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Important Changes for Practicing Physicians in the Focused Atrial Fibrillation Guideline Update

Originally publishedhttps://doi.org/10.1161/CIRCULATIONAHA.118.038300Circulation. 2020;142:2399–2401

The 2018 American Heart Association/American College of Cardiology/Heart Rhythm Society atrial fibrillation (AF) guideline is a focused update of the 2014 guideline regarding the same topic.1,2 Additions and clarifications to the prior guideline include revised recommendations regarding the use of novel oral anticoagulants (NOACs) in patients with AF and valvular heart disease; the relative benefits of NOACs over warfarin; the role of sex in determining stroke risk; the indications for AF ablation in heart failure; and the management of patients with AF and coronary disease (Table).

Table. 2014 AF Guideline Recommendations Revised and Updated in 2018

2014 Guideline (Class of Recommendation)2018 Guideline (Class of Recommendation)Comment
With prior stroke, TIA, or CHA2DS2-VASc score ≥2, oral anticoagulants are recommended (I)For patients with AF with an elevated CHA2DS2-VASc score of ≥2 in men or ≥3 in women, oral anticoagulants are recommended (I)Female sex now a modifier
NOACs (dabigatran, rivaroxaban, apixaban, and edoxaban) are recommended over warfarin in NOAC-eligible patients with AF (except with moderate to severe mitral stenosis or a mechanical heart valve) (I)New recommendation; in 2014, no preference to warfarin or NOACs; a narrower definition of what constitutes valve disease is new
With CHA2DS2-VASc score ≥2 and end-stage CKD (CrCl <15 mL/min) or on hemodialysis, it is reasonable to prescribe warfarin for oral anticoagulation (IIa)For patients with AF who have a CHA2DS2-VASc score of ≥2 in men or ≥3 in women, and who have end-stage CKD (CrCl <15 mL/min) or are on dialysis, it is reasonable to prescribe warfarin (INR, 2.0–3.0) or apixaban for oral anticoagulation (IIa)Apixaban now recommended also in end-stage renal disease
With nonvalvular AF and a CHA2DS2-VASc score of 1, no antithrombotic therapy or treatment with an oral anticoagulant or aspirin may be considered (IIb)For patients with AF (except with moderate to severe mitral stenosis or a mechanical heart valve) and a CHA2DS2-VASc score of 1 in men and 2 in women, prescribing an oral anticoagulant to reduce thromboembolic stroke risk may be considered (IIb)Aspirin is no longer recommended
Percutaneous left atrial appendage occlusion may be considered in patients with AF at increased risk of stroke who have contraindications to long-term anticoagulation (IIb)New recommendation
AF catheter ablation may be reasonable in selected patients with symptomatic AF and heart failure with reduced LV ejection fraction to potentially lower mortality and reduce heart failure hospitalization (IIb)New recommendation. Previous recommendations recommended ablation only for reduction of symptoms
Following coronary revascularization in patients with CHA2DS2-VASc score of ≥2, it may be reasonable to use clopidogrel concurrently with oral anticoagulants, but without aspirin (IIb)If triple therapy (oral anticoagulant, aspirin and P2Y12 inhibitor) is prescribed for patients with AF at increased risk of stroke based on CHA2DS2-VASc risk assessment of ≥2 who have undergone PCI with stenting for ACS, it is reasonable to choose clopidogrel in preference to prasugrel (IIa).Clarification of the use of triple therapy to include only clopidogrel and not prasugrel; now a class IIa rather than a class IIb
Following coronary revascularization in patients with CHA2DS2-VASc score of ≥2, it may be reasonable to use clopidogrel concurrently with oral anticoagulants, but without aspirin (IIb)In patients with AF at increased risk of stroke based on a CHA2DS2-VASc risk assessment of ≥2 who have undergone PCI with stenting for ACS, double therapy with a P2Y12 inhibitor (clopidogrel or ticagrelor) and dose-adjusted vitamin K antagonist is reasonable to reduce the risk of bleeding in comparison with triple therapy (IIa)Stronger statement regarding preference of dual therapy in comparison with triple therapy
In patients with AF at increased risk of stroke based on CHA2DS2-VASc risk assessment of ≥2 who have undergone PCI with stenting for ACS, double therapy with clopidogrel and low-dose rivaroxaban (15 mg daily) is reasonable to reduce the risk of bleeding in comparison with triple therapy (IIa)Now rivaroxaban allowed; in 2014, only warfarin was allowed
In patients with AF at increased risk of stroke based on CHA2DS2-VASc risk assessment of ≥2 who have undergone PCI with stenting for ACS, double therapy with a P2Y12 inhibitor (clopidogrel) and dabigatran 150 mg twice daily is reasonable to reduce the risk of bleeding in comparison with triple therapy (IIa).Now dabigatran allowed; in 2014, only warfarin was allowed
If triple therapy (oral anticoagulant, aspirin, and P2Y12 inhibitor) is prescribed for patients with AF who are at increased risk of stroke based on CHA2DS2-VASc risk assessment of ≥2 and who have undergone PCI with stenting (drug eluting or bare metal) for ACS, a transition to double therapy (oral anticoagulant and P2Y12 inhibitor) at 4–6 weeks may be considered (IIb).New recommendation

ACS indicates acute coronary syndrome; AF, atrial fibrillation; CKD, chronic kidney disease; CrCl, creatinine clearance; INR, international normalized ratio; LV, left ventricular; NOAC, novel oral anticoagulant; PCI, percutaneous coronary intervention; and TIA, transient ischemic attack.

In the 2014 guideline, valvular heart disease was defined as rheumatic mitral stenosis, a mechanical or bioprosthetic heart valve, or mitral valve repair. In patients with these valvular conditions that presented with AF, only warfarin was recommended for anticoagulation. In the current guideline, valvular conditions requiring warfarin for AF anticoagulation are more narrowly defined as moderate to severe mitral stenosis and mechanical valves. For patients with other valve lesions and those with bioprosthetic valves, anticoagulation with either warfarin or NOACs is now appropriate.

NOACs are now favored over warfarin for patients with nonvalvular AF. This differs from the previous guidelines in which no preference for warfarin or NOACs was given as the initial agent for anticoagulation.

In the new guideline, men or women without another risk factor for stroke are not recommended for anticoagulation. The guideline suggests that female sex should be considered a risk modifier rather than a risk factor for stroke in patients with AF. The revised guideline stipulates that female sex does not equate with a CHA2DS2-VASc score of 1. The guideline recommends that, for men with a CHA2DS2-VASc score of 2 and women with a CHA2DS2-VASc score of 3, anticoagulation is strongly recommended (class I). For men with a CHA2DS2-VASc score of 1 and women with a score of 2, anticoagulation may be reasonable (class IIb). This weaker recommendation is in contrast to the recent guideline from the American Association of Chest Physicians published in Chest that more strongly recommends stroke prevention in this patient population.3 Given the improved safety and efficacy of the NOACs, I support the more liberal treatment recommendations from the American Association of Chest Physicians, for those patients in whom a NOAC is an option. It is important to note that aspirin is no longer recommended as an alternative agent for stroke prophylaxis in AF.

The guideline extends and clarifies the use of NOACs in patients with AF and renal disease. Warfarin or apixaban is considered useful (IIa) for those with end-stage renal disease (hemodialysis or creatinine clearance <15 mL/min) in patients with AF at risk of stroke. For patients with a creatinine clearance of 15 to 30 mL/min, warfarin or NOACs at reduced dosages may be useful (IIb). Although data on the efficacy of apixaban in patients on hemodialysis are limited, I do think these recommendations are reasonable.

In the 2014 guideline, surgical left atrial appendage occlusion was only recommended in patients undergoing cardiac surgery. In 2018, this indication has been expanded to now include percutaneous left atrial appendage occlusion with the Watchman device (Boston Scientific). However, the Watchman device is only given a class IIb recommendation and only for those who have contraindications to long-term oral anticoagulation.

Also discussed is a new treatment recommendation for catheter ablation in patients with symptomatic AF and heart failure with reduced ejection fraction. This new guideline provides a limited class IIb recommendation for ablation in these patients. Two recent randomized clinical trials demonstrated reduced mortality with AF ablation in patients with AF and heart failure with reduced ejection fraction.4,5 The weakness of this recommendation may have been informed by the as-yet-unpublished CABANA trial (Catheter Ablation vs Anti-arrhythmic Drug Therapy for Atrial Fibrillation Trial) results that did not demonstrate a reduction in mortality with AF ablation in patients with or without heart failure. As it stands currently, the only strong recommendation for catheter ablation in patients with AF is for the reduction of symptoms.

In 2014, patients with coronary artery disease and AF with increased risk of thromboembolism received a class I recommendation for anticoagulation with warfarin; however, in the current guideline, NOACs are also recommended. There are important new clarifications to anticoagulation of patients with AF who have concomitant coronary disease. If triple therapy (warfarin or NOAC, aspirin, and P2Y12 inhibitor) is needed, clopidogrel is preferable to prasugrel or ticagrelor (IIa). Double therapy with either full-dose warfarin, rivaroxaban 15 mg once a day, or dabigatran 150 mg twice a day, plus a P2Y12 inhibitor (and no aspirin) is recommended for those with a percutaneous coronary intervention with stenting for acute coronary syndrome (class IIa). It should be acknowledged that the 15 mg versus 20 mg dose of rivaroxaban has not been shown to reduce the risk of thromboembolism in those with normal renal function. For patients receiving triple therapy, the panel recommended transition from triple therapy to dual therapy at 4 to 6 weeks (class IIb).

The new guideline provides little guidance on whether to anticoagulate patients who have AF incidentally detected by a device (eg, implantable cardioverter-defibrillator or pacemaker). They recommend that, in these circumstances, the patient should receive further evaluation. Although there are currently no clear data on the lower threshold duration of device-detected AF that increases thrombotic risk, nearly all observational data demonstrate that durations of AF over 24 hours increase the risk of stroke. The American Society of Chest Physicians did recommend that patients with incidentally discovered AF >24 hours and appropriate CHA2DS2-VASc score should be anticoagulated.3

There are a few differences between this guideline and the recently published guideline by the American Society of Chest Physicians, but their similarities stand out, including recommending NOACs over warfarin, keeping the 48-hour duration of AF as an indication for anticoagulation before cardioversion, and minimizing the use of triple therapy in coronary disease. Future recommendations regarding anticoagulation in the case of AF in patients with coronary disease and selection of patients for ablation await further randomized clinical trials, both ongoing and planned.

Footnotes

The opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.

https://www.ahajournals.org/journal/circ

Mark S. Link, MD, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390. Email

References

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