This document provides a summary of the CCS AF guidelines from 2010 to present. It includes diagnostic and treatment recommendations for atrial fibrillation management. The recommendations are intended to provide a practical clinical approach but are not a substitute for clinical judgment. Adherence to the guidelines will not necessarily produce successful outcomes in every case.
Atrial fibrillation is characterized by an irregular heartbeat and is classified as paroxysmal, persistent, or permanent based on duration. It is associated with risks like stroke and is diagnosed by ECG showing irregular rhythms. Treatment involves rate control with medications, anticoagulation based on stroke risk scores, and catheter ablation or antiarrhythmic drugs for rhythm control.
1. Atrial fibrillation (AF) is a common arrhythmia where abnormal electrical signals in the atria cause an irregular heartbeat.
2. AF increases the risk of stroke by 5 times and is associated with increased mortality, hospitalization, and decreased quality of life.
3. Management involves rate or rhythm control as well as anticoagulation to prevent stroke, with treatment depending on factors like symptoms, age, and stroke risk level.
This document provides guidelines for the classification and management of atrial fibrillation (AF). It discusses the introduction, classification, mechanisms, causes and features of AF. The diagnostic evaluation and management guidelines cover rate control versus rhythm control strategies, pharmacological and electrical cardioversion options, and drugs used for rate and rhythm control. The goals are to control the heart rate, prevent thromboembolism, and restore normal sinus rhythm when possible. Management is individualized based on the frequency, duration and symptoms of AF and patient characteristics.
Management of atrial fibrillation in critically ill patientsChamika Huruggamuwa
This document discusses the management of atrial fibrillation in critically ill patients. It finds that AF is a common arrhythmia in ICU patients and is associated with increased mortality and morbidity. The incidence of new-onset AF increases with age, underlying cardiac conditions, and severity of acute illness. AF can cause hemodynamic instability and organ dysfunction if untreated. Treatment involves restoring hemodynamic stability, pharmacological or electrical cardioversion for rhythm control, and anticoagulation based on stroke risk scores. Rate control drugs like beta-blockers are preferred initially for hemodynamically stable patients.
Atrial fibrillation can be characterized on electrocardiogram by low-amplitude baseline oscillations and irregular ventricular rhythm. It is classified as paroxysmal if self-terminating within 7 days, persistent between 7 days to 1 year, or permanent if lasting over 1 year. Risk factors include heart disease, hypertension, age, and obesity. Prevention of thromboembolic complications involves risk stratification using CHADS2 or CHA2DS2-VASc scores to determine need for anticoagulation. Warfarin reduces risk of stroke but comes with risk of bleeding, while newer oral anticoagulants such as dabigatran and rivaroxaban are equally effective with less monitoring
The document summarizes guidelines for managing atrial fibrillation. It discusses recommendations for stroke prevention using anticoagulants, rate control therapy, and rhythm control therapy. It also recommends catheter ablation of accessory pathways in Wolff-Parkinson-White syndrome patients with atrial fibrillation to prevent rapid conduction across pathways leading to dangerous arrhythmias.
Atrial fibrillation is the most common arrhythmia and increases mortality risk. It is classified as paroxysmal, persistent, or permanent based on duration. The CHA2DS2-VASc score is used to assess stroke risk and determine need for anticoagulation. Treatment focuses on rate control with medications like calcium channel blockers or cardioversion for hemodynamic instability. Anticoagulation is recommended for CHA2DS2-VASc score over 2 to prevent stroke.
Atrial Fibrillation is the most common arrhythmia encountered by a physician. The global prevalence is increasing because of aging population and better detection methods. Prediction of new onset AF is possible. AF is also a lifestyle disease. Lifestyle therapy, rate or rhythm control and stroke risk stratification are are four main pillars of AF management.
Atrial fibrillation is characterized by an irregular heartbeat and is classified as paroxysmal, persistent, or permanent based on duration. It is associated with risks like stroke and is diagnosed by ECG showing irregular rhythms. Treatment involves rate control with medications, anticoagulation based on stroke risk scores, and catheter ablation or antiarrhythmic drugs for rhythm control.
1. Atrial fibrillation (AF) is a common arrhythmia where abnormal electrical signals in the atria cause an irregular heartbeat.
2. AF increases the risk of stroke by 5 times and is associated with increased mortality, hospitalization, and decreased quality of life.
3. Management involves rate or rhythm control as well as anticoagulation to prevent stroke, with treatment depending on factors like symptoms, age, and stroke risk level.
This document provides guidelines for the classification and management of atrial fibrillation (AF). It discusses the introduction, classification, mechanisms, causes and features of AF. The diagnostic evaluation and management guidelines cover rate control versus rhythm control strategies, pharmacological and electrical cardioversion options, and drugs used for rate and rhythm control. The goals are to control the heart rate, prevent thromboembolism, and restore normal sinus rhythm when possible. Management is individualized based on the frequency, duration and symptoms of AF and patient characteristics.
Management of atrial fibrillation in critically ill patientsChamika Huruggamuwa
This document discusses the management of atrial fibrillation in critically ill patients. It finds that AF is a common arrhythmia in ICU patients and is associated with increased mortality and morbidity. The incidence of new-onset AF increases with age, underlying cardiac conditions, and severity of acute illness. AF can cause hemodynamic instability and organ dysfunction if untreated. Treatment involves restoring hemodynamic stability, pharmacological or electrical cardioversion for rhythm control, and anticoagulation based on stroke risk scores. Rate control drugs like beta-blockers are preferred initially for hemodynamically stable patients.
Atrial fibrillation can be characterized on electrocardiogram by low-amplitude baseline oscillations and irregular ventricular rhythm. It is classified as paroxysmal if self-terminating within 7 days, persistent between 7 days to 1 year, or permanent if lasting over 1 year. Risk factors include heart disease, hypertension, age, and obesity. Prevention of thromboembolic complications involves risk stratification using CHADS2 or CHA2DS2-VASc scores to determine need for anticoagulation. Warfarin reduces risk of stroke but comes with risk of bleeding, while newer oral anticoagulants such as dabigatran and rivaroxaban are equally effective with less monitoring
The document summarizes guidelines for managing atrial fibrillation. It discusses recommendations for stroke prevention using anticoagulants, rate control therapy, and rhythm control therapy. It also recommends catheter ablation of accessory pathways in Wolff-Parkinson-White syndrome patients with atrial fibrillation to prevent rapid conduction across pathways leading to dangerous arrhythmias.
Atrial fibrillation is the most common arrhythmia and increases mortality risk. It is classified as paroxysmal, persistent, or permanent based on duration. The CHA2DS2-VASc score is used to assess stroke risk and determine need for anticoagulation. Treatment focuses on rate control with medications like calcium channel blockers or cardioversion for hemodynamic instability. Anticoagulation is recommended for CHA2DS2-VASc score over 2 to prevent stroke.
Atrial Fibrillation is the most common arrhythmia encountered by a physician. The global prevalence is increasing because of aging population and better detection methods. Prediction of new onset AF is possible. AF is also a lifestyle disease. Lifestyle therapy, rate or rhythm control and stroke risk stratification are are four main pillars of AF management.
1. The document discusses classification, management, and treatment of atrial fibrillation. It describes classification as paroxysmal, persistent, or permanent based on episode duration.
2. For stable patients, the first steps are evaluation, rate control if needed, and decision on cardioversion. For unstable patients, urgent cardioversion may be required. Electrical cardioversion is preferred but drugs can be used.
3. Anticoagulation for at least 3 weeks prior to and 4 weeks after cardioversion is recommended for episodes over 48 hours. For episodes under 48 hours, practices vary from anticoagulation in all to risk-based approaches.
Management of atrial fibrillation (summary)Adel Hasanin
Based on the guidelines presented in the document, the following procedures would not be considered or would fail for rhythm control in atrial fibrillation:
1. Percutaneous balloon cryoablation for pulmonary vein isolation in atrial fibrillation
2. Percutaneous endoscopic catheter laser balloon ablation
The document recommends left atrial catheter ablation or left atrial surgical ablation if drug treatment fails to control symptoms. It does not mention the above specific ablation procedures.
A 56-year-old woman presents with symptoms of hyperthyroidism including palpitations, weight loss, and anxiety. Her pulse is irregular at 140-150 bpm. Examination shows signs of Graves' disease including a goiter and exophthalmos. The diagnosis is hyperthyroidism causing atrial fibrillation. Investigations would include thyroid function tests.
Rhythm control for atrial fibrillation is pursued over rate control when a patient remains symptomatic despite adequate rate control or has a strong preference for restoring normal rhythm.
This document discusses current management of atrial fibrillation including evaluating thromboembolic risk, rate or rhythm control strategies, anticoagulation guidelines, cardio
This document discusses non-pharmacological management options for atrial fibrillation (AF), including ablation procedures. Pulmonary vein isolation is the cornerstone ablation strategy, as 95% of AF triggers originate from the pulmonary veins. During this procedure, radiofrequency energy is applied to electrically isolate the pulmonary veins from the left atrium. Complete isolation of the pulmonary veins has shown success rates of over 80% for preventing AF recurrence. Other ablation procedures discussed include modifying the atrioventricular node to control ventricular rate during AF and linear ablation techniques. The document also reviews the electrophysiological mechanisms of AF and the rationale behind different ablation strategies.
This document discusses strategies for the acute management of atrial fibrillation. It covers stroke prevention using risk stratification tools like CHA2DS2-VASc to guide anticoagulation decisions. It also compares warfarin to newer oral anticoagulants and discusses tools to assess bleeding risk. Finally, it reviews evidence that rate control is equivalent to rhythm control for stroke prevention and recommends individualized heart rate targets, with digoxin reserved for inadequate rate control.
Atrial fibrillation is the most common cardiac arrhythmia. It is characterized by irregular heart rhythms without distinct P waves due to irregular activation of the atria. The prevalence increases with age and is higher in men. Risk factors include hypertension, heart disease, heart failure, thyroid disorders, obesity, and lung disease. If left untreated, atrial fibrillation can lead to stroke, heart failure, reduced quality of life, and death. The pathogenesis involves multiple activation wavelets in the atria which causes the muscle to shorten its refractory period, making further arrhythmias more likely. Atrial fibrillation is classified based on its pattern and duration.
This document discusses atrial fibrillation (AF) in critically ill patients. It covers the following key points:
1) AF is a common arrhythmia in ICU patients, affecting up to 10% of general ICU patients and up to 50% of cardiac ICU patients.
2) Management of AF involves either rate control or rhythm control depending on patient hemodynamics and symptoms. Electrical cardioversion is recommended for hemodynamically unstable patients.
3) For stable patients, a rate control strategy using beta-blockers and other medications is usually pursued unless the patient is symptomatic despite rate control, in which case a rhythm control strategy may be considered.
This document provides an overview of atrial fibrillation (AF). It defines AF as a supraventricular arrhythmia characterized by disorganized, rapid, and irregular atrial activation with loss of atrial contraction. Some key points:
- AF prevalence increases with age and is more common in men and whites. It is the most common sustained arrhythmia.
- AF increases the risk of stroke, heart failure, dementia and mortality.
- Causes include hypertension, heart disease, sleep apnea and genetic factors.
- Treatment involves rate control or rhythm control with medications like beta blockers, calcium channel blockers, and antiarrhythmics. Electrical cardioversion and catheter ablation are also
This document discusses atrial fibrillation (AF), the most common cardiac arrhythmia. It provides background on AF including its history, classification, epidemiology, etiology, pathophysiology, clinical features, diagnosis and electrocardiographic characteristics. Key points discussed are that AF results from triggers in the pulmonary veins initiating reentry circuits in the atria, and that it begets itself over time through electrical and structural remodeling of the atria. Management involves identifying and treating underlying causes, rate control, and anticoagulation to prevent thromboembolism.
A comprehensive approach to Atrial Fibrillation. Everything you need to know about Atrial fibrillation. Including recent 2014 AHA guidelines of management.
This document summarizes guidelines for the management of atrial fibrillation (AF) with special reference to the 2016 European Society of Cardiology guidelines. It discusses the classification and pathophysiology of AF, ongoing clinical trials studying anticoagulation in patients with AF, and recommendations for anticoagulation and rate/rhythm control. Newer approaches like left atrial appendage closure and catheter ablation are also covered. Controversies around certain recommendations and the use of biomarkers are noted. Stroke risk and management in AF patients is addressed. Reversal of anticoagulation in bleeding patients and resuming anticoagulation post-hemorrhagic stroke are discussed.
Atrial fibrillation is the most common arrhythmia and becomes more prevalent with age. It is associated with increased risks of mortality, stroke, and heart failure. The estimated global prevalence is over 30 million people and is expected to rise significantly by 2030. Treatment involves rate or rhythm control, with rhythm control indicated to improve symptoms in those remaining symptomatic on rate control. Anticoagulation therapy is crucial to prevent stroke in high risk patients based on risk scores like CHA2DS2-VASc. Non-vitamin K antagonist oral anticoagulants are suitable alternatives to warfarin for stroke prevention.
Atrial fibrillation review of principlesJwan AlSofi
Atrial fibrillation is the most common cardiac arrhythmia, affecting around 1% of people aged 60-64 and 9% of those over 80. It occurs due to abnormal automatic firing in the atria and re-entry circuits. Episodes are initiated by ectopic beats from the pulmonary veins and become sustained via re-entry or continued ectopic firing. Management involves rate or rhythm control as well as anticoagulation to prevent strokes. Rate control uses medications like beta-blockers, digoxin, and calcium channel blockers while rhythm control attempts cardioversion or ablation. Anticoagulants include warfarin and newer direct oral anticoagulants that are as effective as warfarin
This document summarizes guidelines on the management of atrial fibrillation from the American Heart Association, American College of Cardiology, and Heart Rhythm Society. It discusses the epidemiology and pathophysiology of atrial fibrillation in India. Key points include that rheumatic heart disease is a leading cause of atrial fibrillation in younger Indian patients, and the prevalence of atrial fibrillation increases with the severity of rheumatic valve disease. Pulmonary veins and ganglionic plexi are important triggers of atrial fibrillation, while multiple re-entrant wavelets and localized sources maintain the arrhythmia. The document reviews risk factors, clinical presentation, and treatment approaches for atrial fib
Atrial fibrillation is the most common cardiac arrhythmia. It is characterized by uncoordinated atrial activation and ineffective atrial contraction. The risk of stroke and heart failure increases with AF. Treatment involves rate or rhythm control as well as anticoagulation according to stroke risk. Rate control uses medications while rhythm control may involve cardioversion, antiarrhythmic drugs, catheter ablation, or surgery. Anticoagulation is recommended long-term in most patients to prevent thromboembolism.
Management of new onset atrial fibrillation involves assessing risk factors, controlling the ventricular rate, and determining an anticoagulation strategy. Rate control can be achieved acutely with intravenous medications like metoprolol or verapamil, with a target rate of 80-100 bpm. Pharmacological cardioversion with medications like ibutilide, flecainide or amiodarone may be considered. For anticoagulation, the CHA2DS2-VASc score is used to determine risk of stroke, and the HASBLED score evaluates bleeding risk. Long-term management focuses on preventing thromboembolism, symptom relief, managing underlying conditions, and rate or rhythm control.
This document discusses atrial fibrillation and new treatment paradigms. It begins with an overview that atrial fibrillation is a progressive disease with hemodynamic and myocardial consequences like reduced cardiac output and heart failure. It causes increased risk of stroke, hospitalizations, reduced quality of life, and decreased survival. The Active trial found that adding clopidogrel to aspirin for atrial fibrillation patients at high risk of stroke reduced major vascular events due to fewer strokes, but increased bleeding risk. Dabigatran was similarly effective to warfarin for stroke prevention in atrial fibrillation with lower bleeding risk. Rhythm control provides benefits over rate control but requires weighing reduced hospitalizations against potential for more
nonpharmacological treatment of atrial fibrillationsaritadmcardio
This document discusses various non-pharmacological treatment options for atrial fibrillation (AFib), including catheter ablation procedures and implantable devices. It provides details on complete AV node ablation and pacemaker placement, which involves ablating the AV node to control ventricular rate and implanting a permanent pacemaker to avoid pacemaker dependence. The document summarizes the advantages and disadvantages of this approach and guidelines for appropriate candidates. It also discusses focal catheter ablation of AF triggers within the pulmonary veins and techniques for pulmonary vein isolation.
This document discusses the management of atrial fibrillation. It provides information on the causes, consequences, classification, and epidemiology of AF. It describes the acute management of AF including assessing hemodynamic status, starting anticoagulation, and deciding between rate and rhythm control strategies. Methods for rhythm control include electrical cardioversion and pharmacological cardioversion with drugs like amiodarone, ibutilide, flecainide, and propafenone. Rate control strategies use drugs like digoxin, beta blockers, calcium channel blockers, and amiodarone. The document also discusses anticoagulation for thromboembolism prevention and newer oral anticoagulants.
This document summarizes the risk factors, pathophysiology, treatment, and role of new oral anticoagulants in preventing strokes related to atrial fibrillation. It describes how conditions like hypertension, heart failure, and diabetes increase stroke risk in atrial fibrillation patients. The pathophysiology leads to irregular heart rhythms that increase clotting. Treatment involves rate/rhythm control and anticoagulation using warfarin or new oral anticoagulants. Clinical trials found the new anticoagulants reduce stroke and intracranial bleeds compared to warfarin, with similar or lower risks of major bleeding. Patient characteristics and renal function help determine which new anticoagulant
Atrial fibrillation (AF) is a common heart rhythm disorder that increases the risk of stroke, heart failure, and other cardiovascular issues. The document summarizes guidelines for managing AF, including establishing rate control with medications, assessing stroke risk using the CHA2DS2-VASc score to determine anticoagulation needs, and considering rhythm control options like ablation for symptomatic patients. An integrated care approach is recommended, involving specialists, primary care, and informed patients, to consistently manage AF and improve outcomes through treatment of underlying conditions, anticoagulation, and controlling heart rate and rhythm issues.
1. The document discusses classification, management, and treatment of atrial fibrillation. It describes classification as paroxysmal, persistent, or permanent based on episode duration.
2. For stable patients, the first steps are evaluation, rate control if needed, and decision on cardioversion. For unstable patients, urgent cardioversion may be required. Electrical cardioversion is preferred but drugs can be used.
3. Anticoagulation for at least 3 weeks prior to and 4 weeks after cardioversion is recommended for episodes over 48 hours. For episodes under 48 hours, practices vary from anticoagulation in all to risk-based approaches.
Management of atrial fibrillation (summary)Adel Hasanin
Based on the guidelines presented in the document, the following procedures would not be considered or would fail for rhythm control in atrial fibrillation:
1. Percutaneous balloon cryoablation for pulmonary vein isolation in atrial fibrillation
2. Percutaneous endoscopic catheter laser balloon ablation
The document recommends left atrial catheter ablation or left atrial surgical ablation if drug treatment fails to control symptoms. It does not mention the above specific ablation procedures.
A 56-year-old woman presents with symptoms of hyperthyroidism including palpitations, weight loss, and anxiety. Her pulse is irregular at 140-150 bpm. Examination shows signs of Graves' disease including a goiter and exophthalmos. The diagnosis is hyperthyroidism causing atrial fibrillation. Investigations would include thyroid function tests.
Rhythm control for atrial fibrillation is pursued over rate control when a patient remains symptomatic despite adequate rate control or has a strong preference for restoring normal rhythm.
This document discusses current management of atrial fibrillation including evaluating thromboembolic risk, rate or rhythm control strategies, anticoagulation guidelines, cardio
This document discusses non-pharmacological management options for atrial fibrillation (AF), including ablation procedures. Pulmonary vein isolation is the cornerstone ablation strategy, as 95% of AF triggers originate from the pulmonary veins. During this procedure, radiofrequency energy is applied to electrically isolate the pulmonary veins from the left atrium. Complete isolation of the pulmonary veins has shown success rates of over 80% for preventing AF recurrence. Other ablation procedures discussed include modifying the atrioventricular node to control ventricular rate during AF and linear ablation techniques. The document also reviews the electrophysiological mechanisms of AF and the rationale behind different ablation strategies.
This document discusses strategies for the acute management of atrial fibrillation. It covers stroke prevention using risk stratification tools like CHA2DS2-VASc to guide anticoagulation decisions. It also compares warfarin to newer oral anticoagulants and discusses tools to assess bleeding risk. Finally, it reviews evidence that rate control is equivalent to rhythm control for stroke prevention and recommends individualized heart rate targets, with digoxin reserved for inadequate rate control.
Atrial fibrillation is the most common cardiac arrhythmia. It is characterized by irregular heart rhythms without distinct P waves due to irregular activation of the atria. The prevalence increases with age and is higher in men. Risk factors include hypertension, heart disease, heart failure, thyroid disorders, obesity, and lung disease. If left untreated, atrial fibrillation can lead to stroke, heart failure, reduced quality of life, and death. The pathogenesis involves multiple activation wavelets in the atria which causes the muscle to shorten its refractory period, making further arrhythmias more likely. Atrial fibrillation is classified based on its pattern and duration.
This document discusses atrial fibrillation (AF) in critically ill patients. It covers the following key points:
1) AF is a common arrhythmia in ICU patients, affecting up to 10% of general ICU patients and up to 50% of cardiac ICU patients.
2) Management of AF involves either rate control or rhythm control depending on patient hemodynamics and symptoms. Electrical cardioversion is recommended for hemodynamically unstable patients.
3) For stable patients, a rate control strategy using beta-blockers and other medications is usually pursued unless the patient is symptomatic despite rate control, in which case a rhythm control strategy may be considered.
This document provides an overview of atrial fibrillation (AF). It defines AF as a supraventricular arrhythmia characterized by disorganized, rapid, and irregular atrial activation with loss of atrial contraction. Some key points:
- AF prevalence increases with age and is more common in men and whites. It is the most common sustained arrhythmia.
- AF increases the risk of stroke, heart failure, dementia and mortality.
- Causes include hypertension, heart disease, sleep apnea and genetic factors.
- Treatment involves rate control or rhythm control with medications like beta blockers, calcium channel blockers, and antiarrhythmics. Electrical cardioversion and catheter ablation are also
This document discusses atrial fibrillation (AF), the most common cardiac arrhythmia. It provides background on AF including its history, classification, epidemiology, etiology, pathophysiology, clinical features, diagnosis and electrocardiographic characteristics. Key points discussed are that AF results from triggers in the pulmonary veins initiating reentry circuits in the atria, and that it begets itself over time through electrical and structural remodeling of the atria. Management involves identifying and treating underlying causes, rate control, and anticoagulation to prevent thromboembolism.
A comprehensive approach to Atrial Fibrillation. Everything you need to know about Atrial fibrillation. Including recent 2014 AHA guidelines of management.
This document summarizes guidelines for the management of atrial fibrillation (AF) with special reference to the 2016 European Society of Cardiology guidelines. It discusses the classification and pathophysiology of AF, ongoing clinical trials studying anticoagulation in patients with AF, and recommendations for anticoagulation and rate/rhythm control. Newer approaches like left atrial appendage closure and catheter ablation are also covered. Controversies around certain recommendations and the use of biomarkers are noted. Stroke risk and management in AF patients is addressed. Reversal of anticoagulation in bleeding patients and resuming anticoagulation post-hemorrhagic stroke are discussed.
Atrial fibrillation is the most common arrhythmia and becomes more prevalent with age. It is associated with increased risks of mortality, stroke, and heart failure. The estimated global prevalence is over 30 million people and is expected to rise significantly by 2030. Treatment involves rate or rhythm control, with rhythm control indicated to improve symptoms in those remaining symptomatic on rate control. Anticoagulation therapy is crucial to prevent stroke in high risk patients based on risk scores like CHA2DS2-VASc. Non-vitamin K antagonist oral anticoagulants are suitable alternatives to warfarin for stroke prevention.
Atrial fibrillation review of principlesJwan AlSofi
Atrial fibrillation is the most common cardiac arrhythmia, affecting around 1% of people aged 60-64 and 9% of those over 80. It occurs due to abnormal automatic firing in the atria and re-entry circuits. Episodes are initiated by ectopic beats from the pulmonary veins and become sustained via re-entry or continued ectopic firing. Management involves rate or rhythm control as well as anticoagulation to prevent strokes. Rate control uses medications like beta-blockers, digoxin, and calcium channel blockers while rhythm control attempts cardioversion or ablation. Anticoagulants include warfarin and newer direct oral anticoagulants that are as effective as warfarin
This document summarizes guidelines on the management of atrial fibrillation from the American Heart Association, American College of Cardiology, and Heart Rhythm Society. It discusses the epidemiology and pathophysiology of atrial fibrillation in India. Key points include that rheumatic heart disease is a leading cause of atrial fibrillation in younger Indian patients, and the prevalence of atrial fibrillation increases with the severity of rheumatic valve disease. Pulmonary veins and ganglionic plexi are important triggers of atrial fibrillation, while multiple re-entrant wavelets and localized sources maintain the arrhythmia. The document reviews risk factors, clinical presentation, and treatment approaches for atrial fib
Atrial fibrillation is the most common cardiac arrhythmia. It is characterized by uncoordinated atrial activation and ineffective atrial contraction. The risk of stroke and heart failure increases with AF. Treatment involves rate or rhythm control as well as anticoagulation according to stroke risk. Rate control uses medications while rhythm control may involve cardioversion, antiarrhythmic drugs, catheter ablation, or surgery. Anticoagulation is recommended long-term in most patients to prevent thromboembolism.
Management of new onset atrial fibrillation involves assessing risk factors, controlling the ventricular rate, and determining an anticoagulation strategy. Rate control can be achieved acutely with intravenous medications like metoprolol or verapamil, with a target rate of 80-100 bpm. Pharmacological cardioversion with medications like ibutilide, flecainide or amiodarone may be considered. For anticoagulation, the CHA2DS2-VASc score is used to determine risk of stroke, and the HASBLED score evaluates bleeding risk. Long-term management focuses on preventing thromboembolism, symptom relief, managing underlying conditions, and rate or rhythm control.
This document discusses atrial fibrillation and new treatment paradigms. It begins with an overview that atrial fibrillation is a progressive disease with hemodynamic and myocardial consequences like reduced cardiac output and heart failure. It causes increased risk of stroke, hospitalizations, reduced quality of life, and decreased survival. The Active trial found that adding clopidogrel to aspirin for atrial fibrillation patients at high risk of stroke reduced major vascular events due to fewer strokes, but increased bleeding risk. Dabigatran was similarly effective to warfarin for stroke prevention in atrial fibrillation with lower bleeding risk. Rhythm control provides benefits over rate control but requires weighing reduced hospitalizations against potential for more
nonpharmacological treatment of atrial fibrillationsaritadmcardio
This document discusses various non-pharmacological treatment options for atrial fibrillation (AFib), including catheter ablation procedures and implantable devices. It provides details on complete AV node ablation and pacemaker placement, which involves ablating the AV node to control ventricular rate and implanting a permanent pacemaker to avoid pacemaker dependence. The document summarizes the advantages and disadvantages of this approach and guidelines for appropriate candidates. It also discusses focal catheter ablation of AF triggers within the pulmonary veins and techniques for pulmonary vein isolation.
This document discusses the management of atrial fibrillation. It provides information on the causes, consequences, classification, and epidemiology of AF. It describes the acute management of AF including assessing hemodynamic status, starting anticoagulation, and deciding between rate and rhythm control strategies. Methods for rhythm control include electrical cardioversion and pharmacological cardioversion with drugs like amiodarone, ibutilide, flecainide, and propafenone. Rate control strategies use drugs like digoxin, beta blockers, calcium channel blockers, and amiodarone. The document also discusses anticoagulation for thromboembolism prevention and newer oral anticoagulants.
This document summarizes the risk factors, pathophysiology, treatment, and role of new oral anticoagulants in preventing strokes related to atrial fibrillation. It describes how conditions like hypertension, heart failure, and diabetes increase stroke risk in atrial fibrillation patients. The pathophysiology leads to irregular heart rhythms that increase clotting. Treatment involves rate/rhythm control and anticoagulation using warfarin or new oral anticoagulants. Clinical trials found the new anticoagulants reduce stroke and intracranial bleeds compared to warfarin, with similar or lower risks of major bleeding. Patient characteristics and renal function help determine which new anticoagulant
Atrial fibrillation (AF) is a common heart rhythm disorder that increases the risk of stroke, heart failure, and other cardiovascular issues. The document summarizes guidelines for managing AF, including establishing rate control with medications, assessing stroke risk using the CHA2DS2-VASc score to determine anticoagulation needs, and considering rhythm control options like ablation for symptomatic patients. An integrated care approach is recommended, involving specialists, primary care, and informed patients, to consistently manage AF and improve outcomes through treatment of underlying conditions, anticoagulation, and controlling heart rate and rhythm issues.
NEJM Clinical Guidelines Watch Update. Abril 2014Jaime dehais
This document provides guidelines for the assessment and management of overweight and obesity in adults. It recommends:
1) All overweight and obese patients should receive counseling on modest weight loss through dietary changes, increased physical activity, and behavioral therapy to improve health outcomes.
2) If lifestyle changes alone do not achieve sufficient weight loss, anti-obesity medications may be considered for some patients.
3) Bariatric surgery should be considered for some patients with a BMI of 40 or greater, or between 35-40 with obesity-related conditions, when lifestyle changes and medications have failed.
Acute Decompensated Heart Failure : What is New ?drucsamal
Prof. U. C. SAMAL is an expert in cardiology who has held leadership positions in several cardiological societies. The document discusses the management of acute decompensated heart failure and summarizes recent changes to guidelines. It provides an overview of pharmacological interventions for acute heart failure such as diuretics, vasodilators, and inotropes. Non-invasive ventilation and risk stratification scores are also mentioned. The document emphasizes the importance of both short-term stabilization and long-term management through multi-disciplinary programs to prevent readmissions.
1. Atrial fibrillation (AF) is classified based on duration and presence of symptoms, including first diagnosed, paroxysmal (<7 days), persistent (≥7 days), long-standing persistent (≥12 months), and permanent.
2. Risk factors for incident AF include structural heart disease, hypertension, obesity, smoking, diabetes, and age.
3. Treatment recommendations include long-term antiarrhythmic drugs like amiodarone, dronedarone, and flecainide/propafenone based on patient characteristics, as well as cardioversion and catheter ablation.
This document summarizes the 2016 European Society of Cardiology guidelines for the management of atrial fibrillation. It begins with an introduction stating that AF remains a major cause of stroke, heart failure, and other cardiovascular issues worldwide. It also notes that the number of AF patients is predicted to rise significantly. The document then discusses common problems seen with AF patients in critical care and outpatient settings. It lists "do nots" in AF management, such as not using antiplatelet therapy alone for stroke prevention. It provides recommendations on rate control, rhythm control, anticoagulation for stroke prevention, and managing bleeding. It asks about determining the CHA2DS2-VASC score for a hypothetical patient case and discusses
Hypertension
2. Which of the following medications has been shown
to improve both mortality and quality of life in patients
with CHF?
a) ACE inhibitors
b) Diuretics
c) Digoxin
d) Beta blockers
Professor DR Md . TOUFIQUR RAHMAN , FCPS, MD
Professor & Head, Cardiology, CMMC, Manikganj
drtoufiq19711@yahoo.com; drtoufiq1971@gmail.com
3. A 50 year old male presents with BP-180/100 mmHg. How will you investigate him? (DU-18Ju)
When investigating a patient with high blood pressure, several tests can be done to determine the cause and severity of the hypertension. Some of the tests that can be performed include:
Blood tests: This may include a complete blood count (CBC), kidney function tests, fasting glucose level, and lipid profile.
Urine tests: A urinalysis may be done to check for the presence of protein or blood in the urine, which could indicate kidney damage.
Electrocardiogram (ECG): This test records the electrical activity of the heart and can help detect any abnormalities in heart function.
Echocardiogram: This test uses sound waves to create an image of the heart and can help detect any structural abnormalities or problems with the heart's function.
Ambulatory blood pressure monitoring (ABPM): This is a portable device that measures blood pressure at regular intervals over a 24-hour period, providing a more accurate assessment of blood pressure patterns.
Renal artery ultrasound: This test uses sound waves to create an image of the renal arteries, which supply blood to the kidneys, and can help identify any blockages or narrowing in these arteries.
CT or MRI angiography: These imaging tests can provide detailed images of the blood vessels in the body, including the renal arteries, to help identify any blockages or narrowing.
The specific tests ordered will depend on the individual patient and their medical history, and should be decided by a healthcare professional.
4. A 25 year old woman has presented with repeated recordings of blood pressure above 160/100 mmHg. (DU- 21M)
a. What history and clinical signs you would look for?
b. What are the factors affecting the choice of antihypertensive drugs?
a. When evaluating a young woman with repeated recordings of high blood pressure, it is important to take a detailed history and perform a thorough physical exam to identify any underlying causes or risk factors. Some key points to consider include:
Family history of hypertension or cardiovascular disease
Personal history of kidney disease, diabetes, or other chronic medical conditions
Lifestyle factors such as diet, exercise, and tobacco and alcohol use
Medications or supplements that may contribute to hypertension
Symptoms such as headaches, chest pain, or shortness of breath
Physical exam findings such as enlarged kidneys, abnormal heart sounds, or signs of hormonal imbalances
b. The choice of antihypertensive drugs depends on several factors, including the patient's age, overall health status, and specific blood pressure goals. Some factors to consider when selecting a medication include:
The drug's mechanism of action and potential side effects
The patient's medical history
Atrial fibrilation diagnosis and management updated guidline. NICE 2021.GMHasan3
This document discusses the presentation, diagnosis, and management of atrial fibrillation. It begins with an overview of atrial fibrillation, including its pathogenesis and classification. It then covers detection and diagnosis, including assessment of cardiac function. Major sections discuss management strategies for non-acute and acute presentations, including rate control, rhythm control, anticoagulation, and prevention of postoperative atrial fibrillation. Scoring systems to assess stroke and bleeding risk are also presented.
A 65-year-old female presented with palpitations and was found to be in atrial fibrillation. The document discusses:
1) Rate control vs rhythm control strategies for managing atrial fibrillation.
2) Anticoagulation is recommended based on stroke risk scores like CHA2DS2-VASc.
3) For this patient, with a history of dyslipidemia and no other risk factors, oral anticoagulation is recommended based on her moderate stroke risk.
1) The document provides guidelines for coronary artery revascularization from the 2021 ACC/AHA/SCAI, including definitions of lesion severity, recommendations for revascularization of infarct arteries in STEMI, and timing of invasive strategies for NSTE-ACS.
2) It recommends using tools like the SYNTAX score and coronary physiology to help define lesion severity and guide revascularization decisions for intermediate lesions.
3) For STEMI patients, the guidelines recommend PCI if within 12 hours of symptoms or CABG if mechanical complications occur, and provide recommendations for revascularizing non-infarct arteries.
This document analyzes the benefits of aldosterone receptor antagonists (ARAs) in treating heart failure based on evidence from major clinical trials. ARAs such as spironolactone and eplerenone, when added to standard heart failure therapies, were shown to significantly reduce mortality and hospitalization rates compared to placebo in patients with NYHA class II-IV symptoms and reduced ejection fraction. However, ARAs remain underutilized in practice due to concerns about side effects like hyperkalemia. Ongoing research is exploring more selective next-generation ARAs that may have fewer safety issues.
In this overview, we draw inspiration from the article titled "Managing Hypertension in Primary Care“, published in the Canadian Family Physician journal (Vol 65: October 2019).
The article, edited by Khrystine Waked PharmD, Jeff Nagge PharmD, and Kelly Grindrod PharmD MSc,.
It provides valuable insights and evidence-based approaches to tackle Hypertension Management In Primary Care.
By incorporating the recommendations discussed in this article, we can enhance our ability to manage hypertension and ultimately improving patient outcomes and quality of life.
This document provides guidelines and recommendations for diagnosing and managing acute heart failure. It includes algorithms and tables on:
- Diagnosing acute heart failure based on BNP/NT-proBNP levels
- Therapeutic goals for acute heart failure treatment aimed at understanding etiology, alleviating symptoms, and establishing follow up care
- Acute management considerations including use of diuretics, vasodilators, inotropes based on patient status and goals of alleviating symptoms and optimizing treatment
- Diuretic dosing recommendations based on creatinine clearance
During atrial fibrillation, the heart's upper chambers — called the atria — beat chaotically and irregularly. They beat out of sync with the lower heart chambers, called the ventricles. For many people, AFib may have no symptoms. But AFib may cause a fast, pounding heartbeat, shortness of breath or light-headedness.
The 2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease provides recommendations for the diagnosis and management of lower extremity PAD. Key recommendations include:
- Using the ankle-brachial index with or without segmental pressures and waveforms to establish a diagnosis of PAD in patients with symptoms or risk factors suggestive of the condition.
- Using exercise treadmill testing for patients with exertional leg symptoms and a normal or borderline ankle-brachial index at rest to evaluate for PAD.
- Screening patients with symptomatic PAD for abdominal aortic aneurysm with duplex ultrasound.
- Treating all patients with PAD with antiplatelet therapy, statins, and controlling
1. Rate control has equivalent efficacy to rhythm control for managing atrial fibrillation and has less drug-related side effects.
2. Drugs like digoxin, beta blockers, and calcium channel blockers can be used for rate control, while antiarrhythmics like amiodarone, dofetilide and sotalol are used for rhythm control.
3. Electrical cardioversion can be used to restore sinus rhythm but has a risk of recurrence, so anticoagulation is recommended afterwards to prevent stroke from clots that may form during the arrhythmia.
Similar to Atrial Fibrillation Guidelines 2016 (20)
Basavarajeeyam is a Sreshta Sangraha grantha (Compiled book ), written by Neelkanta kotturu Basavaraja Virachita. It contains 25 Prakaranas, First 24 Chapters related to Rogas& 25th to Rasadravyas.
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These lecture slides, by Dr Sidra Arshad, offer a quick overview of the physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar lead (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
6. Describe the flow of current around the heart during the cardiac cycle
7. Discuss the placement and polarity of the leads of electrocardiograph
8. Describe the normal electrocardiograms recorded from the limb leads and explain the physiological basis of the different records that are obtained
9. Define mean electrical vector (axis) of the heart and give the normal range
10. Define the mean QRS vector
11. Describe the axes of leads (hexagonal reference system)
12. Comprehend the vectorial analysis of the normal ECG
13. Determine the mean electrical axis of the ventricular QRS and appreciate the mean axis deviation
14. Explain the concepts of current of injury, J point, and their significance
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. Chapter 3, Cardiology Explained, https://www.ncbi.nlm.nih.gov/books/NBK2214/
7. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Rasamanikya is a excellent preparation in the field of Rasashastra, it is used in various Kushtha Roga, Shwasa, Vicharchika, Bhagandara, Vatarakta, and Phiranga Roga. In this article Preparation& Comparative analytical profile for both Formulationon i.e Rasamanikya prepared by Kushmanda swarasa & Churnodhaka Shodita Haratala. The study aims to provide insights into the comparative efficacy and analytical aspects of these formulations for enhanced therapeutic outcomes.
8 Surprising Reasons To Meditate 40 Minutes A Day That Can Change Your Life.pptxHolistified Wellness
We’re talking about Vedic Meditation, a form of meditation that has been around for at least 5,000 years. Back then, the people who lived in the Indus Valley, now known as India and Pakistan, practised meditation as a fundamental part of daily life. This knowledge that has given us yoga and Ayurveda, was known as Veda, hence the name Vedic. And though there are some written records, the practice has been passed down verbally from generation to generation.
share - Lions, tigers, AI and health misinformation, oh my!.pptxTina Purnat
• Pitfalls and pivots needed to use AI effectively in public health
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• Equipping health professionals to address questions, concerns and health misinformation
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2. About this Pocket Guide
This document is linked to an updated summary of all standing CCS AF recommendations, from 2010 to the present
2016 Focused Update; the supplement is available at www.ccs.ca.
This pocket guide is a quick-reference tool that features diagnostic and treatment recommendations based on the
CCS Atrial Fibrillation Guidelines (2010, 2012, 2014, and 2016).
These recommendations are intended to provide a reasonable and practical approach to care for specialists and allied
health professionals. They are subject to change as scientific knowledge and technology advance and practice
patterns evolve, and are not intended to be a substitute for clinical judgement. Adherence to these recommendations
will not necessarily produce successful outcomes in every case.
Please visit www.ccs.ca for more information or additional resources.
Co-Chairs:
Laurent Macle and Atul Verma
CCS Atrial Fibrillation Guidelines Primary Panel
Laurent Macle MD, John Cairns MD, Kori Leblanc MD, Teresa Tsang MD, Allan Skanes MD, Jafna L. Cox MD, Jeff
S. Healey MD, Alan Bell MD, Louise Pilote MD, Jason G. Andrade MD, L. Brent Mitchell MD, Clare Atzema MD, David
Gladstone MD, Mike Sharma MD, Subodh Verma MD, Stuart Connolly MD, Paul Dorian MD, Ratika Parkash MD,
Mario Talajic MD, Stanley Nattel MD and Atul Verma MD for the CCS Atrial Fibrillation Guidelines Committee.
3. Table of Contents
Etiology and Clinical Investigation………………………………………………………………………. 1
Rate and Rhythm Management…………………………………………………………………………. 4
Catheter Ablation………………………………………………………………………………………….. 11
Prevention of Stroke……………………………………………………………………………………… 12
Antithrombotic Therapy…………………………………………………………………………………... 16
Management of AF in the ED .………………………………………………………………………..... 23
Peri-Procedure / Anticoagulation Management …………………………………………………….... 25
Pre-Procedure Management …………………………………………………………………………… 27
Post-Procedure Management …………………………………………………………………………… 28
Post-Operative Management of AF…………………………………………………………................. 29
4. Etiology and Clinical Investigation
Baseline Evaluation for All Patients 1
HISTORY AND PHYSICAL EXAM
• Establish pattern (new onset, paroxysmal, persistent or permanent)
• Establish severity (including impact on quality of life)
• Identify etiology
• Identify reversible causes (hyperthyroidism, ventricular pacing,
supra-ventricular tachycardia, exercise, etc)
• Identify risk factors whose treatment could reduce recurrent AF or
improve overall prognosis (i.e. hypertension, sleep apnea, left
ventricular dysfunction, etc)
• Take social history to identify potential triggers (i.e. alcohol,
intensive aerobic training, etc)
• Elicit family history to identify potentially heritable causes of AF
(particularly lone AF)
• Determine thromboembolic risks
• Determine bleeding risk to guide appropriate antiplatelet or
antithrombotic therapy
• Review prior pharmacological therapy for AF, both for efficacy and
adverse effects
• Measure blood pressure and heart rate
• Determine patient height and weight
• Comprehensive precordial cardiac examination and assessment of
jugular venous pressure, carotid and peripheral pulses to detect
evidence of structural heart disease
12-LEAD ELECTROCARDIOGRAM
• Document presence of AF
• Assess for structural heart disease (myocardial infarction,
ventricular hypertrophy atrial enlargement, congenital heart disease)
or electrical heart disease (ventricular pre-excitation, Brugada
syndrome)
• Identify risk factors for complications of therapy for AF (conduction
disturbance, sinus node dysfunction or abnormal repolarization)
• Document baseline PR, QT and QRS intervals
ECHOCARDIOGRAM
• Document ventricular size, wall thickness and function
• Evaluate left atrial size (if possible, left atrial volume)
• Estimate ventricular filling pressures and pulmonary arterial
pressure
• Exclude significant valvular or congenital heart disease (particularly
atrial septal defects)
OTHER
• Complete blood count
• Coagulation profile
• Renal function
• Thyroid and liver function
• Fasting lipid profile
• Fasting glucose
5. Additional Investigations for Selected Patients
2
Etiology and Clinical Investigation
Investigation of patients with established symptom-rhythm correlation of coronary artery
disease, assessment of rate control
Electrophysiologic study
6. Etiology and Clinical Investigation
Established Patterns and Severity of Atrial Fibrillation 3
7. Overview of AF Management
4
Assessment of
Thromboembolic
Risk (CHADS65)
Major Goals of AF/AFL Arrhythmia Management
• Identify and treat underlying structural heart disease and other predisposing conditions
• Relieve symptoms
• Improve functional capacity/quality of life
• Reduce morbidity/mortality associated with AF/AFL
Prevent tachycardia-induced cardiomyopathy
Reduce/prevent emergency room visits or hospitalizations secondary to AF/AFL
• Prevent stroke or systemic thromboembolism
Rate and Rhythm Management
8. Rate and Rhythm Management
Algorithm for Rate vs Rhythm Control for Patients with Symptomatic AF 5
Catheter
ablation
Pill in pocket
anti-arrhythmic
therapy
Maintenance
anti-arrhythmic
therapy
Observe. If AF
recurs, determine if
symptomatic
Symptoms
improve,
but AF recurs
Symptoms improve,
and patient maintains
sinus rhythm
Symptoms
don’t change
in sinus
rhythm and
AF recurs
Low burden
recurrence
High burden
recurrence
CONTINUE RATE
CONTROL
MODIFY RATE CONTROL - CONSIDER RHYTHM CONTROL
SYMPTOMS RESOLVE
ATTEMPT RATE CONTROL
Beta-blocker
Calcium channel blocker
SYMPTOMATIC AF
Paroxysmal AF
NO
Special circumstances in
which to consider early
rhythm control:
• Highly symptomatic
• Multiple recurrences
• Extreme impairment in QOL
• Arrhythmia-induced
cardiomyopathy
Consider cardioversion
Persistent AF
YES
9. Rate and Rhythm Management
Digoxin and Mortality - Recommendations
6
Values and preferences: Digoxin is considered as a second-line agent in that, although some published cohort, retrospective,
and subgroup studies show no harm, there are others that suggesting possible harm.
Practical tip: When digoxin is used, dosing should be adjusted according to renal function and potential drug interactions.
With analyses that suggested higher drug concentrations are associated with adverse outcomes, maximum trough digoxin serum
concentration of 1.2 ng/mL would be prudent. When digoxin is being used to treat patients with concomitant left ventricular
systolic dysfunction, its use should be dictated by the recommendations of the CCS Heart Failure Clinical Guidelines.
We suggest that digoxin can be considered as a therapeutic option to achieve rate-control in patients with AF and symptoms
caused by rapid ventricular rates whose response to beta-blockers and/or calcium channel blockers is inadequate, or in whom
such rate-controlling drugs are contraindicated or not tolerated (Conditional Recommendation, Moderate Quality Evidence).
10. Rate and Rhythm Management
Overview of Rate Management 7
Drugs are listed in alphabetical order
*
Non-dihydropyridine calcium channel blockers (diltiazem, verapamil)
Drugs are listed in alphabetical order
* Beta-Blockers preferred in CAD
Non-dihydropyridine calcium channel blockers (diltiazem, verapamil)
We suggest that digoxin not be used as initial therapy for active patients and be
reserved for rate control in patients who are sedentary or who have left ventricular
systolic dysfunction
eta- lo ers
i o in
eta- lo ers
CC
Combination
eta- lo ers
CC
i o in
Combination
11. Rate and Rhythm Management
Managing Rate Control - Recommended Drugs
8
bradycardia, hypotension, fatigue, depression, bronchospasm
12. Rate and Rhythm Management
Overview of Rhythm Management 9
‡
‡
‡
13. Rate and Rhythm Management
Managing of Rhythm Control - Recommended Drugs
10
14. Catheter Ablation 11
Catheter Ablation
• We recommend catheter ablation of AF in patients who remain symptomatic following an adequate trial of antiarrhythmic drug
therapy and in whom a rhythm control strategy remains desired (Strong Recommendation, Moderate Quality Evidence).
• We suggest catheter ablation to maintain sinus rhythm as first-line therapy for relief of symptoms in highly selected patients
with symptomatic, paroxysmal atrial fibrillation (Conditional Recommendation, Moderate Quality Evidence).
• We recommend curative catheter ablation for symptomatic patients with typical atrial flutter as first line therapy or as a
reasonable alternative to pharmacologic rhythm or rate control therapy (Strong Recommendation, Moderate Quality Evidence).
15. The “CCS Algorithm” (“CHADS65”) for OAC Therapy in AF
12
Prevention of Stroke
Consider and modify (if possible) all factors influencing risk of bleeding during OAC treatment (hypertension, antiplatelet drugs, NSAIDs, corticosteroids,
excessive alcohol, labile INRs) and specifically bleeding risks for NOACs (low creatinine clearance, age ≥ 75, low body weight).
* A NOAC is preferred over warfarin for non-valvular AF
The use of NOACs is contraindicated in the presence of mechanical heart valves, rheumatic mitral stenosis, or moderate and severe nonrheumatic mitral stenosis.
“CCS algorithm” (“CHADS65”) for OAC therapy in AF
A e
CA or
Arterial as ular disease
oronary aorti eri heral
AC
o
antithromboti
thera y
AC ASA
S S S
Stro e A eri heral embolism or
y ertension or
eart Failure or
iabetes ellitus
C A S ris a tors
16. Prevention of Stroke
Definitions of Stroke Risk Factors 13
FACTOR
Congestive heart failure
Documented moderate to severe systolic dysfunction; signs and symptoms of heart
failure with reduced ejection fraction; or recent decompensated heart failure that
required hospitalization irrespective of ejection fraction
Resting blood pressure > 140 mm Hg systolic and/or > 90 mm Hg diastolic on at
least 2 occasions orcurrent antihypertensive pharmacological treatment
Age ≥ 65 years
Fasting plasma glucose concentration ≥ 7.0 mmol/L (126 mg/dL) or treatment with
oral hypoglycemic agents and/or insulin
Ischemic stroke: focal neurologic deficit of sudden onset diagnosed by a neurologist,
lasting > 24 hours, and caused by ischemia;
Transient ischemic attack: focal neurological deficit of sudden onset diagnosed by
a neurologist, lasting < 24 hours;
Peripheral embolism: thromboembolism outside the brain, heart, eyes, and lungs,
or pulmorany embolism (defined by the responsible physician)
Coronary artery disease, perpheral artery disease, or aortic plaque
Hypertension
Age 65
Diabetes mellitus
Stroke / transient ischemic attack / peripheral embolism
Vascular disease
DEFINITION
17. Recommendations for Dosage of Oral Anticoagulants Based on Renal Function
14
Prevention of Stroke
CrCL > 50 mL/min
ARISTOTLE, Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation; bid, twice daily; CrCl, creatinine clearance; INR,
international normalized ratio; RCT, randomized clinical trial.
*Consider dabigatran 110 mg oral bid if age > 75 years.
† Consider apixaban 2.5 mg oral bid if 2 of the 3 following criteria are present: (1) age > 80 years; (2) body weight < 60 kg; or (3) serum creatinine > 133 µmol/L.
‡ Dose-adjusted warfarin has been used, but data regarding safety and efficacy are conflicting
§ The ARISTOTLE trial did include patients with a CrCl as low as 25 mL/min, but this was a very small number of patients (1.5% of patients in the trial).
¶ Dose-adjusted warfarin has been used, but data regarding safety and efficacy are conflicting and might lean toward causing harm.
ll No published studies support a dose for this level of renal function; product monographs suggest the drug is contraindicated for this level of renal function.
Dose adjusted for
INR 2.0-3.0
150 mg bid* 20 mg daily 5 mg bid
CrCL 30-49 mL/min
Dose adjusted for
INR 2.0-3.0
Consider 110 mg bid
in preference to
150 bid
15 mg daily
5 mg bid
(consider 2.5 mg bid)†
CrCL < 15 mL/min
(or the patient is
dialysis-dependent)
No RCT Data¶
No RCT Datall
No RCT Datall
No RCT Datall
CrCL 15-29 mL/min No RCT Data‡
No RCT Data No RCT Data
Very limited
RCT data§
18. Reversal Agents for NOACs - Recommendations 15
• We recommend administering idarucizimab for emergency reversal of dabigatran's anticoagulant effect in patients with
uncontrollable or potentially life-threatening bleeding and/or in patients requiring urgent surgery for which normal hemostasis is
necessary (Strong Recommendation, Moderate Quality Evidence).
Practical tips - In the acute, life-threatening bleeding situation where standard resuscitation (such as local measures, transfusion,
etc) is not anticipated to be sufficient (e.g. ICH), or in the situation where it has not stabilized the patient, idarucizumab should be
administered as soon as possible. Although dilute thrombin time and ecarin clotting time were used to identify the presence of
dabigatran in REVERSE-AD, these tests are not widely available. Thrombin time (TT) and activated partial thromboplastin time
(aPTT) are widely available and can qualitatively identify the presence of active dabigatran in a patient, however obtaining these tests
should not delay the administration of idarucizumab. In many instances of life-threatening bleeding, clinicians have to base a
treatment decision on a history of dabigatran use rather than laboratory evidence. Renal function and timing of the last dose of
dabigatran provide key information regarding the likely extent of remaining dabigatran effect. The timing of surgery may permit
clinicians to obtain coagulation parameters like stat TT or aPTT to identify patients who no longer have dabigatran present, and who
would be unlikely to benefit from idarucizumab. No dose adjustment for idarucizumab is required in patients with renal impairment. In
some patients, coagulation parameters may rise between 12-24 hours after initial administration of idarucizumab, possibly reflecting
redistribution of extravascular dabigatran into the intravascular space. Reversing dabigatran therapy exposes patients to the
thrombotic risk of their underlying disease. OAC should be reintroduced as soon as medically appropriate.
Practical tips - In the acute, life-threatening bleeding situation where standard resuscitation (such as local measures, transfusion,
etc) is not anticipated to be sufficient (e.g. ICH), or in the situation where it has not stabilized the patient, idarucizumab should be
administered as soon as possible. Although dilute thrombin time and ecarin clotting time were used to identify the presence of
dabigatran in REVERSE-AD, these tests are not widely available. Thrombin time (TT) and activated partial thromboplastin time
(aPTT) are widely available and can qualitatively identify the presence of active dabigatran in a patient, however obtaining these tests
should not delay the administration of idarucizumab. In many instances of life-threatening bleeding, clinicians have to base a
treatment decision on a history of dabigatran use rather than laboratory evidence. Renal function and timing of the last dose of
dabigatran provide key information regarding the likely extent of remaining dabigatran effect. The timing of surgery may permit
clinicians to obtain coagulation parameters like stat TT or aPTT to identify patients who no longer have dabigatran present, and who
would be unlikely to benefit from idarucizumab. No dose adjustment for idarucizumab is required in patients with renal impairment. In
some patients, coagulation parameters may rise between 12-24 hours after initial administration of idarucizumab, possibly reflecting
redistribution of extravascular dabigatran into the intravascular space. Reversing dabigatran therapy exposes patients to the
thrombotic risk of their underlying disease. OAC should be reintroduced as soon as medically appropriate.
Values and Preferences: This recommendation places relatively greater value on the ability of idarucizimab to reverse coagulation
parameters indicative of dabigatran’s effect, its potential to decrease bleeding-related outcomes and risks of urgent surgery and its
safety and tolerability profile, and less value on the absence of a control group in the RE-VERSE AD trial
Values and Preferences: This recommendation places relatively greater value on the ability of idarucizimab to reverse coagulation
parameters indicative of dabigatran’s effect, its potential to decrease bleeding-related outcomes and risks of urgent surgery and its
safety and tolerability profile, and less value on the absence of a control group in the RE-VERSE AD trial and the cost of the drug.
Prevention of Stroke
19. Management of Antithrombotic Therapy - General Recommendations
16
Antithrombotic Therapy
When OAC is indicated in the presence of CAD, we suggest a NOAC in preference to warfarin for NVAF (Conditional Recommendation,
Low Quality Evidence).
We recommend that patients who have concomitant AF and CAD receive a regimen of antithrombotic therapy that is on the basis of a balanced
assessment of their risks of stroke, of a coronary event and of hemorrhage associated with use of antithrombotic agents (Strong Recommen-
dation, High Quality Evidence).
Practical Tip - When CAD is present, some expert clinicians prefer a combination of a NOAC and aspirin rather than NOAC alone in preference to
warfarin alone for patients perceived to be at higher risk of coronary events and low risk of major bleeding and may choose a NOAC alone as a
reasonable option in those with average to lower risk of coronary events and higher risk of bleeding.
Practical Tip - In general, the recommended doses of NOACs are the usual doses studied in the RCTs of NVAF. For patients requiring
combinations of antiplatelet and OAC agents for concomitant AF and CAD, we suggest that measures be employed to reduce the risk of bleeding,
including careful consideration of HAS-BLED risk factors and vigorous efforts to mitigate them; specific measures during invasive procedures (radial
access, small-diameter sheaths, early sheath removal from femoral site and minimized use of acute procedural anti-thrombotic therapies);
consideration of routine proton pump inhibitor (PPI); avoidance of prasugrel and ticagrelor in conjunction with OAC; the use of warfarin in the lower
INR range; consideration of the lower effective doses of NOACs; and delaying non-urgent catheterization until there is clarity about coagulation
status and renal function. If the risk of restenosis is relatively low, the option of a BMS rather than a second generation DES should be considered.
Values and Preferences: The suggestion for use of a NOAC rather than warfarin places relatively greater weight on the ease of use of NOACs
versus warfarin and on the data from RCTs of NOACs versus warfarin for NVAF, showing equal or greater reduction of stroke, equal or less major
bleeding, less intracranial bleeding and no net increase in CAD outcomes. It places relatively less weight on the absence of long-term data on the
effect of NOACs on coronary outcomes as opposed to the data for efficacy of warfarin.
•
•
General recommendations regarding antithrombotic therapy in the context of concomitant
AF and CAD(asymptomatic, stable CAD, elective PCI, NSTEACS or STEMI):
20. Antithrombotic Therapy
Management of Antithrombotic Therapy 17
Recommendations for Patients with an Indication for Primary Prevention or Stable CAD/
Arterial Vascular Disease
If the patient has no evidence of CAD/vascular disease and is aged < 65 years with no CHADS2
risk factors, we suggest no
antithrombotic therapy for stroke prevention (Conditional Recommendation, Moderate Quality Evidence).
If the patient has stable CAD/vascular disease and is aged < 65 years with no CHADS2
risk factors, we suggest aspirin 81
mg daily (Conditional Recommendation, Moderate Quality Evidence).
For patients with AF, with an indication for primary prevention or stable CAD/arterial vascular disease (peripheral vascular
disease or aortic plaque), the selection of antithrombotic therapy should be based on their risk of stroke as follows:
If the patient has stable CAD/vascular disease and is ≥ or the CHADS2
≥ 1, we recommend OAC therapy (Strong
Recommendation, High Quality Evidence).
•
•
•
21. Antithrombotic Therapy
Management of Antithrombotic Therapy
18
For patients with AF with an indication for primary CAD prevention
or stable CAD/arterial vascular disease
Age < 65 and CHADS2
= 0
No CAD / vascular disease
Age < 65 and CHADS2
= 0
Stable CAD / vascular disease
Age ≥ 65 or CHADS2
≥ 1
Stable CAD / vascular disease
†
No antithrombotic
therapy
ASA OAC* alone
* A NOAC is preferred over warfarin for non-valvular AF
† Primary CAD prevention with ASA may be considered
in selected high-risk patients
22. Antithrombotic Therapy
Management of Antithrombotic Therapy 19
Recommendations for Patients with AF and Recent Elective PCI
• ≥ 2
≥
2 I (Conditional Recommendation, Moderate Quality Evidence)
(Strong Recommendation, High Quality Evidence).
For patients with AF and recent elective PCI, the selection of antithrombotic therapy should be based on their risk of stroke
as follows:
• s 2
e the
2 2 ).
Practical Tip - patients at high stent and is
2 he g
2 n .
23. Antithrombotic Therapy
Management of Antithrombotic Therapy
20
For patients with AF and recent elective PCI
A e and C A S A e and C A S
ASA
Clo ido rel
or months
AC
Clo ido rel
or months
ASA alone
a ter months
AC alone
a ter months
* A NOAC is preferred over warfarin for non-valvular AF
24. Antithrombotic Therapy
Management of Antithrombotic Therapy 21
If the patient is aged ≥ 65 or the CHADS2
≥ 1 and no PCI is undertaken, we suggest the combination of clopidogrel 75 mg daily (rather than
prasugrel or ticagrelor) and OAC be given, without concomitant ASA, for 12 months, to be followed by OAC alone (Conditional Recommendation,
Low Quality Evidence).
If the patient is aged ≥ 65 or the CHADS2
≥ 1 and PCI is undertaken, we suggest the combination of aspirin 81 mg daily and clopidogrel 75 mg
daily and OAC (TT) for 3-6 months (duration depending on the perceived risks of coronary thrombosis and major bleeding). After 3-6 months we
suggest the combination of clopidogrel and OAC to be continued until 12 months after ACS, to be followed by OAC alone (Conditional
Recommendation, Low Quality Evidence).
•
•
Practical Tip - Some patients who are at high risk of stent thrombosis and whose risk of major bleeding is acceptable may continue the combination
of OAC and clopidogrel for longer than 12 months post ACS.
Practical Tip - Some patients at particularly high risk of major bleeding may have their clopidogrel discontinued earlier than 12 months and continue
to receive only OAC.
Practical Tip - Some clinicians may prefer the combination of clopidogrel and OAC beginning from the time of PCI, placing more weight on the
reduced bleeding and no increase of thrombotic events compared to TT in the WOEST trial and less value on the fact that only 25% of patients in
this trial had PCI for ACS. A combination of aspirin and ticagrelor, or aspirin and prasugrel, or aspirin and clopidogrel may also be used in preference
to TT for some patients with CHADS2
=1 at the lower end of the stroke risk spectrum (e.g. isolated hypertension), reserving TT or OAC + clopidogrel
for patients at higher stroke risk.
Values and Preferences: The suggestion of TT for the first 3-6 months places greater weight on more reduction of coronary events (versus OAC
+ clopidogrel) and on more SSE prevented (versus DAPT) but less weight on the increased risk of major bleeding. The balance of stroke/systemic
embolus prevented and major bleeds caused could be judged as appropriate only for patients with a higher risk of stroke (e.g. CHADS2
≥ 2).
If the patient is aged < 65 years with no CHADS2
risk factors, we recommend an APT therapy regimen without OAC, as per Part 7,
Recommendations 11-19 of the Supplementary Material (adapted from the CCS 2012 APT Guidelines).
For patients with AF, in association with NSTEACS or STEMI, the selection of antithrombotic therapy should
be based on their risk of stroke as follows:
•
Recommendations for Patients with AF, in Association with NSTEACS or STEMI
25. Antithrombotic Therapy
Management of Antithrombotic Therapy
22
For patients with AF in association with NSTEACS or STEMI
A e and C A S
o PC PC o PC PC
A e or C A S
ASA
i a relor or Clo ido rel
or months
ASA
i a relor or Prasu rel or Clo ido rel
or months
AC
Clo ido rel
or months
AC
Clo ido rel ASA
or to months
ASA alone
a ter months
ASA alone
a ter months
AC alone
a ter months
AC alone
a ter months
AC
Clo ido rel
throu h to months
* A NOAC is preferred over warfarin for non-valvular AF
26. Management of AF in the ED - Recommendations 23
S
mmediate is
or Stro e
i h is
o thera euti AC ee s and one o :
nset hours or un no n or
Stro e A months or
e hani al or rheumati al e disease
o is
Clear onset hours or
hera euti AC s
Pharma olo i al
or ele tri al C at -
(immediate anticoagulation in ED
before CV not required)
Antithrombotic therapy
- nitiate AC u on dis har e rom
or ontinue urrent AC i
a e or C A S
- ther ise initiate ASA i CA or
as ular disease
- arly e ert ollo -u to re ie
lon -term AC
Antithrombotic therapy
- nitiate immediate AC
in and ontinue or
ee s i any hi h-ris
eatures resent see bo
abo e
- arly ollo -u to re ie
lon -term AC
Antithrombotic therapy
- Continue AC or
ee s a ter C
- arly ollo -u re ie
lon -term AC
Antithrombotic therapy
- nitiate immediate AC
in and ontinue or
ee s
- arly ollo -u to
re ie lon -term AC
nstable - AF ausin :
y otension or
Cardia is hemia or
Pulmonary edema
Consider ur ent
ele tri al C i rate
ontrol not e e ti e
hera euti AC or
ee s be ore
out atient C
rans-eso a eal
e ho ardio ra hy
uided C
ate ontrol
s Patient Stable
Management of AF in the ED
27. Management of AF in the ED
Management of AF in the ED - Recommendations
24
28. Periprocedural Anticoagulation Management - Recommendations 25
Peri-Procedure / Antithrombotic Management
• Practical tip - Duration of preprocedural interruption of NOACs should be adjusted according to renal function (see Part 11,
Recommendations 6 and 7 of the Supplementary Material). The Thrombosis Canada Perioperative Anticoagulant Management
Algorithm is a helpful tool to aid decisions regarding periprocedural anticoagulation
(http://thrombosiscanada.ca/?page_id¼502&calc¼perioperativeAnticoagulantAlgorithm).
• When a decision to interrupt warfarin therapy for an invasive procedure has been made for a patient with AF/AFL, we suggest
that bridging therapy with LMWH or UFH be instituted when the INR is below therapeutic level only in patients at high risk of
thromboembolic events (CHADS2, score 4, mechanical heart valve, stroke/transient ischemic attack within 3 months, rheumatic
heart disease) (Conditional Recommendation, Low-Quality Evidence).
• We recommend no bridging (LMWH or UFH) for NVAF patients receiving NOACs who undergo elective surgery or invasive
procedures requiring interruption of anticoagulation (Strong Recommendation, Moderate-Quality Evidence).
• We suggest that interruption of anticoagulant therapy, particularly for VKAs, in a patient with AF/AFL is not necessary for most
procedures with a low risk of bleeding, such as cardiac device implantation (pacemaker or implantable defibrillator), and most
dental procedures (see table) (Conditional Recommendation, Moderate Quality Evidence).
Refer to the AF supplementary material for recommendations on the following:
• Preprocedural interruption of various antithrombotic agents: Part 11, Recommendations 4-7 of the Supplementary Material.
• Pre- and postprocedural management of heparin bridging: Part 11, Recommendations 10 and 11 of the Supplementary Material.
• Reintroduction of antithrombotic agents after an invasive procedure: Part 11, Recommendations 12 and 13 of the Supplementary
Material.
29. Bleeding Risks for Various Invasive / Surgical Procedures
26
Peri-Procedure / Antithrombotic Management
• Any surgery or procedure with neuraxial
(spinal or epidural) anesthesia
• Neurosurgery (intracranial or spinal)
• Cardiac surgery (e.g. CABG, heart valve
replacement)
• Major intra-abdominal surgery
• Major vascular surgery (e.g. aortic
aneurysm repair, aortofemoral bypass)
• Major orthopedic surgery (e.g. hip or knee
replacement)
• Lung resection surgery
• Urological surgery (e.g. prostatectomy,
bladder tumour resection)
• Extensive cancer surgery (e.g. pancreas,
liver)
• Intestinal anastomosis surgery
• Reconstructive plastic surgery
• Selected procedures (e.g. kidney biopsy,
prostate biopsy, cervical cone biopsy,
pericardiocentesis, colonic polypectomy)
• Other intra-abdominal surgery (e.g.
laparoscopic cholecystectomy, hernia
repair)
• Other general surgery (e.g. breast)
• Other intrathoracic surgery
• Other orthopedic surgery
• Other vascular surgery
• Non-cataract ophthalmologic surgery
• Gastroscopy or colonoscopy with biopsies
• Selected procedures (e.g. bone marrow
biopsy, lymph node biopsy)
• Complex dental procedure (e.g. multiple
tooth extractions)
• Dental extractions (1 or 2 teeth),
endodontic (root canal) procedure,
subgingival scaling or other cleaning
• Cataract surgery
• Dermatologic procedures (e.g. biopsy)
• Gastroscopy or colonoscopy without
biopsies
• Coronary angiography
• Permanent pacemaker insertion or
internal defibrillator placement (if bridging
anticoagulation is not used)
• Selected procedures (e.g. thoracentesis,
paracentesis, arthrocentesis)
The procedural/ surgical risk categorization list may be updated based on new information, and can be found at Thrombosis Canada. (http://thrombosiscanada.ca)
30. Surgical Therapy for AF - Recommendations 27
• We suggest that a surgical AF ablation procedure should be considered in association with mitral valve, aortic valve or CABG surgery in
patients with AF, when the likelihood of success is deemed to be high, the additional risk is low and sinus rhythm is expected to achieve
substantial symptomatic benefit (Conditional Recommendation, Moderate Quality Evidence).
• In patients with AF, we suggest that closure (excision or obliteration) of the LAA should be considered as part of the surgical ablation of AF
associated with mitral, aortic valve or coronary arterty bypass surgery if this does not increase the risk of the surgery (Conditional
Recommendation, Low Quality Evidence).
Values and preferences: This recommendation recognizes that individual institutional experience and patient considerations best determine
for whom the surgical procedure is performed. Importantly, the symptomatic benefit of sinus rhythm needs to be balanced with the attendant
risks of ablation surgery, including the need for permanent pacing. This recommendation also recognizes that LA endocardial access is not
routinely required for aortic or coronary surgery; limiting ablation to newer epicardial approaches.
Values and preferences: This recommendation places a high value on the potential for stroke reduction and a lower value on loss of atrial
transport-function with LAA-closure. It places less value on the need to continue OAC even after LAA surgical excision.
Surgical AF ablation procedures
Surgical LAA exclusion for stroke prevention
Surgical Therapy for AF
31. Prevention and Treatment of AF After Cardiac Surgery - Recommendations
28
AF After Cardiac Surgery
We recommend that postoperative AF may be appropriately treated with either a ventricular response rate-control strategy or a
rhythm-control strategy (Strong Recommendation, Moderate Quality Evidence).
Values and preferences: This recommendation places a high value on the randomized controlled trials investigating rate control as an
alternative to rhythm control for AF, including one trial specifically addressing the cardiac postoperative period. Choice of strategy should
therefore be individualized based on the degree of symptoms experienced by the patient.
Values and preferences: This recommendation places a high value on preventing POAF using novel therapies that are supported by
lower-quality data; with a higher value on the lower probability of adverse effects from magnesium versus colchicine. The use of biatrial pacing
needs to be individualized by patient and institution, as the potential for adverse effects may outweigh benefit based on local expertise.
We suggest that patients who have a contraindication to beta-blocker therapy and to amiodarone before or after cardiac surgery be
considered for prophylactic therapy to prevent POAF with intravenous magnesium (Conditional Recommendation, Low Quality Evidence) or
colchicine (Conditional Recommendation, Low Quality of Evidence) or with biatrial pacing (Conditional Recommendation, Low Quality of
Evidence).
32. Prophylactic Therapies for the Prevention of Post-Operative Tachyarrhythmias 29
Post-Operative Management of AF
35. Update your AF iCCS app
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and contains the most up-to-date
guideline information
Download the
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For more information visit CCS.CA/apps
36. Please visit us at
www.ccs.ca
Pocket Guide Print / Version Number: AF-2016-12-P1
Printing of this pocket guide made possible through grants provided by
Bayer and the Bristol-Myers Squibb and Pfizer alliance.