Upload
others
View
2
Download
0
Embed Size (px)
Citation preview
Post operative atrial fibrilation
(POAF) :
What do the Guidelines say ?
Pr. Dan Longrois, Department of Anesthesia and Intensive Care
Bichat-Claude Bernard Hospital, Assistance Publique-Hôpitaux de Paris, University Paris 7, Denis Diderot, Unité INSERM U1148, Paris, France
CEEA Kosice 2016
Male, 68 Years, J2 post pneumectomy,asymptomatic POAF,
Amiodarone (IV, 2 + 6 Amp/ 24h)
THANK YOU FOR YOUR
ATTENTION AND SEE YOU
NEXT YEAR !
In fact…• AF in general
• Epidemiology/pathophysiology of POAF
– Cardiac surgery/ thoracic surgery/ other types of
surgery
• Treatment
– HD instability/ symptoms
– HR control
– Return to sinus rhythm
– Prevention of re-occurrence of POAF
– Anticoagulation ?
• Duration of postoperative anticoagulation ?
AF
« Medical »POAF
Cardiac
surgery
POAF non-
cardiac
surgery
Thoracic non-cardiac surgeryOther types of surgery
ICU
Lancet 2012; 379: 648–61
J Am Coll Cardiol 2011;57:e101–98
CHEST 2012; 141(2)(Suppl):e531S–e575S
ISSN: 1524-4539 Copyright © 2011 American Heart Association. All rights reserved. Print ISSN: 0009-7322. Online
72514Circulation is published by the American Heart Association. 7272 Greenville Avenue, Dallas, TX
DOI: 10.1161/CIR.0b013e31820f14c0 published online Feb 14, 2011; Circulation
Richard L. Page, David J. Slotwiner, William G. Stevenson and Cynthia M. Tracy Michael D. Ezekowitz, Warren M. Jackman, Craig T. January, James E. Lowe,
L. Samuel Wann, Anne B. Curtis, Kenneth A. Ellenbogen, N.A. Mark Estes, III, Guidelines
Cardiology Foundation/American Heart Association Task Force on PracticeAtrial Fibrillation (Update on Dabigatran): A Report of the American College of
2011 ACCF/AHA/HRS Focused Update on the Management of Patients With
http://circ.ahajournals.org/cgi/content/full/CIR.0b013e31820f14c0/DC1Data Supplement (unedited) at:
http://circ.ahajournals.org
located on the World Wide Web at: The online version of this article, along with updated information and services, is
http://www.lww.com/reprintsReprints: Information about reprints can be found online at
[email protected]. E-mail:
Fax:Kluwer Health, 351 West Camden Street, Baltimore, MD 21202-2436. Phone: 410-528-4050. Permissions: Permissions & Rights Desk, Lippincott Williams & Wilkins, a division of Wolters
http://circ.ahajournals.org/subscriptions/Subscriptions: Information about subscribing to Circulation is online at
at INSERM U-541 on February 17, 2011 circ.ahajournals.orgDownloaded from
Circulation. 2011;123:104 –123
ESC GUIDELINES
2016 ESC Guidelines for the management of atrial
fibrillat ion developed in collaboration with EACTS
The Task Force for the management of at r ial fibr illat ion of the
European Society of Cardiology (ESC)
Developed with the special contr ibut ion of the European Heart
Rhythm Associat ion (EHRA) of the ESC
Endorsed by the European Stroke Organisat ion (ESO)
Authors/Task Force Members: Paulus Kirchhof (Chairperson) (UK/Germany),*
Stefano Benussi*1 (Co-Chairperson) (Switzer land), Dipak Kotecha (UK),
Anders Ahlsson1 (Sweden), Dan Atar (Norway), Barbara Casadei (UK),
Manuel Castella1 (Spain), Hans-Chr istoph Diener2 (Germany), Hein Heidbuchel
(Belgium), Jeroen Hendr iks (The Nether lands), Gerhard Hindr icks (Germany),
Antonis S. Manolis (Greece), Jonas Oldgren (Sweden), Bogdan Alexandru Popescu
(Romania), Ulr ich Schot t en (The Nether lands), Bart Van Putte1 (The Nether lands),
and Panagiot is Vardas (Greece)
Document Reviewers: Stefan Agewall (CPG Review Co-ordinat or) (Norway), John Camm (CPG Review
Co-ordinator ) (UK), Gonzalo Baron Esquivias (Spain), W erner Budts (Belgium), Scipione Carer j (Italy),
Filip Casselman (Belgium ), Antonio Coca (Spain), Raffaele De Cater ina (Italy), Spir idon Deftereos (Greece),
Dobromir Dobrev (Germany), Jose M. Ferro (Portugal), Gerasimos Filippatos (Greece), Donna Fitzsimons (UK),
* Correspondingauthors: Paulus Kirchhof, Institute of Cardiovascular Sciences, University of Birmingham, SWBH and UHBNHStrusts, IBR, Room 136, Wolfson Drive, Birmingham
B15 2TT, United Kingdom, Tel: + 44 121 4147042, E-mail: [email protected]; Stefano Benussi, Department of Cardiovascular Surgery, University Hospital Zurich, Ramistrasse
100, 8091 Zurich, Switzerland, Tel: + 41(0)788933835, E-mail: [email protected] ing the European Associat ion for Cardio-Thoracic Surgery (EACTS)2Represent ing the European Stroke Associat ion (ESO)
ESC Committee for Pract ice Guidelines (CPG) and National Cardiac Societ ies Reviewers can be found in the Appendix.
ESC ent it ies having part icipated in the development of this document:
Associat ions: European Association for Cardiovascular Prevention and Rehabilitation (EACPR), European Association of Cardiovascular Imaging (EACVI), European Heart Rhythm
Association (EHRA), Heart Failure Association (HFA).
Councils: Council on Cardiovascular Nursing and Allied Professions, Council for Cardiology Practice, Council on Cardiovascular Primary Care, Council on Hypertension.
W orking Groups: Cardiac Cellular Electrophysiology, Cardiovascular Pharmacotherapy, Grown-up Congenital Heart Disease, Thrombosis, Valvular Heart Disease.
Thecontent of theseEuropean Society of Cardiology (ESC) Guidelineshasbeen published for personal and educational useonly.No commercial use isauthorized.No part of theESC
Guidelines may be translated or reproduced in any form without written permission from the ESC. Permission can be obtained upon submission of awritten request to Oxford Uni-
versity Press, the publisher of the European Heart Journal and the party authorized to handle such permissions on behalf of the ESC ([email protected]).
Disclaimer .The ESC Guidelines represent the viewsof the ESC and were produced after careful consideration of the scientific and medical knowledge and the evidence available at
the time of their publication. The ESC is not responsible in the event of any contradiction, discrepancy and/or ambiguity between the ESC Guidelines and any other official recom-
mendations or guidelines issued by the relevant public health authorities, in particular in relation to good use of healthcare or therapeutic strategies. Health professionals are encour-
aged to take the ESC Guidelines fully into account when exercising their clinical judgment, as well as in the determination and the implementation of preventive, diagnostic or
therapeutic medical strategies; however, the ESC Guidelines do not override, in any way whatsoever, the individual responsibility of health professionals to make appropriate and
accurate decisions in consideration of each patient’s health condition and in consultation with that patient and, where appropriate and/or necessary, the patient’s caregiver. Nor
do theESC Guidelinesexempt health professionals from takinginto full and careful consideration the relevant official updated recommendations or guidelines issued by thecompetent
public health authorities, in order to manage each patient’scase in light of the scientifically accepted datapursuant to their respective ethical and professional obligations. It isalso the
health professional’s responsibility to verify the applicable rules and regulations relating to drugs and medical devices at the time of prescription.
& The European Society of Cardiology 2016. All rights reserved. For permissions please email: [email protected].
doi:10.1093/europace/euw295
Europace (2016) 18, 1609–1678
by g
ue
st o
n N
ove
mb
er 2
7, 2
01
6D
ow
nlo
ad
ed
from
YancyMurray, Ralph L. Sacco, William G. Stevenson, Patrick J. Tchou, Cynthia M. Tracy and Clyde W.
T.E. Cigarroa, Jamie B. Conti, Patrick T. Ellinor, Michael D. Ezekowitz, Michael E. Field, Katherine Craig T. January, L. Samuel Wann, Joseph S. Alpert, Hugh Calkins, Joseph C. Cleveland, Jr, Joaquin
Association Task Force on Practice Guidelines and the Heart Rhythm SocietyExecutive Summary: A Report of the American College of Cardiology/American Heart
2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation:
Print ISSN: 0009-7322. Online ISSN: 1524-4539 Copyright © 2014 American Heart Association, Inc. All rights reserved.
is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231Circulation published online March 28, 2014;Circulation.
http://circ.ahajournals.org/content/early/2014/04/10/CIR.0000000000000040.citation
World Wide Web at: The online version of this article, along with updated information and services, is located on the
http://circ.ahajournals.org/content/suppl/2014/04/10/CIR.0000000000000040.DC3.html http://circ.ahajournals.org/content/suppl/2014/03/24/CIR.0000000000000040.DC2.html http://circ.ahajournals.org/content/suppl/2014/03/24/CIR.0000000000000040.DC1.html
Data Supplement (unedited) at:
http://circ.ahajournals.org//subscriptions/
is online at: Circulation Information about subscribing to Subscriptions:
http://www.lww.com/reprints Information about reprints can be found online at: Reprints:
document. Permissions and Rights Question and Answer available in the
Permissions in the middle column of the Web page under Services. Further information about this process isOnce the online version of the published article for which permission is being requested is located, click Request
can be obtained via RightsLink, a service of the Copyright Clearance Center, not the Editorial Office.Circulation Requests for permissions to reproduce figures, tables, or portions of articles originally published inPermissions:
by guest on September 1, 2014http://circ.ahajournals.org/Downloaded from by guest on September 1, 2014http://circ.ahajournals.org/Downloaded from by guest on September 1, 2014http://circ.ahajournals.org/Downloaded from by guest on September 1, 2014http://circ.ahajournals.org/Downloaded from by guest on September 1, 2014http://circ.ahajournals.org/Downloaded from by guest on September 1, 2014http://circ.ahajournals.org/Downloaded from by guest on September 1, 2014http://circ.ahajournals.org/Downloaded from by guest on September 1, 2014http://circ.ahajournals.org/Downloaded from by guest on September 1, 2014http://circ.ahajournals.org/Downloaded from by guest on September 1, 2014http://circ.ahajournals.org/Downloaded from by guest on September 1, 2014http://circ.ahajournals.org/Downloaded from by guest on September 1, 2014http://circ.ahajournals.org/Downloaded from by guest on September 1, 2014http://circ.ahajournals.org/Downloaded from by guest on September 1, 2014http://circ.ahajournals.org/Downloaded from by guest on September 1, 2014http://circ.ahajournals.org/Downloaded from by guest on September 1, 2014http://circ.ahajournals.org/Downloaded from by guest on September 1, 2014http://circ.ahajournals.org/Downloaded from by guest on September 1, 2014http://circ.ahajournals.org/Downloaded from by guest on September 1, 2014http://circ.ahajournals.org/Downloaded from by guest on September 1, 2014http://circ.ahajournals.org/Downloaded from by guest on September 1, 2014http://circ.ahajournals.org/Downloaded from by guest on September 1, 2014http://circ.ahajournals.org/Downloaded from by guest on September 1, 2014http://circ.ahajournals.org/Downloaded from by guest on September 1, 2014http://circ.ahajournals.org/Downloaded from by guest on September 1, 2014http://circ.ahajournals.org/Downloaded from by guest on September 1, 2014http://circ.ahajournals.org/Downloaded from by guest on September 1, 2014http://circ.ahajournals.org/Downloaded from by guest on September 1, 2014http://circ.ahajournals.org/Downloaded from by guest on September 1, 2014http://circ.ahajournals.org/Downloaded from by guest on September 1, 2014http://circ.ahajournals.org/Downloaded from by guest on September 1, 2014http://circ.ahajournals.org/Downloaded from by guest on September 1, 2014http://circ.ahajournals.org/Downloaded from by guest on September 1, 2014http://circ.ahajournals.org/Downloaded from by guest on September 1, 2014http://circ.ahajournals.org/Downloaded from by guest on September 1, 2014http://circ.ahajournals.org/Downloaded from by guest on September 1, 2014http://circ.ahajournals.org/Downloaded from by guest on September 1, 2014http://circ.ahajournals.org/Downloaded from by guest on September 1, 2014http://circ.ahajournals.org/Downloaded from by guest on September 1, 2014http://circ.ahajournals.org/Downloaded from by guest on September 1, 2014http://circ.ahajournals.org/Downloaded from by guest on September 1, 2014http://circ.ahajournals.org/Downloaded from by guest on September 1, 2014http://circ.ahajournals.org/Downloaded from by guest on September 1, 2014http://circ.ahajournals.org/Downloaded from by guest on September 1, 2014http://circ.ahajournals.org/Downloaded from by guest on September 1, 2014http://circ.ahajournals.org/Downloaded from by guest on September 1, 2014http://circ.ahajournals.org/Downloaded from by guest on September 1, 2014http://circ.ahajournals.org/Downloaded from by guest on September 1, 2014http://circ.ahajournals.org/Downloaded from by guest on September 1, 2014http://circ.ahajournals.org/Downloaded from by guest on September 1, 2014http://circ.ahajournals.org/Downloaded from by guest on September 1, 2014http://circ.ahajournals.org/Downloaded from by guest on September 1, 2014http://circ.ahajournals.org/Downloaded from
guideline-directed medical therapy (GDMT) to represent optimal medical therapy
as defined by ACC/AHA guideline (primarily Class I)-recommended therapies
Clin. Cardiol. 37, 1, 7–13 (2014)
2014 AATS guidelines for the prevention and management of
per ioperative atr ial fibr illation and flutter for thoracic
surgical procedures
Gyorgy Frendl, MD, PhD,aAlissa C. Sodickson, MD,aMina K. Chung, MD,b Albert L. Waldo, MD, PhD,c,d
Bernard J. Gersh, MB, ChB, DPhi,eJames E. Tisdale, PharmD,f Hugh Calkins, MD,g Sary Aranki, MD,h
Tsuyoshi Kaneko, MD,h Stephen Cassivi, MD,i Sidney C. Smith, Jr, MD,j Dawood Darbar, MD,k
Jon O. Wee, MD,l Thomas K. Waddell, MD, MSc, PhD,m David Amar, MD,n and Dale Adler, MDo
Supplemental material is available online.
PREAMBLE
Our mission was to develop evidence-based guidelines for
theprevention and treatment of perioperative/postoperative
atrial fibrillation and flutter (POAF) for thoracic surgical
procedures. Sixteen experts were invited by the American
Association for Thoracic Surgery (AATS) leadership: 7 car-
diologists and electrophysiology specialists, 3 intensivists/
anesthesiologists, 1 clinical pharmacist, joined by 5
thoracic and cardiac surgeons who represented AATS (see
Online Data Supplement 1 for the list of members and
OnlineData Supplement 2 for theconflict of interest decla-
ration online).
Methods of Review
Membersweretaskedwithmakingrecommendationsbased
onareview of theliterature, withgradingthequality of theev-
idence supporting the recommendations, and with assessing
the risk-benefit profile for each recommendation. The level
of evidence was graded by the task force panel according to
standards published by the Institute of Medicine (Table 1).
For thedevelopment of theguidelineswefollowedtherecom-
mendationsof TheInstituteof Medicine(IOM) 2011Clinical
PracticeGuidelinesWeCan Trust: Standardsfor Developing
Trustworthy Clinical Practice Guidelines; www.iom.edu/
cpgstandards.1Effortsweremadetominimizerepetitionof ex-
istingguidelines2-4; rather wefocusedonnew informationand
advances in diagnosis and therapy, and present these current
guidelines within the framework of the new IOM
recommendations. In order to meet these standards, most
societies (American Heart Association and AATS included)
initiated therevision2,3 of existing guidelines.
Task force subgroups were formed and tasked with pre-
paring a summary of the available literature for each sub-
topic. Literature searches were conducted using PubMed,
focused on articles published since 2000 except in rare cir-
cumstances. Both the summaries and original articles were
made available to each task force member via a shared
electronic folder. The subgroup summaries as well as the
original literature were presented and discussed at 9 sched-
uled teleconferences. Theconferenceswere recorded. Arti-
cleswereselected for inclusion based on consensusopinion
by task force members. Writing groups were formed to
develop the draft guidelines for each subtopic, with 3 to 7
members and a leader for each group. Group recommenda-
tions were submitted before being presented for discussion
and voting at a 1-day face-to-face conference.
Members were specifically asked to assess the applica-
bility of the available evidence to patients undergoing
thoracic surgery. All recommendations were subjected to
a vote. Acceptance for the final document required greater
than 75% approval of each of the recommendations.
A final draft was prepared by the chairman of the task
force and madeavailable in awritten form to each member
for final comments. Subsequently, the recommendations
were posted for public comments for AATS members (via
REDCap), and then peer reviewed by outside experts
selected by the AATS Council.
From the Department of Anesthesiology,aPerioperativeCritical Care and Pain Med-
icine, Brigham and Women’sHospital and Harvard Medical School, Boston, Mass;
Department of Cardiovascular Medicine,b Heart and Vascular Institute, Depart-
ment of Molecular Cardiology, Lerner Research InstituteCleveland Clinic, Lerner
College of Medicine of Case Western Reserve University Cleveland Clinic, Cleve-
land, Ohio; Division of Cardiovascular Medicine,c Department of Medicine, Case
Western Reserve University, Cleveland, Ohio; Harrington Heart & Vascular Insti-
tute,dUniversity HospitalsCaseMedical Center, Cleveland, Ohio; Division of Car-
diovascular Diseases and Internal Medicine,e Department of Medicine, Mayo
Clinic College of Medicine, Rochester, Minn; Department of Pharmacy Practice,f
College of Pharmacy, Purdue University and Indiana University School of Medi-
cine, Indianapolis, Ind; Department of Medicine,g Cardiac Arrhythmia Service,
Johns Hopkins University, Baltimore, Md; Division of Cardiac Surgery,h Depart-
ment of Surgery, Brigham and Women’s Hospital and Harvard Medical School,
Boston, Mass; Division of Thoracic Surgery,i Department of Surgery, Mayo Clinic
College of Medicine, Rochester, Minn; Center for Heart and Vascular Care,j
Department of Medicine, University of North Carolina, Chapel Hill, NC; Division
of Cardiovascular Medicine,k Department of Medicine, Arrhythmia Service, Van-
derbilt University School of Medicine, Nashville, Tenn; Division of Thoracic Sur-
gery,l Department of Surgery, Brigham and Women’s Hospital and Harvard
Medical School, Boston, Mass; Division of Thoracic Surgery,mDepartment of Sur-
gery, University of Toronto, Toronto, Ontario, Canada; Memorial Sloan-Kettering
Cancer Center,n Department of Anesthesiology and Critical Care Medicine, New
York, NY; Division of Cardiovascular Medicine,o Department of Medicine, Brig-
ham and Women’s Hospital and Harvard Medical School, Boston, Mass.
Disclosures: See Online Data Supplement 2.
Received for publication June 9, 2014; accepted for publication June 10, 2014.
Address for reprints: Gyorgy Frendl, MD, PhD, Department of Anesthesiology, Peri-
operativeand Pain Medicine, Brigham and Women’sHospital, CWN-L1, 75 Fran-
cis St, Boston, MA 02115 (E-mail : [email protected]).
J Thorac Cardiovasc Surg 2014;148:e153-93
0022-5223/$36.00
Copyright Ó 2014 by The American Association for Thoracic Surgery
http://dx.doi.org/10.1016/j.jtcvs.2014.06.036
The Journal of Thoracic and Cardiovascular Surgery c Volume 148, Number 3 e153
Frendl et al Clinical Guidelines
Thorac Cardiovasc Surg 2014;148:e153-93
Risk factors of AF (1)
• Clinical risk factors
– Age, HTN, diabetes, obesity, OAS, smoking,
alcohol, hyperthyroidia, familiy Hx,
– Cardiopathies (ischemic, valvular)
– Heart failure
– Cardiothoracic surgery
– European descent
– Genetic predisposition
Circulation. 2014;129: – .
NONE OF THEM IS AVOIDABLE
Other risk factor of AF (2)
• ECG
– LVH
• Echocardiography
– Dilatation of LA
– Altered LVEF
• Biomarkers
– Increased BNP/ CRP
Circulation. 2014;129: – .
NONE OF THEM IS AVOIDABLE
Pathophysiology of AF
Physiol Rev 91: 265–325, 2011;
Physiol Rev 91: 265–325, 2011;
Europace (2012) 14, 159–174
REVIEW
Post-operat ive atr ial fibrillat ion: a maze
of mechanisms
Bart Maesen 1,2, Jan Nijs1, Jos Maessen 1, Maur its Allessie 2, and Ulr ich Schot ten 2*
1Department of Cardiothoracic Surgery, University Hospital of Maastricht, PO Box 5800, 6202 AZ Maastricht, The Netherlands; and 2Department of Physiology, University
Maastricht, PO Box 616, 6200 MD Maastricht, The Netherlands
Received 24 March 2011; accepted after revision 7 June 2011; online publish-ahead-of-print 6 August 2011
Post-operative atrial fibrillation (POAF) is one of the most frequent complications of cardiac surgery and an important predictor of patient
morbidity aswell asof prolonged hospitalization. It significantly increases costs for hospitalization. Insights into the pathophysiological factors
causing POAFhave been provided by both experimental and clinical investigations and show that POAFis ‘multi-factorial’. Facilitating factors
in the mechanism of the arrhythmia can be classified asacute factors caused by the surgical intervention and chronic factors related to struc-
tural heart disease and ageing of the heart. Furthermore, some proarrhythmic mechanisms specifically occur in the setting of POAF. For
example, inflammation and beta-adrenergic activation have been shown to play a prominent role in POAF, while these mechanisms are
less important in non-surgical AF. More recently, it has been shown that atrial fibrosis and the presence of an electrophysiological substrate
capable of maintaining AF also promote the arrhythmia, indicating that POAF has some proarrhythmic mechanisms in common with other
forms of AF. The clinical setting of POAF offers numerous opportunities to study its mechanisms. During cardiac surgery, biopsies can be
taken and detailed electrophysiological measurements can be performed. Furthermore, the specific time course of POAF, with the delayed
onset and the transient character of the arrhythmia, also provides important insight into its mechanisms.
This review discusses the mechanistic interaction between predisposing factorsand the electrophysiological mechanisms resulting in POAF
and their therapeutic implications.- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -Keywor ds Atrial fibrillation † Post-operative atrial fibrillation † Inflammation † Sympathetic activation † Oxidative stress †
Atrial remodelling † Fibrosis † Ageing
Int roduct ion
Atrial arrhythmias and atrial fibrillation (AF) in particular are well-
known complications after cardiac surgery with a reported inci-
dence between 10 and 60%.1–17 The incidence ishigher in patients
undergoing valve surgery than in patients undergoing coronary
artery bypass surgery (CABG).1,2,7,8,10,11,17,18 Post-operative atrial
arrhythmias also occur after non-cardiac surgery, especially after
oesophagectomy,19 lung surgery,20–24 and large abdominal
surgery.25–27 The incidence after non-cardiac surgery is,
however, lower with incidences ranging from 0.3 to 29%.22,28,29
Postoperative atrial arrhythmias are associated with prolonged
hospital stay, haemodynamic instability, an increased risk of
stroke, and increased mortality.2–4,6,10,12,13,24,28,30–33
The exact pathophysiological mechanisms responsible for the
onset and perpetuation of post-operative atrial arrhythmias are
incompletely understood. Factors facilitating post-operative AF
(POAF) can be classified in acute factors directly related to
surgery (e.g. adrenergic stimulation) and factors that are reflecting
a chronic and progressive process of remodelling or ageing of the
heart (e.g. left atrial enlargement).14,15 These predisposing factors
can on the one hand provoke triggers able to initiate the arrhyth-
mia and on the other hand enhance the development of a sub-
strate capable of perpetuating AF.
The association of POAF with specific kinds of surgery and the
time course of the arrhythmia can help to better understand its
mechanisms. First, the association of POAF with cardiac surgery
and degree of structural heart disease suggests a direct role for
* Corresponding author. Tel: + 31 43 3881077; fax: + 3143 3884166, Email: [email protected]
Published on behalf of the European Society of Cardiology. All rights reserved. & The Author 2011. For permissions please email: [email protected].
The online version of this article has been published under an open access model. Users are entitled to use, reproduce, disseminate, or display the open access version of thisarticle
for non-commercial purposes provided that the original authorship is properly and fully attributed; the Journal, Learned Society and Oxford University Press are attributed as the
original place of publication with correct citation details given; if an article is subsequently reproduced or disseminated not in itsentirety but only in part or as aderivative work this
must be clearly indicated. For commercial re-use, please contact [email protected].
Europace (2012) 14, 159–174
doi:10.1093/europace/eur208
at Inserm
/Disc o
n N
ov
ember 1
6, 2
01
3http
://euro
pace
.ox
ford
jou
rnals.o
rg/
Do
wn
load
ed
from
Europace (2012) 14, 159–174
Peaks of incidence different between POAF in
cardiac and non-cardiac surgery
Europace (2012) 14, 159–174
EPIDEMIOLOGY of POAF:
Cardiac surgery: 30-40 %
What is the incidence of POAF
after non-cardiac surgery ?
Incidence of POAF• Non-cardiac thoracic surgery: 30 %
– Exploratory thoraco/segmentectomy: 4 %
– lobectomies, bilobectomies,
pneumonectomies : 10-33 %
– Single/double lung transplantation: 40 %
– Oesophagectomy: 13-25 % of rhythm
abnormalities including POAF.
• TAVI 10-20%
J Cardiothorac.Vasc.Anesth. 2010; 24: 752-61
J Cardiothorac.Vasc.Anesth. 2011;
Anesthesiol.Clin. 2008; 26: 325-35
Epidemiology of AF in ICU patients (outside of
the cardiac surgery context)
• AF : relatively frequent in ICU patient
Surgical ICU:
3 - 25% POAFChung & al, Crit Care Med 2000
Beck-Nielsen & al, Acta Med Scand 1973
Goodman & al, Chest 1978
Medical ICU :
6.5% - 20% Ledingham & al, Lancet 1978
Reinelt & al, Intensive Care Med 2001
Annane & al, AJ Respiratory and Crit Care Med 2008
Incidence of POAF (non-
thoracic surgery)• General surgery: 2-4 % rhythm
disturbances including POAF
• Surgical ICU, 5-8 % have POAF
– In patients with severe sepsis/septic shock,
46 % have a POAF
Crit Care Med. 2004; 32: 722-6
Crit Care. 2010; 14: R108
Frequent spontaneous conversion to sinus rhythm
Is POAF a « severe »
complication ? • Yes in cardiac surgery
– POAF is an independent risk factor for short
term/long term mortality and for postoperative
stroke
– This statistical association justifies prevention/
treatment
Association between POAF and
complications (chronology not taken into
account)
• post-op stroke : OR 2.23 [1.78-2.80] P <.00001
• Resp failure: OR 2.30 [1.71-3.11] P <.00001
• Card failure: OR 1.82 [0.78-4.23] P = 0.2
• MI : OR 0.98 [0.56-1.71] P= 0.9
• LOS: OR 1.48 [1.09–1.87] P <.00001
J Thorac Cardiovasc Surg 2011;141:1305-12
And in the other types of
surgery ?
• Incidence: 29% (65/224 patients)
• Emphysema: 37% / Mucoviscidosis:27%
• Bi pulmonary: 56%
• Amiodarone: in 56% of patients with POAF
Henri C et al. Circ Arrhythm Electrophysiol. 2012;5:61-7
Risk factors for mortality (multivariate analysis)
Bronchial leak: 3.8 (1.4-10.2); P = 0.007
Vasoconstrictors during surg 2.3 (0.9-7.9); P = 0.06
POAF 1.5 (0.5-4.6); P= 0.4
Lack of statistical power very probable
2014 AATS guidelines for the prevention and management of
per ioperative atr ial fibr illation and flutter for thoracic
surgical procedures
Gyorgy Frendl, MD, PhD,aAlissa C. Sodickson, MD,aMina K. Chung, MD,b Albert L. Waldo, MD, PhD,c,d
Bernard J. Gersh, MB, ChB, DPhi,eJames E. Tisdale, PharmD,f Hugh Calkins, MD,g Sary Aranki, MD,h
Tsuyoshi Kaneko, MD,h Stephen Cassivi, MD,i Sidney C. Smith, Jr, MD,j Dawood Darbar, MD,k
Jon O. Wee, MD,l Thomas K. Waddell, MD, MSc, PhD,m David Amar, MD,n and Dale Adler, MDo
Supplemental material is available online.
PREAMBLE
Our mission was to develop evidence-based guidelines for
theprevention and treatment of perioperative/postoperative
atrial fibrillation and flutter (POAF) for thoracic surgical
procedures. Sixteen experts were invited by the American
Association for Thoracic Surgery (AATS) leadership: 7 car-
diologists and electrophysiology specialists, 3 intensivists/
anesthesiologists, 1 clinical pharmacist, joined by 5
thoracic and cardiac surgeons who represented AATS (see
Online Data Supplement 1 for the list of members and
OnlineData Supplement 2 for theconflict of interest decla-
ration online).
Methods of Review
Membersweretaskedwithmakingrecommendationsbased
onareview of theliterature, withgrading thequality of theev-
idence supporting the recommendations, and with assessing
the risk-benefit profile for each recommendation. The level
of evidence was graded by the task force panel according to
standards published by the Institute of Medicine (Table 1).
For thedevelopment of theguidelineswefollowedtherecom-
mendationsof TheInstituteof Medicine(IOM) 2011Clinical
PracticeGuidelinesWeCan Trust: Standardsfor Developing
Trustworthy Clinical Practice Guidelines; www.iom.edu/
cpgstandards.1Effortsweremadetominimizerepetitionof ex-
istingguidelines2-4; rather wefocusedonnew informationand
advances in diagnosis and therapy, and present these current
guidelines within the framework of the new IOM
recommendations. In order to meet these standards, most
societies (American Heart Association and AATS included)
initiated therevision2,3 of existing guidelines.
Task force subgroups were formed and tasked with pre-
paring a summary of the available literature for each sub-
topic. Literature searches were conducted using PubMed,
focused on articles published since 2000 except in rare cir-
cumstances. Both the summaries and original articles were
made available to each task force member via a shared
electronic folder. The subgroup summaries as well as the
original literature were presented and discussed at 9 sched-
uled teleconferences. Theconferenceswere recorded. Arti-
cleswereselected for inclusion based on consensusopinion
by task force members. Writing groups were formed to
develop the draft guidelines for each subtopic, with 3 to 7
members and a leader for each group. Group recommenda-
tions were submitted before being presented for discussion
and voting at a 1-day face-to-face conference.
Members were specifically asked to assess the applica-
bility of the available evidence to patients undergoing
thoracic surgery. All recommendations were subjected to
a vote. Acceptance for the final document required greater
than 75% approval of each of the recommendations.
A final draft was prepared by the chairman of the task
force and madeavailable in awritten form to each member
for final comments. Subsequently, the recommendations
were posted for public comments for AATS members (via
REDCap), and then peer reviewed by outside experts
selected by the AATS Council.
From the Department of Anesthesiology,aPerioperative Critical Care and Pain Med-
icine, Brigham and Women’sHospital and Harvard Medical School, Boston, Mass;
Department of Cardiovascular Medicine,b Heart and Vascular Institute, Depart-
ment of Molecular Cardiology, Lerner Research Institute Cleveland Clinic, Lerner
College of Medicine of Case Western Reserve University Cleveland Clinic, Cleve-
land, Ohio; Division of Cardiovascular Medicine,c Department of Medicine, Case
Western Reserve University, Cleveland, Ohio; Harrington Heart & Vascular Insti-
tute,dUniversity Hospitals CaseMedical Center, Cleveland, Ohio; Division of Car-
diovascular Diseases and Internal Medicine,e Department of Medicine, Mayo
Clinic College of Medicine, Rochester, Minn; Department of Pharmacy Practice,f
College of Pharmacy, Purdue University and Indiana University School of Medi-
cine, Indianapolis, Ind; Department of Medicine,g Cardiac Arrhythmia Service,
Johns Hopkins University, Baltimore, Md; Division of Cardiac Surgery,h Depart-
ment of Surgery, Brigham and Women’s Hospital and Harvard Medical School,
Boston, Mass; Division of Thoracic Surgery,i Department of Surgery, Mayo Clinic
College of Medicine, Rochester, Minn; Center for Heart and Vascular Care,j
Department of Medicine, University of North Carolina, Chapel Hill, NC; Division
of Cardiovascular Medicine,k Department of Medicine, Arrhythmia Service, Van-
derbilt University School of Medicine, Nashville, Tenn; Division of Thoracic Sur-
gery,l Department of Surgery, Brigham and Women’s Hospital and Harvard
Medical School, Boston, Mass; Division of Thoracic Surgery,mDepartment of Sur-
gery, University of Toronto, Toronto, Ontario, Canada; Memorial Sloan-Kettering
Cancer Center,n Department of Anesthesiology and Critical Care Medicine, New
York, NY; Division of Cardiovascular Medicine,o Department of Medicine, Brig-
ham and Women’s Hospital and Harvard Medical School, Boston, Mass.
Disclosures: See Online Data Supplement 2.
Received for publication June 9, 2014; accepted for publication June 10, 2014.
Address for reprints: Gyorgy Frendl, MD, PhD, Department of Anesthesiology, Peri-
operativeand Pain Medicine, Brigham and Women’sHospital, CWN-L1, 75 Fran-
cis St, Boston, MA 02115 (E-mail : [email protected]).
J Thorac Cardiovasc Surg 2014;148:e153-93
0022-5223/$36.00
Copyright Ó 2014 by The American Association for Thoracic Surgery
http://dx.doi.org/10.1016/j.jtcvs.2014.06.036
The Journal of Thoracic and Cardiovascular Surgery c Volume 148, Number 3 e153
Frendl et al Clinical Guidelines
Management of POAF
J Thorac Cardiovasc Surg 2014;148:e153-93
Attempt to get a preoperatoy EKG
(pre-excitation, long QTc)
J Thorac Cardiovasc Surg 2014;148:e153-93
J Thorac Cardiovasc Surg 2014;148:e153-93
J Thorac Cardiovasc Surg 2014;148:e153-93
Severe symptoms of POAF ?
Why control HR before
cardioversion ?
• Low primary success of cardioversion (35 %)
• In medical cardiology seting amiodarone vs placebo => 64
% of return to SR at 24h in the placebo group 1
• Re-occurrence of POAF , 38 - 62 % of cases at 24h and
48h 2
1 Fuster V et al. Circulation 2011; 123: e269-3672 Mayr A et al. Crit Care Med 2003; 31: 401-3
2014 AATS guidelines for the prevention and management of
per ioperative atr ial fibr illation and flutter for thoracic
surgical procedures
Gyorgy Frendl, MD, PhD,aAlissa C. Sodickson, MD,aMina K. Chung, MD,b Albert L. Waldo, MD, PhD,c,d
Bernard J. Gersh, MB, ChB, DPhi,eJames E. Tisdale, PharmD,f Hugh Calkins, MD,g Sary Aranki, MD,h
Tsuyoshi Kaneko, MD,h Stephen Cassivi, MD,i Sidney C. Smith, Jr, MD,j Dawood Darbar, MD,k
Jon O. Wee, MD,l Thomas K. Waddell, MD, MSc, PhD,m David Amar, MD,n and Dale Adler, MDo
Supplemental material is available online.
PREAMBLE
Our mission was to develop evidence-based guidelines for
theprevention and treatment of perioperative/postoperative
atrial fibrillation and flutter (POAF) for thoracic surgical
procedures. Sixteen experts were invited by the American
Association for Thoracic Surgery (AATS) leadership: 7 car-
diologists and electrophysiology specialists, 3 intensivists/
anesthesiologists, 1 clinical pharmacist, joined by 5
thoracic and cardiac surgeons who represented AATS (see
Online Data Supplement 1 for the list of members and
OnlineData Supplement 2 for theconflict of interest decla-
ration online).
Methods of Review
Membersweretaskedwithmakingrecommendationsbased
onareview of theliterature, withgradingthequality of theev-
idence supporting the recommendations, and with assessing
the risk-benefit profile for each recommendation. The level
of evidence was graded by the task force panel according to
standards published by the Institute of Medicine (Table 1).
For thedevelopment of theguidelineswefollowedtherecom-
mendationsof TheInstituteof Medicine(IOM) 2011Clinical
PracticeGuidelinesWeCan Trust: Standardsfor Developing
Trustworthy Clinical Practice Guidelines; www.iom.edu/
cpgstandards.1Effortsweremadetominimizerepetitionof ex-
istingguidelines2-4; rather wefocusedonnew informationand
advances in diagnosis and therapy, and present these current
guidelines within the framework of the new IOM
recommendations. In order to meet these standards, most
societies (American Heart Association and AATS included)
initiated therevision2,3 of existing guidelines.
Task force subgroups were formed and tasked with pre-
paring a summary of the available literature for each sub-
topic. Literature searches were conducted using PubMed,
focused on articles published since 2000 except in rare cir-
cumstances. Both the summaries and original articles were
made available to each task force member via a shared
electronic folder. The subgroup summaries as well as the
original literature were presented and discussed at 9 sched-
uled teleconferences. Theconferenceswere recorded. Arti-
cleswereselected for inclusion based on consensusopinion
by task force members. Writing groups were formed to
develop the draft guidelines for each subtopic, with 3 to 7
members and a leader for each group. Group recommenda-
tions were submitted before being presented for discussion
and voting at a 1-day face-to-face conference.
Members were specifically asked to assess the applica-
bility of the available evidence to patients undergoing
thoracic surgery. All recommendations were subjected to
a vote. Acceptance for the final document required greater
than 75% approval of each of the recommendations.
A final draft was prepared by the chairman of the task
force and made available in awritten form to each member
for final comments. Subsequently, the recommendations
were posted for public comments for AATS members (via
REDCap), and then peer reviewed by outside experts
selected by the AATS Council.
From the Department of Anesthesiology,aPerioperativeCritical Care and Pain Med-
icine, Brigham and Women’sHospital and Harvard Medical School, Boston, Mass;
Department of Cardiovascular Medicine,b Heart and Vascular Institute, Depart-
ment of Molecular Cardiology, Lerner Research InstituteCleveland Clinic, Lerner
Collegeof Medicine of Case Western Reserve University Cleveland Clinic, Cleve-
land, Ohio; Division of Cardiovascular Medicine,c Department of Medicine, Case
Western Reserve University, Cleveland, Ohio; Harrington Heart & Vascular Insti-
tute,dUniversity Hospitals CaseMedical Center, Cleveland, Ohio; Division of Car-
diovascular Diseases and Internal Medicine,e Department of Medicine, Mayo
Clinic College of Medicine, Rochester, Minn; Department of Pharmacy Practice,f
College of Pharmacy, Purdue University and Indiana University School of Medi-
cine, Indianapolis, Ind; Department of Medicine,g Cardiac Arrhythmia Service,
Johns Hopkins University, Baltimore, Md; Division of Cardiac Surgery,h Depart-
ment of Surgery, Brigham and Women’s Hospital and Harvard Medical School,
Boston, Mass; Division of Thoracic Surgery,i Department of Surgery, Mayo Clinic
College of Medicine, Rochester, Minn; Center for Heart and Vascular Care,j
Department of Medicine, University of North Carolina, Chapel Hill, NC; Division
of Cardiovascular Medicine,k Department of Medicine, Arrhythmia Service, Van-
derbilt University School of Medicine, Nashville, Tenn; Division of Thoracic Sur-
gery,l Department of Surgery, Brigham and Women’s Hospital and Harvard
Medical School, Boston, Mass; Division of Thoracic Surgery,mDepartment of Sur-
gery, University of Toronto, Toronto, Ontario, Canada; Memorial Sloan-Kettering
Cancer Center,n Department of Anesthesiology and Critical Care Medicine, New
York, NY; Division of Cardiovascular Medicine,o Department of Medicine, Brig-
ham and Women’s Hospital and Harvard Medical School, Boston, Mass.
Disclosures: See Online Data Supplement 2.
Received for publication June 9, 2014; accepted for publication June 10, 2014.
Address for reprints: Gyorgy Frendl, MD, PhD, Department of Anesthesiology, Peri-
operativeand Pain Medicine, Brigham and Women’sHospital, CWN-L1, 75 Fran-
cis St, Boston, MA 02115 (E-mail : [email protected]).
J Thorac Cardiovasc Surg 2014;148:e153-93
0022-5223/$36.00
Copyright Ó 2014 by The American Association for Thoracic Surgery
http://dx.doi.org/10.1016/j.jtcvs.2014.06.036
The Journal of Thoracic and Cardiovascular Surgery c Volume 148, Number 3 e153
Frendl et al Clinical Guidelines
The Journal of Thoracic and Cardiovascular Surgery c Volume 148, Number 3
What drugs/doses to be used to
treat POAF ?
J Am Coll Cardiol 2014;64:660–8
J Thorac Cardiovasc Surg 2014;148:e153-93
• Dose-dependance :
– 1st prescriptions (> 400mg/j) : toxicity 5 à 15%
– Doses < 400mg/j : toxicity 1,6 à 2%
– NO non-toxic doses2
• Cumulative doses are to be taken into consideration
• Risk factors for pulmonary toxicity: male gender, age1
• Ethnic factor ?
• Oxygenotherapy, mech ventilation, after cardiac surgery
Pulmonary toxicity of amiodarone:
1 L. Pilote, Am J Cardiol 20112 Int J Cardiol. 2011 Nov.
• Prospective randomized study 100 pneumectomies and 200
lobectomies
• Comparaison: amiodarone/verapamil versus Placebo
• Amiodarone:150 mg IV in 2 min then 1200 mg/j for 3 days
• Study interrupted: too many side effects in the amiodarone arm
Van Mieghem W et al. Chest 1994; 105:1642-5
Amiodarone and the Development of ARDS After
Lung Surgery
• Retrospective study of 310 lobectomies and 242 pneumonectomies on
5 years
• Incidence of POAF: 19%
• ARDS:
– 11% of patients treated with amiodarone vs 1.8% (P<0,0001) in
patients without amiodarone
– pneumonectomies > lobectomies
• Pathophysiology not known
Amiodarone nor recommanded in patients with
pneumonectomy ++
Van Mieghem W et al. Chest 1994; 105:1642-5
Amiodarone and the Development of ARDS After
Lung Surgery
Anticoagulation of POAF
High risk of TE for medical AF
CHADS2
ICC 1
Hypertension 1
Age ≥75 years 1
Diabetes 1
Stroke/TIA/TE 2
Maximum 6
Recommandations for anticoagulation of
medical AF
Risk of bleeding
ESC GUIDELINES
2016 ESC Guidelines for the management of atrial
fibrillat ion developed in collaboration with EACTS
The Task Force for the management of at r ial fibr illat ion of the
European Society of Cardiology (ESC)
Developed with the special contr ibut ion of the European Heart
Rhythm Associat ion (EHRA) of the ESC
Endorsed by the European Stroke Organisat ion (ESO)
Authors/Task Force Members: Paulus Kirchhof (Chairperson) (UK/Germany),*
Stefano Benussi*1 (Co-Chairperson) (Switzer land), Dipak Kotecha (UK),
Anders Ahlsson1 (Sweden), Dan Atar (Norway), Barbara Casadei (UK),
Manuel Castella1 (Spain), Hans-Chr istoph Diener2 (Germany), Hein Heidbuchel
(Belgium), Jeroen Hendr iks (The Nether lands), Gerhard Hindr icks (Germany),
Antonis S. Manolis (Greece), Jonas Oldgren (Sweden), Bogdan Alexandru Popescu
(Romania), Ulr ich Schot t en (The Nether lands), Bart Van Putte1 (The Nether lands),
and Panagiot is Vardas (Greece)
Document Reviewers: Stefan Agewall (CPG Review Co-ordinat or) (Norway), John Camm (CPG Review
Co-ordinator ) (UK), Gonzalo Baron Esquivias (Spain), W erner Budts (Belgium), Scipione Carer j (Italy),
Filip Casselman (Belgium ), Antonio Coca (Spain), Raffaele De Cater ina (Italy), Spir idon Deftereos (Greece),
Dobromir Dobrev (Germany), Jose M. Ferro (Portugal), Gerasimos Filippatos (Greece), Donna Fitzsimons (UK),
* Correspondingauthors: Paulus Kirchhof, Institute of Cardiovascular Sciences, University of Birmingham, SWBH and UHBNHStrusts, IBR, Room 136, Wolfson Drive, Birmingham
B15 2TT, United Kingdom, Tel: + 44 121 4147042, E-mail: [email protected]; Stefano Benussi, Department of Cardiovascular Surgery, University Hospital Zurich, Ramistrasse
100, 8091 Zurich, Switzerland, Tel: + 41(0)788933835, E-mail: [email protected] ing the European Associat ion for Cardio-Thoracic Surgery (EACTS)2Represent ing the European Stroke Associat ion (ESO)
ESC Committee for Pract ice Guidelines (CPG) and National Cardiac Societ ies Reviewers can be found in the Appendix.
ESC ent it ies having part icipated in the development of this document:
Associat ions: European Association for Cardiovascular Prevention and Rehabilitation (EACPR), European Association of Cardiovascular Imaging (EACVI), European Heart Rhythm
Association (EHRA), Heart Failure Association (HFA).
Councils: Council on Cardiovascular Nursing and Allied Professions, Council for Cardiology Practice, Council on Cardiovascular Primary Care, Council on Hypertension.
W orking Groups: Cardiac Cellular Electrophysiology, Cardiovascular Pharmacotherapy, Grown-up Congenital Heart Disease, Thrombosis, Valvular Heart Disease.
Thecontent of theseEuropean Society of Cardiology (ESC) Guidelineshasbeen published for personal and educational useonly.No commercial use isauthorized.No part of theESC
Guidelines may be translated or reproduced in any form without written permission from the ESC. Permission can be obtained upon submission of awritten request to Oxford Uni-
versity Press, the publisher of the European Heart Journal and the party authorized to handle such permissions on behalf of the ESC ([email protected]).
Disclaimer .The ESC Guidelines represent the viewsof the ESC and were produced after careful consideration of the scientific and medical knowledge and the evidence available at
the time of their publication. The ESC is not responsible in the event of any contradiction, discrepancy and/or ambiguity between the ESC Guidelines and any other official recom-
mendations or guidelines issued by the relevant public health authorities, in particular in relation to good use of healthcare or therapeutic strategies. Health professionals are encour-
aged to take the ESC Guidelines fully into account when exercising their clinical judgment, as well as in the determination and the implementation of preventive, diagnostic or
therapeutic medical strategies; however, the ESC Guidelines do not override, in any way whatsoever, the individual responsibility of health professionals to make appropriate and
accurate decisions in consideration of each patient’s health condition and in consultation with that patient and, where appropriate and/or necessary, the patient’s caregiver. Nor
do theESC Guidelinesexempt health professionals from takinginto full and careful consideration the relevant official updated recommendations or guidelines issued by thecompetent
public health authorities, in order to manage each patient’scase in light of the scientifically accepted datapursuant to their respective ethical and professional obligations. It isalso the
health professional’s responsibility to verify the applicable rules and regulations relating to drugs and medical devices at the time of prescription.
& The European Society of Cardiology 2016. All rights reserved. For permissions please email: [email protected].
doi:10.1093/europace/euw295
Europace (2016) 18, 1609–1678
by g
ue
st o
n N
ove
mb
er 2
7, 2
01
6D
ow
nlo
ad
ed
from
ESC GUIDELINES
2016 ESC Guidelines for the management of atrial
fibrillat ion developed in collaboration with EACTS
The Task Force for the management of at r ial fibr illat ion of the
European Society of Cardiology (ESC)
Developed with the special contr ibut ion of the European Heart
Rhythm Associat ion (EHRA) of the ESC
Endorsed by the European Stroke Organisat ion (ESO)
Authors/Task Force Members: Paulus Kirchhof (Chairperson) (UK/Germany),*
Stefano Benussi*1 (Co-Chairperson) (Switzer land), Dipak Kotecha (UK),
Anders Ahlsson1 (Sweden), Dan Atar (Norway), Barbara Casadei (UK),
Manuel Castella1 (Spain), Hans-Chr istoph Diener2 (Germany), Hein Heidbuchel
(Belgium), Jeroen Hendr iks (The Nether lands), Gerhard Hindr icks (Germany),
Antonis S. Manolis (Greece), Jonas Oldgren (Sweden), Bogdan Alexandru Popescu
(Romania), Ulr ich Schot t en (The Nether lands), Bart Van Putte1 (The Nether lands),
and Panagiot is Vardas (Greece)
Document Reviewers: Stefan Agewall (CPG Review Co-ordinat or) (Norway), John Camm (CPG Review
Co-ordinator ) (UK), Gonzalo Baron Esquivias (Spain), W erner Budts (Belgium), Scipione Carer j (Italy),
Filip Casselman (Belgium ), Antonio Coca (Spain), Raffaele De Cater ina (Italy), Spir idon Deftereos (Greece),
Dobromir Dobrev (Germany), Jose M. Ferro (Portugal), Gerasimos Filippatos (Greece), Donna Fitzsimons (UK),
* Correspondingauthors: Paulus Kirchhof, Institute of Cardiovascular Sciences, University of Birmingham, SWBH and UHBNHStrusts, IBR, Room 136, Wolfson Drive, Birmingham
B15 2TT, United Kingdom, Tel: + 44 121 4147042, E-mail: [email protected]; Stefano Benussi, Department of Cardiovascular Surgery, University Hospital Zurich, Ramistrasse
100, 8091 Zurich, Switzerland, Tel: + 41(0)788933835, E-mail: [email protected] ing the European Associat ion for Cardio-Thoracic Surgery (EACTS)2Represent ing the European Stroke Associat ion (ESO)
ESC Committee for Pract ice Guidelines (CPG) and National Cardiac Societ ies Reviewers can be found in the Appendix.
ESC ent it ies having part icipated in the development of this document:
Associat ions: European Association for Cardiovascular Prevention and Rehabilitation (EACPR), European Association of Cardiovascular Imaging (EACVI), European Heart Rhythm
Association (EHRA), Heart Failure Association (HFA).
Councils: Council on Cardiovascular Nursing and Allied Professions, Council for Cardiology Practice, Council on Cardiovascular Primary Care, Council on Hypertension.
W orking Groups: Cardiac Cellular Electrophysiology, Cardiovascular Pharmacotherapy, Grown-up Congenital Heart Disease, Thrombosis, Valvular Heart Disease.
Thecontent of theseEuropean Society of Cardiology (ESC) Guidelineshasbeen published for personal and educational useonly.No commercial use isauthorized.No part of theESC
Guidelines may be translated or reproduced in any form without written permission from the ESC. Permission can be obtained upon submission of awritten request to Oxford Uni-
versity Press, the publisher of the European Heart Journal and the party authorized to handle such permissions on behalf of the ESC ([email protected]).
Disclaimer .The ESC Guidelines represent the viewsof the ESC and were produced after careful consideration of the scientific and medical knowledge and the evidence available at
the time of their publication. The ESC is not responsible in the event of any contradiction, discrepancy and/or ambiguity between the ESC Guidelines and any other official recom-
mendations or guidelines issued by the relevant public health authorities, in particular in relation to good use of healthcare or therapeutic strategies. Health professionals are encour-
aged to take the ESC Guidelines fully into account when exercising their clinical judgment, as well as in the determination and the implementation of preventive, diagnostic or
therapeutic medical strategies; however, the ESC Guidelines do not override, in any way whatsoever, the individual responsibility of health professionals to make appropriate and
accurate decisions in consideration of each patient’s health condition and in consultation with that patient and, where appropriate and/or necessary, the patient’s caregiver. Nor
do theESC Guidelinesexempt health professionals from takinginto full and careful consideration the relevant official updated recommendations or guidelines issued by thecompetent
public health authorities, in order to manage each patient’scase in light of the scientifically accepted datapursuant to their respective ethical and professional obligations. It isalso the
health professional’s responsibility to verify the applicable rules and regulations relating to drugs and medical devices at the time of prescription.
& The European Society of Cardiology 2016. All rights reserved. For permissions please email: [email protected].
doi:10.1093/europace/euw295
Europace (2016) 18, 1609–1678
by g
ue
st o
n N
ove
mb
er 2
7, 2
01
6D
ow
nlo
ad
ed
from
ESC GUIDELINES
2016 ESC Guidelines for the management of atrial
fibrillat ion developed in collaboration with EACTS
The Task Force for the management of at r ial fibr illat ion of the
European Society of Cardiology (ESC)
Developed with the special contr ibut ion of the European Heart
Rhythm Associat ion (EHRA) of the ESC
Endorsed by the European Stroke Organisat ion (ESO)
Authors/Task Force Members: Paulus Kirchhof (Chairperson) (UK/Germany),*
Stefano Benussi*1 (Co-Chairperson) (Switzer land), Dipak Kotecha (UK),
Anders Ahlsson1 (Sweden), Dan Atar (Norway), Barbara Casadei (UK),
Manuel Castella1 (Spain), Hans-Chr istoph Diener2 (Germany), Hein Heidbuchel
(Belgium), Jeroen Hendr iks (The Nether lands), Gerhard Hindr icks (Germany),
Antonis S. Manolis (Greece), Jonas Oldgren (Sweden), Bogdan Alexandru Popescu
(Romania), Ulr ich Schot t en (The Nether lands), Bart Van Putte1 (The Nether lands),
and Panagiot is Vardas (Greece)
Document Reviewers: Stefan Agewall (CPG Review Co-ordinat or) (Norway), John Camm (CPG Review
Co-ordinator ) (UK), Gonzalo Baron Esquivias (Spain), W erner Budts (Belgium), Scipione Carer j (Italy),
Filip Casselman (Belgium ), Antonio Coca (Spain), Raffaele De Cater ina (Italy), Spir idon Deftereos (Greece),
Dobromir Dobrev (Germany), Jose M. Ferro (Portugal), Gerasimos Filippatos (Greece), Donna Fitzsimons (UK),
* Correspondingauthors: Paulus Kirchhof, Institute of Cardiovascular Sciences, University of Birmingham, SWBH and UHBNHStrusts, IBR, Room 136, Wolfson Drive, Birmingham
B15 2TT, United Kingdom, Tel: + 44 121 4147042, E-mail: [email protected]; Stefano Benussi, Department of Cardiovascular Surgery, University Hospital Zurich, Ramistrasse
100, 8091 Zurich, Switzerland, Tel: + 41(0)788933835, E-mail: [email protected] ing the European Associat ion for Cardio-Thoracic Surgery (EACTS)2Represent ing the European Stroke Associat ion (ESO)
ESC Committee for Pract ice Guidelines (CPG) and National Cardiac Societ ies Reviewers can be found in the Appendix.
ESC ent it ies having part icipated in the development of this document:
Associat ions: European Association for Cardiovascular Prevention and Rehabilitation (EACPR), European Association of Cardiovascular Imaging (EACVI), European Heart Rhythm
Association (EHRA), Heart Failure Association (HFA).
Councils: Council on Cardiovascular Nursing and Allied Professions, Council for Cardiology Practice, Council on Cardiovascular Primary Care, Council on Hypertension.
W orking Groups: Cardiac Cellular Electrophysiology, Cardiovascular Pharmacotherapy, Grown-up Congenital Heart Disease, Thrombosis, Valvular Heart Disease.
Thecontent of theseEuropean Society of Cardiology (ESC) Guidelineshasbeen published for personal and educational useonly.No commercial use isauthorized.No part of theESC
Guidelines may be translated or reproduced in any form without written permission from the ESC. Permission can be obtained upon submission of awritten request to Oxford Uni-
versity Press, the publisher of the European Heart Journal and the party authorized to handle such permissions on behalf of the ESC ([email protected]).
Disclaimer .The ESC Guidelines represent the viewsof the ESC and were produced after careful consideration of the scientific and medical knowledge and the evidence available at
the time of their publication. The ESC is not responsible in the event of any contradiction, discrepancy and/or ambiguity between the ESC Guidelines and any other official recom-
mendations or guidelines issued by the relevant public health authorities, in particular in relation to good use of healthcare or therapeutic strategies. Health professionals are encour-
aged to take the ESC Guidelines fully into account when exercising their clinical judgment, as well as in the determination and the implementation of preventive, diagnostic or
therapeutic medical strategies; however, the ESC Guidelines do not override, in any way whatsoever, the individual responsibility of health professionals to make appropriate and
accurate decisions in consideration of each patient’s health condition and in consultation with that patient and, where appropriate and/or necessary, the patient’s caregiver. Nor
do theESC Guidelinesexempt health professionals from takinginto full and careful consideration the relevant official updated recommendations or guidelines issued by thecompetent
public health authorities, in order to manage each patient’scase in light of the scientifically accepted datapursuant to their respective ethical and professional obligations. It isalso the
health professional’s responsibility to verify the applicable rules and regulations relating to drugs and medical devices at the time of prescription.
& The European Society of Cardiology 2016. All rights reserved. For permissions please email: [email protected].
doi:10.1093/europace/euw295
Europace (2016) 18, 1609–1678
by g
ue
st o
n N
ove
mb
er 2
7, 2
01
6D
ow
nlo
ad
ed
from
Messages (1)
• Level of knowledge/ stength of
recommandations
– Medical AF> POAF cardiac surgery > POAF
thoracic (non cardiac) surgery > POAF other
surgeries> AF in ICU patients
• Present day extrapolations from cardiac
surgery not always warranted +++++
– Especially anticoagulation of transient POAF
(risk scores for TE/Bleeding)
Messages (2)
• As compared to widespread practice:
– HR control and return to SR are different
goals with different drug strategies
– Do not forget/underestimate the toxicity of
amiodarone
• Contra-indicated in patients who underwent
pneumonectomy/other severe lung lesions ?
• Continue anti-arhythmia therapy for 1
month
Messages (3)
• The most difficult part concerns the
indications/duration of anticoagulation
– Risks of TE/Bleeding extrapolated from the
medical literature
– When to start anticoagulation ?
– Choice of anticoagulants/doses
– Duration: 1 month after return to SR
• Cardiac surgery
• Non-cardiac surgery
Messages (end)
• The complexity of managing POAF is such
that it renders the “Heart Team” necessary
– Prophylaxis, treatment
• Anticoagulation ?
• Multidisciplinary decisions
– Including the surgeon and the patient (if
possible)
• Well traced in the medical record with
information provided to the family/patient
Ann Thorac Surg 2011;92:421–7
Ann Thorac Surg 2011;92:421–7
European Heart Journal doi:10.1093/eurheartj/ehu282
Thank you for your attention
AND DO NOT FORGET:
>> Register now <<
Abstract Submissions:
1 November – 15 December 2016
www.esahq.org