Management of Atrial Fibrillation: 2014 Guidelines

Target Population: Cardiologists, internal medicine practitioners, emergency medicine personnel

Background and Objective

This document is a thorough revision intended to replace the previous guidelines from the sponsoring organizations (published in 2006 and updated in 2011).

Key Points

—The selection of long-term antithrombotic therapy should be guided by the patient's risk for thromboembolism, regardless of (1) whether the pattern of atrial fibrillation (AF) is paroxysmal, persistent, or permanent; or (2) the duration of AF (Class I).

—Patients with nonvalvular AF and a CHA₂DS₂-VASc score ≥2 should receive oral anticoagulation with warfarin, dabigatran, rivaroxaban, or apixaban (Class I). Modified dosages of some of the newer anticoagulants can be considered in patients with non–end-stage chronic kidney disease, depending on the severity of renal dysfunction (Class IIb; Table 1).

—In patients with nonvalvular AF and a CHA₂DS₂-VASc score ≥2 who undergo coronary revascularization (percutaneous or surgical), antiplatelet therapy with clopidogrel (75 mg once daily) but without aspirin may be a reasonable adjunct to oral anticoagulation (Class IIb).

—The following drugs are recommended to maintain sinus rhythm in patients with AF:

• Dofetilide

• Dronedarone

• Flecainide

• Propafenone

• Sotalol

• Amiodarone

Drug selection should depend on underlying heart disease and comorbidities (Table 2); however, owing to its potential toxicities, amiodarone should be used only when other agents have failed or are contraindicated and after thorough risk assessment (Class I).

—Catheter ablation is recommended in patients with symptomatic paroxysmal AF who are unresponsive or intolerant to ≥1 class I or III antiarrhythmic medication (Class I) and may be considered as an initial rhythm-control strategy in those with recurrent AF who have undergone a thorough assessment of the risks and outcomes of drug and ablation therapy (Class IIa).

—Catheter ablation is reasonable in selected patients with symptomatic persistent AF who are unresponsive or intolerant to ≥1 class I or III antiarrhythmic medication (Class IIa).

—AF catheter ablation to restore sinus rhythm should not be performed solely to obviate the need for anticoagulation (Class III).

What's Changed

The following are important additions, changes, and shifts in emphasis from previous guidelines:

• Anticoagulation based on thrombotic risk, irrespective of AF pattern

• Failure to support the common practice of allowing 48 hours of AF before considering long-term anticoagulation.

• Move from CHADS₂ to CHA₂DS₂-VASc for risk assessment

• New oral anticoagulants placed on at least an equal footing with warfarin (The authors comment that “all 3 new oral anticoagulants represent important advances over warfarin because they have more predictable pharmacological profiles, fewer drug–drug interactions, an absence of major dietary effects, and less risk of intracranial bleeding than warfarin.”)

• Consideration of clopidogrel and an anticoagulant without aspirin after coronary reperfusion

• Stronger recommendations for — and cautions about — AF catheter ablation