Atrial Fibrillation Guidelines Across the Atlantic: A Comparison of the Current Recommendations of the European Society of Cardiology/European Heart Rhythm Association/European Association of Cardiothoracic Surgeons, the American College of Cardiology Foundation/American Heart Association/Heart Rhythm Society, and the Canadian Cardiovascular Society

Study Questions:

What are differences in contemporary atrial fibrillation guidelines published by the European Society of Cardiology (ESC), Canadian Cardiovascular Society (CCS), and American College of Cardiology Foundation (ACCF)/American Heart Association (AHA)/Heart Rhythm Society (HRS)?

Methods:

This was a systematic review in which all published recommendations were classified as either identical/overlapping or differing.

Results:

Most recommendations are either identical or overlap between all three sets of guidelines. There are differences, with respect to how structural heart disease is defined, when determining the appropriateness of antiarrhythmic drug therapy. The CCS guidelines only consider heart failure or an ejection fraction <35% as structural heart disease. The recommendations differ slightly in their intensity and the level of intensity to recommend catheter ablation as an alternative to antiarrhythmic drug therapy. The ESC guidelines indicate ablation as first-line therapy in appropriately selected patients with paroxysmal atrial fibrillation with no or minimal heart disease (including left ventricular hypertrophy with preserved left ventricular function). There are differences regarding the dosing of dabigatran, closely linked to national regulatory influences. There are differences in the acceptability of dronedarone in patients with heart failure (with European guidelines reflecting the European Medicines Agency revised label of this medication, which excludes its use in heart failure) and the need for monitoring of liver function.

Conclusions:

There is consensus across national guidelines for the contemporary evaluation and management of atrial fibrillation, with differences on how structural heart disease is defined, the indication for catheter ablation for first-line therapy in appropriately selected patients, dosing of dabigatran, and acceptability of dronedarone in heart failure and need for monitoring of liver function with this antiarrhythmic therapy.

Perspective:

This systematic review of three international updated guidelines for the management of atrial fibrillation indicates general consensus based on the solid evidence-base supporting the recommendations. The subtle differences are likely based on regional variations in the practice of medicine, national differences in expert consensus used to fill evidence gaps, and the potential influence of regulatory approval (which warrants further exploration and justification).

Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Heart Failure and Cardiomyopathies, EP Basic Science, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Novel Agents, Acute Heart Failure

Keywords: Electric Countershock, Canada, Consensus, beta-Alanine, Benzimidazoles, Heart Failure, Liver, Ventricular Function, Hypertrophy, Catheter Ablation, Atrial Flutter


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