Focused Update of the AHA/ACC/HRS Atrial Fibrillation Guideline

January CT, Wann LS, Calkins H, et al.
2019 AHA/ACC/HRS Focused Update of the 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 Clinical Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol 2019;Jan 28:[Epub ahead of print].

The following are key points to remember from this Focused Update of the 2014 American Heart Association/American College of Cardiology/Heart Rhythm Society (AHA/ACC/HRS) Guideline for the Management of Patients With Atrial Fibrillation (AF):

  1. Edoxaban has been added to the list of nonvitamin K oral anticoagulants (NOACs [apixaban, dabigatran, and rivaroxaban]) that can be used for stroke prevention (Class of Recommendation [COR] I, Level of Evidence [LOE] B-R).
  2. NOACs are recommended over warfarin except in patients with moderate to severe mitral stenosis or a prosthetic heart valve (COR I, LOE A).
  3. The decision to use an anticoagulant should not be influenced by whether the AF is paroxysmal or persistent (COR I, LOE B).
  4. Renal and hepatic function should be tested before initiation of a NOAC and at least annually thereafter (COR I, LOE B-NR).
  5. In AF patients with a CHA2DS2-VASc score ≥2 in men or ≥3 in women and a creatinine clearance <15 ml/min or who are on dialysis, it is reasonable to use warfarin or apixaban for oral anticoagulation (COR IIb, LOE B-NR).
  6. Idarucizumab is recommended for the reversal of dabigatran in the event of a life-threatening bleed or urgent procedure (COR I, LOE B-NR).
  7. Andexanet alfa (recombinant factor Xa) can be useful for the reversal of rivaroxaban and apixaban in the event of life-threatening bleeding (COR IIa, LOE B-NR).
  8. Percutaneous left atrial appendage occlusion may be considered for at-risk AF patients with AF at increased risk of stroke who have contraindications to long-term anticoagulation (COR IIb, LOE B-NR).
  9. AF catheter ablation may be reasonable in symptomatic patients with heart failure and a reduced ejection fraction to reduce mortality and heart failure hospitalizations (COR IIb, B-R).
  10. In at-risk AF patients who have undergone coronary artery stenting, double therapy with clopidogrel and low-dose rivaroxaban (15 mg daily) or dabigatran (150 twice daily) is reasonable to reduce the risk of bleeding as compared to triple therapy (COR IIa, B-R).
  11. Weight loss combined with risk factor modification is recommended for overweight and obese patients with AF (COR I, LOE B-R).
  12. In patients with cryptogenic stroke in whom external ambulatory monitoring is inconclusive, implantation of a cardiac monitor is reasonable for detection of subclinical AF (COR IIa, B-R).

Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Prevention, Valvular Heart Disease, Anticoagulation Management and Atrial Fibrillation, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Novel Agents, Acute Heart Failure, Interventions and Structural Heart Disease

Keywords: Antibodies, Monoclonal, Humanized, Anticoagulants, Arrhythmias, Cardiac, Atrial Fibrillation, Atrial Appendage, Catheter Ablation, Heart Failure, Heart Valve Diseases, Hemorrhage, Mitral Valve Stenosis, Monitoring, Ambulatory, Obesity, Overweight, Renal Dialysis, Risk Factors, Secondary Prevention, Stents, Stroke, Stroke Volume, Warfarin, Weight Loss

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