Diagnosis and Management of Atrial Fibrillation (AF) (2023 Update)
SUMMARY:
Atrial fibrillation (AF), the most common cardiac arrhythmia, increases stroke risk and can exacerbate underlying heart disease. The 2023 ACC/AHA/HRS Guideline for the Management of Patients with Atrial Fibrillation offers a comprehensive approach to treating this condition. This new document is an update to the 2014 and 2019 guidelines encompassing new staging system, addressing left atrial appendage occlusion, and emphasis on early and more aggressive rhythm control among other considerations. Of note, these recommendations apply to atrial fibrillation (AF) and atrial flutter (AFl).
- Stages of Atrial fibrillation
- Diagnosis and Workup
- Risk Factor Modification
- Assessing Thromboembolic Risk
- Anticoagulants
- Device Detection of New AF
- Alternatives to Anticoagulation
- Reversal of Bleeding of OAC Therapy
- Chronic CAD and AF
- Rate Control
- Rhythm Control
Stages of Atrial Fibrillation
- Stage 1: At risk for AF with the following risk factors
- Obesity| Hypertension| Sleep apnea| Alcohol use| Diabetes |Lack of fitness | Older age
- Stage 2: Pre-AF
- Evidence of structural or electrical findings predisposing to AF
- Atrial enlargement| Heart failure | Valve disease | Coronary artery disease| Frequent atrial premature beats
- Evidence of structural or electrical findings predisposing to AF
- AF: Further subdivided into
- Stage 3A: Paroxysmal AF |intermittent and terminates within 7 days of onset
- Stage 3B: Persistent AF| continuous and sustains >7 days and requires intervention
- Stage 3C: Long-standing persistent AF| continuous for >12 months
- Stage 3D: Successful AF ablation after ablation or surgical intervention
- Stage 4: Permanent AF
- No further attempts at rhythm control after shared decision making between patient and clinician
Diagnosis and Workup
- Diagnosed by EKG or cardiac monitoring
- Characteristic irregular rhythm without discrete p-waves
- Workup at time of diagnosis should include
- TTE | Thyroid function tests | CBC | Renal function and electrolytes | LFTs | CXR (if suspicion for heart failure or pulmonary disease) | Sleep study (if suspicion for sleep apnea)
- Outpatient management appropriate for hemodynamically stable patients without evidence of severe volume overload or acute coronary syndrome
Risk Factor Modification
- Patients at increased risk of AF or with AF should receive risk factor modifications
- Recommendations include
- At least 10% weight loss if overweight/obese
- Exercise training to target 210 minutes per week
- Smoking cessation
- Minimize or eliminate alcohol consumption.
- Optimal blood pressure control to target <130/80
- Screen for sleep apnea if symptoms suggestive.
Note: Caffeine abstinence to prevent AF episodes is of no benefit, although it may reduce symptoms in patients who report caffeine triggers or worsening AF symptoms
Assessing Thromboembolism Risk
- Goal is to prevent thromboembolic events
- Decision to start anticoagulation should always involve discussion of risks vs benefits
- Patients with AF should be assessed for their annual risk of thromboembolic events using validated risk scores (i.e CHA2DS2-VASc score) which estimates annual stroke risk based on various demographic and comorbid factors.
- Anticoagulation is recommended for score ≥2 in men, ≥3 in women
- Anticoagulation “may be considered” for score 1 in men, 2 in women
- Antiplatelet therapy for the sole indication of thromboembolism prevention in setting of AF is not recommended
- Use of bleeding risk scores (i.e HASBLED) has relatively poor discriminatory ability to predict bleeding
- Consider factors that specifically increase risk of bleeding
- Previous bleeding| Presence of anemia| pPedisposing medications
Anticoagulants
- Anticoagulation with warfarin is required for all patients with a mechanical valve and moderate to severe rheumatic mitral stenosis. DOACs are recommended over warfarin for all other patients.
- Warfarin
- Goal INR typically 2-3
- INR goal may be different for those with mechanical valves due to other co-morbid conditions
- Direct oral anticoagulants (DOACs)
- Dabigatran (Pradaxa) | Rivaroxaban (Xarelto) | Apixaban (Eliquis) | Edoxaban (Savaysa)
- All either superior or non-inferior to warfarin | Do not require INR monitoring | Have lower risk of major bleeding
- All have reduced dose options for CKD
- ESRD
- Use warfarin or apixaban (limited data to support this)
- Bridging
- Bridge with unfractionated or low molecular weight heparin to provide uninterrupted anticoagulation for patients with mechanical heart valves undergoing surgery or other invasive procedure,
- A brief interruption of therapy without bridging is considered safe for all others EXCEPT those with recent stroke|TIA
- Anticoagulation with antiplatelet therapy
- Patients with AF and recent coronary stenting who are on triple therapy (oral anticoagulant + aspirin + P2Y12 inhibitor) may be narrowed to double therapy (warfarin| dabigatran| apixaban |rivaroxaban + P2Y12 inhibitor) to reduce bleeding risk
Dosing
- Apixaban (Eliquis)
- Usual dose: 5 mg twice a day
- Adjusted dose: 2.5 mg twice a day if ≥2 of the following
- Age: ≥80 years
- Body weight: ≤60 kg
- Serum creatinine: ≥1.5 mg/dL
Note: Caution with use of apixaban and the following
- Other medications that can interfere with hemostasis: May increase risk of bleeding
- Aspirin and antiplatelet agents | Other anticoagulants | Heparin | Thrombolytic agents | SSRIs | SNRIs | NSAIDs (chronic use) | Fibrinolytics
- Combined P-gp and strong CYP3A4 inhibitors
- Ketoconazole | Itraconazole | Ritonavir
- Reduce dose by 50% in usual dosing regimen and do not use with 2.5 mg reduced dose | Dose does not need to be altered with clarithromycin
- Combined P-gp and strong CYP3A4 inducers: Avoid concomitant use
- Rifampin | Carbamazepine | Phenytoin | St. John’s wort
- Dabigatran (Pradaxa)
- CrCl >30 mL/min: 150 mg orally, twice daily
- CrCl 15 to 30 mL/min: 75 mg orally, twice daily
Note: Exercise caution with use of dabigatran and the following
- P-gp inducers rifampin: Avoid coadministration
- P-gp inhibitors in patients with CrCl 30-50 mL/min: Reduce dose or avoid
- P-gp inhibitors in patients with CrCl <30 mL/min: Not recommended
- Rivaroxaban (Xarelto)
- 15 or 20 mg, once daily with food
Note: Exercise caution with use of rivaroxaban and the following
- Avoid combined P-gp and strong CYP3A inhibitors and inducers
- Anticoagulants: Avoid concomitant use
- Renal impairment: Avoid or adjust dose
- Hepatic impairment: Avoid use in Child-Pugh B and C hepatic impairment or with any degree of hepatic disease associated with coagulopathy
Device Detection of New AF (Pacemaker or Defibrillator)
- Device-detected atrial high rate episodes lasting >24 hours and a CHA2DS2-VASc score of ≥ 2
- It is reasonable to initiate OAC
- Device-detected atrial high rate episodes lasting between 5 minutes and 24 hours and a CHA2DS2-VASc score ≥3 or equivalent stroke risk
- It may be reasonable to initiate anticoagulation within a shared decision-making that considers episode duration and individual patient risk
- Device-detected atrial high rate episodes lasting <5 minutes and without another indication for OAC
- Should not receive OAC
Alternatives to Anticoagulation
- Since thromboemboli tend to develop in the left atrial appendage (LAA), non-pharmacologic strategies for minimizing stroke risk involve occluding or removing the LAA
- Percutaneous LAA occlusion (Watchman vs Amplatzer Amulet device): For patients with a contraindication to long-term anticoagulation
- Surgical LAA occlusion/excision: Recommended for those undergoing cardiac surgery with CHA2DS2-VASc scorecha ≥ 2
- OAC should be continued
- Surgical LAA exclusion in absence of continued anticoagulation to reduce risk of thromboembolism is uncertain
Reversal of Bleeding on OAC Therapy
- Patients with AF who develop life-threatening bleeding
- Treat with idarucizumab to rapidly reverse dabigatran’s anticoagulant effect
- Patients with AF who develop life-threatening bleeding
- Treat with andexanet alfa vs 4-factor PCC to rapidly reverse factor Xa inhibitors (apixaban|rivaroxaban) anticoagulation effect
- Patients with AF who develop life-threatening bleeding on warfarin
- Treat with 4-factor PCC in addition IV vitamin K to rapidly correct INR
Chronic CAD and AF
- In patients with AF and chronic CAD (>1 year beyond revascularization) without history of stent thrombosis
- OAC monotherapy is recommended over combination of OAC and single antiplatelet therapy (i.e. ASA or Plavix) to decrease risk of major bleeding
Rate Control
- Goal: To reduce symptoms, improve intra-cardiac hemodynamics and perfusion, and prevent tachycardia-induced cardiomyopathy
- Choosing a rate control strategy
- Beta blockers (metoprolol| carvedilol| atenolol) or nondihydropyridine calcium channel blockers (diltiazem|verapamil) are first-line
- Avoid 1st generation CCBs in heart failure with reduced EF
- Second-line options include digoxin and amiodarone (not for long-term use due to toxicities)
- Strict (<80 bpm) vs. lenient (<110 bpm) rate control
- Lenient approach acceptable as long as patient is asymptomatic and with preserved EF
Rhythm Control
- Historically, felt not to be superior to rate control
- Newer data (EAST-AFNET 4, STOP-AF, EARLY-AF) have shown superiority for rhythm control (anti-arrhythmic or ablation) over rate control especially for patients newly diagnosed with atrial fibrillation within the first year
- May be indicated for
- New-onset AF| paroxysmal AF| persistent symptoms | no or mild left atrial enlargement| difficulty achieving rate control | young age| tachycardia-induced cardiomyopathy
- These approaches generally require expert consultation with cardiac electrophysiologist
- Electrical cardioversion
- In non-emergent setting, requires anticoagulation three weeks pre- and four weeks post-procedure (if duration of AF >48 hours or unknown)
- Often preceded by TEE to exclude LA thrombus
- Even if AF <48 hours, consider imaging evaluation to exclude intracardiac thrombus in patients with elevated thromboembolic risk
- Maintaining sinus rhythm
- Typically achieved with antiarrhythmics (e.g. amiodarone| dofetilide| flecainide)
- Caution: These drugs have significant side effects and toxicities
- Catheter ablation
- For symptomatic paroxysmal AF in whom anti-arrhythmic drugs have been
- Ineffective | contraindicated |not tolerated | not preferred
- 1st line therapy for selected patients (younger with few comorbidities) with symptomatic paroxysmal AF to improve symptoms and reduce progression to persistent AF
- Beneficial to improve symptoms, ventricular function, cardiovascular outcomes for patients with AF and HFrEF
- For symptomatic paroxysmal AF in whom anti-arrhythmic drugs have been
Learn More – Primary Sources:
AAFP: Diagnosis and Treatment of Atrial Fibrillation
STOP-AF (rhythm control superior to rate control)
EARLY-AF (rhythym control superior of rate control)
EAST-AFNET (rhythm control superior to rate control )
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