Co-Chairs, Sean Pokorney, MD, MBA, and Emily P. Zeitler, MD, MHS, FACC, FHRS, prepared useful Practice Aids pertaining to nonvalvular atrial fibrillation for this CME/MOC/NCPD/CPE activity titled “Critical Conversations on Atrial Fibrillation: A MasterClass Series.” For the full presentation, downloadable Practice Aids, and complete CME/MOC/NCPD/CPE information, and to apply for credit, please visit us at https://bit.ly/3us6D2T. CME/MOC/NCPD/CPE credit will be available until April 3, 2024.

1. Current Review of Atrial Fibrillation
Diagnosis and Management
Full abbreviations, accreditation, and disclosure information available at PeerView.com/WQZ40
a
Rate control may reduce symptoms by slowing the ventricular rate during recurrent AF. b
In selected patients. c
An association between dyslipidemia and AF was found in a post hoc analysis of ARISTOTLE.2 d
Observational studies have found an association between glycated A1C and
AF risk, and DM contributes one point to the CHA2
DS2
-VASc score; an A1C <7% was associated with lower risk of AF recurrence post ablation.3,4 e
Free thyroxine at the upper end of the normal reference range was associated with increased risk of AF in a large retrospective study.5
1. Michaud GF, Stevenson WG. N Engl J Med. 2021:384:353-361. 2. Pol T et al. J Am Heart Assoc. 2018;7:e007444. 3. Zhao H et al. PLoS One. 2020;15:e0227262. 4. Donnellan E et al. JACC Clin Electrophysiol. 2019;5:897-903. 5. Anderson JL et al. J Cardiovasc Electrophysiol. 2020;31:18-29.
Care Pathway1
Management
Diagnosis
Rate Control
During AF
Stroke Prevention
Treatment
of Risk Factors
Long-Term Strategy for
Reducing Symptomsa
Maintain sinus rhythm
Hypertension
Diabetes mellitusd
Obesity
Sleep apnea,
hyperthyroidisme
Excessive alcohol use
Hyperlipidemiac
Digoxin
AV junction ablation
plus pacemakerb
Verapamil, diltiazem
Echocardiography
Sleep studyb
Thyroid function and other
laboratory evaluations
ECG
Anticoagulation
Occlusion or resection
of atrial appendageb
Antiarrhythmic
medications
Catheter ablation
Surgical ablation
or
Manage continued AF
if rhythm control
is not a goala
Beta blockers
History and physical
examination

2. Anticoagulation Strategies for Preventing Stroke and
Systemic Embolism in Atrial Fibrillation1
Full abbreviations, accreditation, and disclosure information available at PeerView.com/WQZ40
a
The 2020 ACC/AHA VHD guidelines now recommend DOACs for selected patients with VHD, including native, nonrheumatic valvular disease, contingent on CHA2
DS2
-VASc score, and bioprosthetic valves, contingent on CHA2
DS2
-VASc score and time of AF onset.
1. https://thrombosis.org/wp-content/uploads/2021/09/NATF-ACC-Patients-Sept-2021.pdf. 2. https://www.accessdata.fda.gov/scripts/cder/daf/. 3. Otto CM et al. Circulation. 2021;143:e72-e227
Dosing frequency Once daily Twice daily Once daily
Onset
Slow
Several days
Fast
A few hours
Fast
A few hours
Fast
A few hours
Fast
A few hours
Kidney function No
Yes
Kidney function affects the dosage
Yes
Kidney function affects the dosage
Yes
Kidney function affects the dosage
Yes
Kidney function affects the dosage
Food effect
Yes
Diets high in vitamin K
necessitate higher doses
No
Yes
Rivaroxaban should be taken with
evening meal or largest meal of the day
No No
Drug interactions Many Few Few Few Few
Routine lab
monitoring
Yes No No No No
Reversal agents
Yes
Vitamin K, fresh frozen plasma,
prothrombin complex concentrates
Yes
Idarucizumab
Yes
Andexanet alfa
Yes
Andexanet alfa
Soon
May use prothrombin complex
concentrates in emergencies
Once daily Twice daily
Warfarin
(Coumadin)
Dabigatran
(Pradaxa)
Rivaroxaban
(Xarelto)
Apixaban
(Eliquis)
Edoxaban
(Savaysa)
Generic Yes No No No No
FDA approval
for NVAF
Before 1982
Warfarin was first used in humans in
1954, before the FDA regulated drugs
October 2010 July 2011 December 2012 January 2015
Populations2,3,a NVAF, VHD, mechanical
valve implants
NVAF, selected VHD NVAF, selected VHD NVAF, selected VHD NVAF, selected VHD
Drug image
Available strengths Variable
75-mg, 110-mg,
or 150-mg capsule
2.5-mg, 10-mg, 15-mg,
or 20-mg tablet
5-mg or 2.5-mg tablet
15-mg, 30-mg,
or 60-mg tablet
For complete information about these medications, please refer to each medication's prescribing information.

3. Stroke and Bleeding Outcomes in NVAF
Using OACs: Clinical Trial Data vs Real-World Evidencea
Full abbreviations, accreditation, and disclosure information available at PeerView.com/WQZ40
a
Scores reported as means. All data reported as mean event rates (% per year), rounded to 1 decimal place. All comparisons are for the named agent vs warfarin.
b
ARISTOTLE: N = 18,201; RE-LY: N = 18,113; ROCKET AF: N = 14,264. c
Aged ≥80 years. d
Sum of all patients included in the propensity-matched groups.
1. Granger CB et al. N Engl J Med. 2011;365:981-992. 2. Connolly SJ et al. N Engl J Med. 2009;361:1139-1151. 3. Patel MR et al. N Engl J Med. 2011;365:883-891. 4. Lip GYH et al. Stroke. 2018;49:2933-2944. 5. Deitelzweig S et al. J Clin Med. 2020;9:1633.
6. Deitelzweig S et al. JACC CardioOncol. 2021;3:411-424. 7. Lip GYH et al. J Intern Med. 2021;289:42-52. 8. Deitelzweig S et al. J Am Geriatr Soc. 2019;67:1662-1671. 9. Deitelzweig S et al. Circulation. 2018;138:A14898. 10. Deitelzweig S et al. Eur J Intern Med. 2023;108:37-42.
RCTs1-3 ARISTOPHANES4-9
Pooledb
(N = 50,578)
Overall
(N = 434,046)
Active Cancer
(n = 40,271)
Very Oldc
(n = 103,525)
Diabetes
(n = ~59,345d
)
Older Frail
(n = 150,487)
Severe Obesity
(n = 34,942)
• Trend toward increasing stroke and bleeding risk going from healthier patients in the RCT patients to older, frail patients1-9
• Consistently lower stroke risks with DOACs than warfarin1-9
• DOACs always delayed stroke events; apixaban and dabigatran always delayed bleeding, relative to warfarin10
CHA2
DS2
-VASc – 2.1-3.5 3.5-3.9 3.9-4.1 4.7-4.8 NR 5.1-5.2
3.6-3.9
1.3 1.3 1.5 1.8 1.9 2.2
1.3
2.1 3.6 6.0 5.0 4.8 6.1
4.6
1.1 1.4 1.9 2.2 1.9 2.6
1.5
3.1 3.6 5.6 6.3 4.7 7.1
5.7
2.1 1.5 1.8 2.2 2.0 2.5
1.3
3.6 5.8 8.6 8.5 7.2 10.2
8.3
1.6-2.4 1.7-1.9 2.2-2.4 2.9-3.0 2.3-2.5 3.1
1.6-1.9
3.1-3.4 5.1-5.6 7.4-9.4 6.9-7.8 6.2-8.1 8.9-9.0
7.4-7.8
Stroke/SE
Apixaban
Dabigatran
Rivaroxaban
Warfarin
Apixaban
Dabigatran
Rivaroxaban
Warfarin
Major
bleeding