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The CCS AF Companion Provides Practical Responses to the Following Questions:What duration of AF is clinically significant?

What are the definitions of stroke risk factors? • What is the current definition of NVAF? • Which types of valvular AF presently exclude the use of a NOAC? • Do other types of valvular AF confer an increased risk of stroke? • Can NOACs be used for patients with some types of valvular AF? • How do we handle the use of NOACs with various forms of VHD?

How do we manage NOACs in patients with compromised renal function? • How should we measure renal function? • Should we use creatinine clearance or GFR? • How often should we measure renal function? • Should we use lower NOAC doses for patients with an eCrCl of 30-50 mL/min? • Can we use NOACs for patients with creatinine clearance ˂ 30 mL/min?

What is the CCS Atrial Fibrillation (AF) Companion?The CCS AF Guidelines Program has generated a series of publications regarding the management of AF, providing evidence-based consensus recom-mendations in a broad range of areas. The CCS AF Companion has been developed in response to feedback from the cardiovascular community and answers a series of questions regarding the practical applications of the guidelines.

Find it OnlineAll CCS AF guideline publications and a full version of the AF companion is available online in the Canadian Journal of Cardiology at www.onlinecjc.ca and at CCS.CA in the guidelines library.

Other CCS Tools and ResourcesAccess these clinical tools and additional educational resources at CCS.CA.

• Pocket Guides • Educational Slide Decks • Library of Guidelines (AF, HF, Lipids and more) • AF Companion • iCCS Mobile App

Adapted from:

Macle, L., Verma, A., et al, The 2014 Atrial Fibrillation Guidelines Companion: A Practical Approach to the Use of the Canadian Cardiovascular Society Guidelines. Canadian Journal of Cardiology. 2015;31:1207-1218.

FRONT

A Practical Approach to

the Use of the CCS Atrial Fibrillation Guidelines

Laurent Macle, John A. Cairns, Jason G. Andrade, L. Brent Mitchell,

Stanley Nattel, Atul Verma on behalf of the CCS AF Guidelines Committee

Table 1. Defi nitions of Stroke Risk Factors in the CCS AF Guidelines UpdateFactor Definition

Congestive heart failure Documented moderate-to-severe systolic dysfunction; signs and symptoms of heart failure with reduced ejection fraction; or recent decompensated heart failure requiring hospitalization irrespective of ejection fraction

Hypertension Resting blood pressure > 140 mmHg systolic and/or > 90 mmHg diastolic on at least two occasions or current antihypertensive pharmacological treatment

Age 65 Age 65 years or greater

Diabetes mellitus Fasting plasma glucose concentration ≥ 7.0 mmol/L (126 mg/dL) or treatment with oral hypoglycemic agents and/or insulin

Stroke/transient ischemic attack/peripheral embolism

Ischemic stroke: focal neurologic deficit of sudden onset diagnosed by a neurologist, lasting > 24hours, and caused by ischemia;Transient ischemic attack: focal neurological deficit of sudden onset diagnosed by a neurologist, lasting< 24 hours;Peripheral embolism: thromboembolism outside the brain, heart, eyes, and lungs, or pulmonaryembolism (defined by the responsible physician)

Vascular disease Coronary artery disease, peripheral artery disease, or aortic plaque

NOAC use is contraindicated NOAC use is reasonable

Mechanical heart valves • In any position (100% agreement)

Rheumatic mitral stenosis • mild (47% agreement)• moderate-severe (88% agreement)• post commissurotomy (42% agreement)

Non-rheumatic mitral stenosis • moderate or severe (69% agreement)

Bioprosthetic heart valve • aortic position (82% agreement)• mitral position (73% agreement)

Mitral annuloplasty • with or without prosthetic ring (88% agreement)

Non-Rheumatic mitral stenosis • mild (97% agreement)

Mitral regurgitation• mild (97% agreement)• moderate-severe (>90% agreement)

Tricuspid regurgitation • Any severity (98% agreement)

Aortic Stenosis or Regurgitation • Mild (98% agreement)• Moderate-Severe (80% agreement)

*A NOAC is preferred over warfarin for non-valvular AF

Consider and modify (if possible) all factors influencing risk of bleeding during OAC treatment (hypertension, antiplatelet drugs, NSAIDs, corticosteroids, excessive alcohol, labile INRs) and specifically bleeding risks for NOACs (low creatinine clearance, age ≥ 75, low body weight)†

NO

YES

“CCS algorithm” (“CHADS65”) for OAC therapy in AF

Age ≥ 65 OAC*

YESOAC*

NO

Stroke / TIA / peripheral embolism orHypertension orHeart Failure orDiabetes Mellitus

(CHADS2 risk factors)

NO

YESCAD orArterial vascular disease

(coronary, aortic, perpheral)ASA

No antithrombotic therapy

NOAC, novel non-vitamin K antagonist

Table 5. Expert opinion survey regarding the clinical use of a NOAC in relation to the following commonly encountered scenarios: Would you consider NOAC use to be 1) contraindicated or 2) not contraindicated (i.e. reasonable to use) with the following valvular disorders?

The simplifi ed ”CCS algorithm” (“CHADS65”) for deciding which patients with atrial fi brillation (AF) or atrial fl utter (AFL) should receive oral anticoagulation (OAC) therapy. It recommends OAC for most patients ≥65 years and for younger patients with a CHADS2 score≥1; aspirin (ASA) for patients<65 years with CHADS2 score=0 with arterial vascular disease (coronary, aortic, or peripheral); and no antithrombotic therapy for patients <65 years with a CHADS2 score=0 and no arterial vascular disease. Bleeding risks should be modifi ed whenever possible. A non-vitamin K antagonist oral anticoagulant (NOAC) is recommended in pref-erence to warfarin for OAC therapy in non-valvular AF patients.