2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society

Perspective:

The following are 10 points to remember about the 2014 guideline for the management of patients with nonvalvular atrial fibrillation (AF):

1. In assessing risk of stroke in a patient with nonvalvular AF, the writing committee recommends (Class I) the usage of the CHA2DS2-VASc (C=congestive heart failure; H=hypertension; A2=age ≥75 years [doubled]; D=diabetes mellitus; S2=stroke, transient ischemic attack, or thromboembolism [doubled]; V=vascular disease; A=age 65-74 years; Sc=sex category, i.e., female gender) score, as opposed to the CHADS2 score.

2. For nonvalvular AF patients with a history of stroke or transient ischemic attack, or a CHA2DS2-VASc score ≥2, oral anticoagulation is recommended (Class I). Options for oral anticoagulation include warfarin, dabigatran, rivaroxaban, and apixaban.

3. For patients with nonvalvular AF and a CHA2DS2-VASc score of 0, it is reasonable to omit antithrombotic therapy (Class IIa).

4. The following options may be considered with a patient with nonvalvular AF and a CHA2DS2-VASc score of 1: no antithrombotic therapy, oral anticoagulation, or aspirin (Class IIb).

5. None of the novel oral anticoagulants (dabigatran, rivaroxaban, or apixaban) are recommended to be used in patients with AF and a mechanical or bioprosthetic heart valve (Class III harm).

6. As in the earlier guidelines, the committee recommends against the use of certain antiarrhythmic medications (flecainide, propafenone, dofetilide, and sotalol) in patients with severe left ventricular hypertrophy (LVH). In the current guidelines, severe LVH is now defined as wall thickness exceeding 1.5 cm.

7. Oral anticoagulation should be prescribed to patients with hypertrophic cardiomyopathy and AF irrespective of the CHA2DS2-VASc score (Class I).

8. A randomized trial suggested that a lenient (<110 bpm) rate control strategy was as effective as a strict strategy (<80 bpm) in patients with persistent/permanent AF. However, the writing committee still advocates for the latter (Class IIa), as the results of this single trial were not thought to be definitive.

9. Catheter ablation is useful in patients with symptomatic, paroxysmal AF who have not responded to or tolerated antiarrhythmic medications (Class I).

10. Catheter ablation is also reasonable in selected patients with symptomatic, paroxysmal AF prior to a trial of medical therapy, provided that it can be performed at an experienced center (Class IIa).

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

Keywords: Hypertrophy, Left Ventricular, Ischemic Attack, Transient, Morpholines, Cardiomyopathy, Hypertrophic, Thiophenes, Warfarin, Phenethylamines, Fibrinolytic Agents, Thromboembolism, beta-Alanine, Benzimidazoles, Patient Selection, Flecainide, Pyridones, Heart Valves, Hypertension, Sulfonamides, Stroke, Electric Countershock, Pyrazoles, Blood Coagulation, Heart Failure, Propafenone, Sotalol, Catheter Ablation, Diabetes Mellitus


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