgery (prostatectomy, bladder tumour resection)major lower limb orthopedic surgery (hip/knee joint replacement surgery)lung resection surgeryintestinal anastomosis surgeryselected invasive procedures (kidney biopsy, prostate biopsy, cervical cone biopsy, pericardiocentesis, colonic polypectomy or biopsies)other intraabdominal surgeryother intrathoracic surgeryother orthopedic surgeryother vascular surgerylaparoscopic cholecystectomylaparoscopic inguinal hernia repairdental proceduresdermatologic proceduresophthalmologic procedures*coronary angiographygastroscopy or colonoscopyselected invasive procedures (bone marrow aspirate and biopsy, lymph node biopsy, thoracentesis, paracentesis, arthrocentesis)cardiac device implantation surgery (pacemaker or implantable defibrillator)**dental extractions (1 or 2 teeth) or teeth cleaningskin biopsy or skin cancer removalcataract removal

Pre-Procedure / Antithrombotic Management When a decision to interrupt aspirin or clopidogrel therapy for an invasive procedure has been made for a patient with AF or AFL, we suggest that the interruption begin 5-7 days prior to the day of the procedure excepting those procedures with a very high risk of bleeding when we suggest that the interruption begin 7-10 days prior to the procedure (Conditional Recommendation, Low Quality Evidence).

When a decision to interrupt warfarin therapy for an invasive procedure has been made for a patient with AF or AFL, we suggest that the interruption begin 5 days prior to the procedure and that a procedure with a low bleeding risk may proceed when the INR is

Post-Procedure / Antithrombotic Management When LMWH or UFH bridging is used for an invasive procedure, we suggest that such therapy be restarted after the procedure when hemostasis is established (usually 24 hours for a procedure with a low risk of bleeding and 48-72 hours for a procedure with an intermediate or high risk of bleeding) in prophylactic dosages for the first 24 to 72 hours and then increased to therapeutic dosages. Bridging is then continued until an OAC is therapeutic (Conditional Recommendation, Low Quality Evidence).

When warfarin, ASA, or clopidogrel therapy has been interrupted for an invasive procedure, we suggest that such therapy be restarted after the procedure when hemostasis is established (usually 24-48 hours for a procedure with a low risk of bleeding and 48-72 hours for a procedure with an intermediate or high risk of bleeding) (Conditional Recommendation, Low Quality Evidence).

When apixaban, dabigatran, or rivaroxaban therapy has been withdrawn for an invasive procedure, we suggest that such therapy be restarted after the procedure one day after hemostasis is established (usually 48 hours for a procedure with a low risk of bleeding and 72 hours for a procedure with an intermediate or high risk of bleeding) (Conditional Recommendation, Low Quality Evidence).

Recommendations

Prevention and Treatment of AF following Cardiac Surgery

Prophylactic Therapies for the Prevention of Post-Operative Atrial Tachyarrhythmias * Dosages used in the randomized studies vary widely and the optimal dosages for this indication have not been established. The dosages provided are those used in the largest positive trial of that therapy and are referenced to that study.

TherapyDosage*CautionsAdverse EffectsPre-opbeta blockerany in usual therapeutic dose (i.e. metoprolol 50 mg) PO q12h or q8h for at least 2 pre-op days, day of surgery, and at least 6 post-op daysreactive airways disease, decompensated CHFsinus bradycardiaAV blockhypotensionbronchospasmPre-op amiodarone10 mg/kg/day (rounded to nearest 100 mg) divided into two daily PO dosages for 6 pre-op days, day of surgery, and 6 post-op days30%-50% reduction in the dosages of other drugs with antiarrhythmic or sinus/AV nodal effects and warfarin will be requiredsinus bradycardiaAV blockhypotensiontorsade de pointes VT (rare)pulmonary toxicity (rare)Post-opamiodarone900 1200 mg IV over 24 hrs beginning within 6 hours of surgery, then 400 mg PO tid each of the next 4 days30%-50% reduction in the dosages of other drugs with antiarrhythmic or sinus/AV nodal effects and warfarin will be requiredsinus bradycardiaAV blockhypotensiontorsade de pointes VT (rare)pulmonary toxicity (rare)Magnesium sulfate1.5 gm IV over 4 hrs first pre-op day, immediately post-op, and next 4 post-op days. Other trials have omitted the pre-op dosagerenal failure hypotension (rare)sedation (very rare)respiratory depression(very rare)

***Age + 65easy to do in office2-3 of populationHx stroke or TIAgreatest risk factorStroke and bleeding highly correlated65+, hypertension, risk for strokeand for sure, bleedingCHADSVasc, yes or no?Possible impossible to have single tool using both CHADSVasc and HAS-BLEDThis algorithm is what you tell Drs to doShould stick with what we had to let Drs know what to doDr NattelAim for simplerthis viewed as being still complicatedRaise question about ASAdifficult to discrimenate when and when not to useConcern about patient older than 65 with no other risk factorsis it OK to put him on OAC? (Dr Connolly)Drop words CHADs and HAS-BLEDpresenting tool that is CHADSVasc-likeNo longer have anything for women with vascular diseaseIn general, what ought you to do? Dr Ivers And how to counsel patients about risk and benefit? Need something for this as wellalgorithm presentation of the guideline onlyDr Stiell prefer to combine 2 middle boxesas CHADS riskscould consider combining all 3 middle boxesCHADS2 with age over 65CHADS 65Dr Dorian OK with this as starting pointRecommendationconsiderwe suggest discussion risk benefits of stroke and bleed with patientsDr DorianA lot of work at getting people to use CHADSgoing away is putting uptake at risk?!ESC algorithm Dr CoxHAS-BLED afterthought of decision to treat to prevent stroke Dr CoxDr Nattel:1 rec modified CHADS age over 652 rec about ASA, eg vascular disease3 rec treat any treatable risk factors4 rec specific RF for bleeding that you would not recommend anticoagulationAnyone has analysis on risk evaluation with OACsRatika Parkash what to do with over 65 pt who cannot take NOAConly Warfarinthat increases bleeding riskthis could constitute a great practical tipDr CairnsCHADS 65Other factors that need to considerReasons to go to other txsThen need to go back to recs to make them match with algorithm

Last 2 bullets, yellow box combine as use a reduced dose

Dr Verma motion to move from discussion FINAL closing of this discussionConcept of CHADS 65 majority vote amongst those in attendanceDesire for simple algorithm that dovetails with CHADS 65 - majorityAssess bleeding risk factors after decision has been made to treat - majorityRecommendation needs to address how to communicate risks to patients

******Age + 65easy to do in office2-3 of populationHx stroke or TIAgreatest risk factorStroke and bleeding highly correlated65+, hypertension, risk for strokeand for sure, bleedingCHADSVasc, yes or no?Possible impossible to have single tool using both CHADSVasc and HAS-BLEDThis algorithm is what you tell Drs to doShould stick with what we had to let Drs know what to doDr NattelAim for simplerthis viewed as being still complicatedRaise question about ASAdifficult to discrimenate when and when not to useConcern about patient older than 65 with no other risk factorsis it OK to put him on OAC? (Dr Connolly)Drop words CHADs and HAS-BLEDpresenting tool that is CHADSVasc-likeNo longer have anything for women with vascular diseaseIn general, what ought you to do? Dr Ivers And how to counsel patients about risk and benefit? Need something for this as wellalgorithm presentation of the guideline onlyDr Stiell prefer to combine 2 middle boxesas CHADS riskscould consider combining all 3 middle boxesCHADS2 with age over 65CHADS 65Dr Dorian OK with this as starting pointRecommendationconsiderwe suggest discussion risk benefits of stroke and bleed with patientsDr DorianA lot of work at getting people to use CHADSgoing away is putting uptake at risk?!ESC algorithm Dr CoxHAS-BLED afterthought of decision to treat to prevent stroke Dr CoxDr Nattel:1 rec modified CHADS age over 652 rec about ASA, eg vascular disease3 rec treat any treatable risk factors4 rec specific RF for bleeding that you would not recommend anticoagulationAnyone has analysis on risk evaluation with OACsRatika Parkash what to do with over 65 pt who cannot take NOAConly Warfarinthat increases bleeding riskthis could constitute a great practical tipDr CairnsCHADS 65Other factors that need to considerReasons to go to other txsThen need to go back to recs to make them match with algorithm



*Age + 65easy to do in office2-3 of populationHx stroke or TIAgreatest risk factorStroke and bleeding highly correlated65+, hypertension, risk for strokeand for sure, bleedingCHADSVasc, yes or no?Possible impossible to have single tool using both CHADSVasc and HAS-BLEDThis algorithm is what you tell Drs to doShould stick with what we had to let Drs know what to doDr NattelAim for simplerthis viewed as being still complicatedRaise question about ASAdifficult to discrimenate when and when not to useConcern about patient older than 65 with no other risk factorsis it OK to put him on OAC? (Dr Connolly)Drop words CHADs and HAS-BLEDpresenting tool that is CHADSVasc-likeNo longer have anything for women with vascular diseaseIn general, what ought you to do? Dr Ivers And how to counsel patients about risk and benefit? Need something for this as wellalgorithm presentation of the guideline onlyDr Stiell prefer to combine 2 middle boxesas CHADS riskscould consider combining all 3 middle boxesCHADS2 with age over 65CHADS 65Dr Dorian OK with this as starting pointRecommendationconsiderwe suggest discussion risk benefits of stroke and bleed with patientsDr DorianA lot of work at getting people to use CHADSgoing away is putting uptake at risk?!ESC algorithm Dr CoxHAS-BLED afterthought of decision to treat to prevent stroke Dr CoxDr Nattel:1 rec modified CHADS age over 652 rec about ASA, eg vascular disease3 rec treat any treatable risk factors4 rec specific RF for bleeding that you would not recommend anticoagulationAnyone has analysis on risk evaluation with OACsRatika Parkash what to do with over 65 pt who cannot take NOAConly Warfarinthat increases bleeding riskthis could constitute a great practical tipDr CairnsCHADS 65Other factors that need to considerReasons to go to other txsThen need to go back to recs to make them match with algorithm



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