New ACC/AHA/HRS Guideline Addresses Management of Patients With AFib

The ACC, American Heart Association and the Heart Rhythm Society, in collaboration with the Society of Thoracic Surgery, have released a new 2014 Guideline for the Management of Patients With Atrial Fibrillation (AFib)  that incorporates new and existing knowledge derived from published clinical trials, basic science, and comprehensive review articles, along with evolving treatment strategies and new drugs.

The guideline, which supersedes the "2006 ACC/AHA/ESC Guideline for the Management of Patients With Atrial Fibrillation" and two subsequent focused updates from 2011, contains the most updated consensus of clinicians with broad expertise related to AFib and its treatment, including adult cardiology, electrophysiology, cardiothoracic surgery, and heart failure.

According to Writing Committee Chair Craig T. January, MD, PhD, the document contains four new significant recommendations. Specifically, the guideline calls for increased use of radio frequency ablation in the treatment of non-valvular atrial AFib, the addition of three new anticoagulants to treatment options, a diminished role in the use of aspirin, and a more comprehensive thromboembolic risk calculator called the CHA2DS2-VASc calculator.

In the previous guideline, treatment protocols called for clinicians to prescribe aspirin to patients with AFib who had a low stroke risk, said January. However, he noted that data showing that aspirin decreases stroke risk "is weak." Previous treatment protocols also only recommended warfarin (Coumadin) as an anticoagulant for use in treating non-valvular AFib. The new guideline now includes recommendations for using dabigatran, rivaroxaban and apixaban – three new anticoagulants that have entered the marketplace within the last two years. The guideline also calls for a greater understanding of rate verses rhythm control treatment strategies in managing AFib.

Given the increasing incidence of AFib in an aging population, the connection of AFib to increased hospitalization, and the close association of AFib with other forms of cardiovascular disease, including hypertension, coronary artery disease and heart failure, January notes that this new guideline is important for physicians and other members of the cardiovascular care team. To that end, he said the Writing Committee worked diligently to ensure that the data, tables, and figures were clear and easy to use. "The goal was to have a document that is useful to the practicing physician and makes sense," he said.

Moving forward, the guideline calls for additional studies to better inform clinicians as to the risks and benefits of therapeutic options for an individual patient, as well as continued research into the mechanisms that initiate and sustain AFib. Other recommendations include the need for new pharmacologic therapies, including antiarrhythmic drugs that have atrial selectivity and drugs that target fibrosis, and continued research into new anticoagulants. "Great promise lies in prevention," the document notes. "Future strategies for reversing the growing epidemic of AFib will come from basic science and genetic, epidemiologic, and clinical studies."

Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Novel Agents

Keywords: Writing, Coronary Artery Disease, Stroke, Morpholines, Warfarin, Pyrazoles, Thoracic Surgery, Electrophysiology, beta-Alanine, Benzimidazoles, Risk Assessment, Pyridones, Hospitalization


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