Afib Slides 2011 Unrestricted

Canadian Cardiovascular Society 2010 Atrial Fibrillation Guidelines
CCS AF Guidelines 2010 Primary Panel

Anne Gillis (co chair) Allan Skanes (co chair) John Cairns Stuart Connolly Jafna Cox Paul Dorian Jeff Healey Laurent Macle Sean McMurtry Brent Mitchell Stanley Nattel Pierre Pag Ratika Parkash P. Timothy Pollak Michael Stephenson Ian Stiell Mario Talajic Teresa Tsang Atul Verma
Atrial Fibrillation Guidelines
CCS AF Guidelines 2010 Secondary Panel

Malcolm Arnold David Bewick Vidal Essebag Milan Gupta Brett Heilbron Charles Kerr Bob Kiaii Jan Surkes George Wyse
Canadian Cardiovascular Society Atrial Fibrillation Guidelines 2010: Implementing GRADE and Achieving Consensus
Anne M Gillis MD Allan C Skanes MD With special acknowledgement of Jan Brozek MD, PhD
A New Approach to Guideline Development & Evaluation
GRADE
Grading of Recommendations, Assessment, Development and Evaluation
GRADE Approach
Clear separation of 2 issues: 1. Four Categories of Quality of Evidence:
High, Moderate, Low or Very Low
2. Strength of Recommendations: 2 Grades

Strong or Conditional (weak) Quality of evidence only one factor
GRADE: Rating Quality of Evidence

Quality
High
Comments
Future research unlikely to change confidence in estimate of effect; e.g. multiple well designed, well conducted clinical trails. Further research likely to have an important impact on confidence in
Moderate
estimate of effect and may change the estimate e.g. limited clinical trials,
inconsistency of results or study limitations. Further research very likely to have a significant impact in the estimate
Low
of effect and is likely to change the estimate e.g. small number of clinical studies or cohort observations. The estimate of effect is very uncertain; e.g. case studies; consensus
Very Low
opinion.
Modified with permission from: Guyatt GH, et al. BMJ 2008;336:926
Factors Determining the Strength of the Recommendation

Factor
Quality of Evidence
Comment
The higher the quality of evidence the greater the probability that a strong recommendation is indicated. e.g. strong recommendation that patients with AF at moderate to high risk of stroke be treated with oral anticoagulants. The greater the difference between desirable and undesirable effects the greater the probability that a strong recommendation is indicated e.g. strong recommendation that patients with AF 48 hr duration receive oral anticoagulation therapy for at least 3 weeks prior to planned cardioversion and 4 weeks following. The greater the variation or uncertainty in values and preferences, the higher the probability that a conditional recommendation is indicated e.g. ASA may be a reasonable alternative to oral anticoagulant therapy in patients at low risk of stroke. The higher the cost the lower the likelihood that a strong recommendation is indicated e.g. conditional recommendation for catheter ablation as first line therapy for AF.
Difference between desirable and undesirable effects Values and Preferences
Cost
Modified with permission from: Guyatt GH, et al. BMJ 2008;336:926
Canadian Cardiovascular Society Atrial Fibrillation Guidelines 2010: Etiology and Investigation
Jeff S Healey MD Ratika Parkash MD P Timothy Pollak MD Teresa SM Tsang MD Paul Dorian MD
Establish Pattern of Atrial Fibrillation

Newly Diagnosed AF
Paroxysmal
Persistent
Permanent
Modified with permission from Fuster et al Circulation 2006;114:e257-354.
History
Establish Severity (including impact on QOL) Identify Etiology Identify reversible causes (hyperthyroidism, ventricular pacing, SVT, exercise) Identify factors whose treatment could reduce recurrent AF or improve overall prognosis (i.e. hypertension, sleep apnea, left ventricular dysfunction) Identify potential triggers (i.e. alcohol, intensive aerobic training) Identify potentially heritable causes of AF (particularly in lone AF)
Determine thromboembolic risk (e.g. CHADS2 Score)

Determine bleeding risk to guide appropriate antithrombotic therapy Review prior pharmacologic therapy for AF, for efficacy and adverse effects
Physical Examination
Measure blood pressure and heart rate
Determine patient height and weight Comprehensive precordial cardiac examination 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 repolarization). Document baseline PR, QT and QRS intervals. Arrhythmia Monitoring Over Time (Holter or Event Recorder) To document AF, assess efficacy of rate or rhythm control
Echocardiogram
Assess ventricular size / LV wall thickness / function Evaluate left atrial size (if possible, left atrial volume) Exclude significant valvular or congenital heart disease (particularly atrial septal defects) Estimate ventricular filling pressures and pulmonary arterial pressure
Recommendations Etiology and Investigations

All patients with AF should have a complete history and physical examination, electrocardiogram, echocardiogram, basic laboratory investigations. Details are highlighted in Table 1.
Other ancillary tests should be considered under specific circumstances. Details included in Table 2.
Strong Recommendation Low Quality Evidence

Practical Tips
Aggressive treatment of hypertension may prevent or reduce recurrences
Choice of antihypertensive therapy should favor rate controlling drugs e.g. -blockers and Ca2+ channel blockers vs inhibitors of renin angiotensin system. Identify and treat obstructive sleep apnea
Establish AF Severity
Use to Guide Therapeutic Approach
CCS SAF Score 0 Impact on QOL Asymptomatic
1
2 3
Minimal effect on QOL

Minor effect of QOL Moderate effect on QOL
Severe effect on QOL

Dorian et al Can J Cardiol 2006;22:383-386
Recommendations Quality of Life

We recommend that the assessment of patient well being, symptoms, and quality of life (QOL) be part of the evaluation of every patient with AF. We suggest that QOL of the AF patient can be assessed in routine care using the CCSSAF scale. Strong Recommendation Low Quality of Evidence Conditional Recommendation Low Quality of Evidence
Values and Preferences: These recommendations recognize that improvement in QOL is a high priority for therapeutic decision making.
CCS SAF Score CCS SAF 0 CCS SAF 1
Impact Asymptomatic
EHRA Class EHRA I EHRA II
Impact No symptoms Mild symptoms
Minimal effect on QOL

Modest effect on QOL
CCS SAF 2
EHRA III
CCS SAF 3
Moderate effect on QOL Severe effect on QOL
EHRA IV
Severe symptoms; daily activity affected Disabling symptoms; Normal daily activity discontinued
CCS SAF 4
Canadian Cardiovascular Society Atrial Fibrillation Guidelines 2010: AF/AFL Rhythm Management
Anne M Gillis MD Atul Verma MD Mario Talajic MD Stanley Nattel MD Paul Dorian MD
Overview of AF Management
AF Detected
Detection and Treatment of Precipitating Causes
Assessment of Thromboembolic Risk (CHADS2)
Management of Arrhythmia
ASA OAC
Rate Control
Rhythm Control
No antithrombotic therapy may be appropriate in selected young patients with no stroke risk factors
Goals of AF 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
Recommendations Rx Goals
We recommend that the goals of ventricular rate control should be to improve symptoms and clinical outcomes which are attributable to excessive ventricular rates We recommend that the goals of rhythm control therapy should be to improve patient symptoms and clinical outcomes, and that these do not necessarily imply the elimination of all AF Strong Recommendation Low Quality Evidence Strong Recommendation Moderate Quality Evidence
Values and Preferences These recommendations place a high value on the decision of individual patients to balance relief of symptoms and improvement in QOL and other clinical outcomes with the potential greater adverse effects of Class I/III antiarrhythmic drugs compared to rate control therapy.
Referral for Specialty Care

Most patients with AF/AFL should be considered for referral to a cardiologist or an internist with an interest in cardiovascular disease for an expert opinion on management. Patients 35 yr old with symptomatic AF should be referred to an arrhythmia specialist to rule out other forms of SVT that may trigger AF and that would be best treated by radiofrequency ablation. Patients who remain highly symptomatic despite multiple trials of antiarrhythmic drug therapy, or who remain unresponsive to, or intolerant of rate controlling therapies should be referred to an arrhythmia specialist for an expert opinion on management alternatives.
Rate or Rhythm Control?

How do you decide if you are going to pursue rate or rhythm control for a patient with AF? No right or wrong answer Often, the two are simultaneous: Rhythm control requires good rate control when patient goes back into AF Need to continuously re-evaluate the strategy as the AF progresses What may have been a good initial strategy may no longer be warranted
Factors Influencing Decision of Rate vs Rhythm Control

Favours Rate Control
Persistent AF
Favours Rhythm Control

Paroxysmal AF Newly Detected AF
Less Symptomatic > 65 years of age
More Symptomatic < 65 years of age
Hypertension
No History of Congestive Heart Failure Previous Antiarrhythmic Drug Failure
No Hypertension
Congestive Heart Failure clearly exacerbated by AF No Previous Antiarrhythmic Drug Failure
What is Optimal Target Heart Rate?

RACE II suggested that strict rate control (< 80 bpm at rest, < 110 bpm with activity) was no different compared to lenient strategy (< 110 bpm at rest) However, actual HR in both groups were 75 and 86 bpm respectively Thus, the trial was not that lenient Few patients had HR > 100 bpm
Ventricular Rate Control

We recommend that ventricular rate be assessed at rest in all patients with persistent and permanent AF/AFL. We recommend that heart rate during exercise be assessed in patients with persistent or permanent AF/AFL and associated exertional symptoms. We recommend that treatment for rate control of persistent/permanent AF/AFL should aim for a resting heart rate of less than 100 beats per minute. Strong Recommendation Moderate Quality Evidence Strong Recommendation Moderate Quality Evidence Strong Recommendation High Quality Evidence
Values and Preferences These recommendations place a high value on the randomized clinical trials and other clinical studies demonstrating that ventricular rate control of AF is an effective treatment approach for many patients with AF.
Rate Control Drug Choices
No Heart Disease Hypertension -blocker Diltiazem Verapamil Combination Rx Digitalis
CAD
Heart Failure
-blocker* Diltiazem Verapamil
-blocker digitalis
Dronedarone
*-blockers preferred in CAD Digitalis may be considered as monotherapy in sedentary individuals

We recommend -blockers or nondihydropyridine calcium channel blockers as initial therapy for rate control of AF/AFL in most patients without a past history of MI or LV dysfunction. 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 LV systolic dysfunction. We suggest that digoxin be added to therapy with beta-blockers or calcium channel blockers in patients whose heart rate remains uncontrolled. Strong Recommendation Moderate Quality Evidence Conditional Recommendation Moderate Quality Evidence Conditional Recommendation Moderate Quality Evidence

We suggest that dronedarone may be added for additional rate control in patients with uncontrolled ventricular rates despite therapy with -blockers, calcium channel blockers and/or digoxin. We suggest that amiodarone for rate control should be reserved for exceptional cases in which other means are not feasible or are insufficient. Conditional Recommendation Moderate Quality Evidence Conditional Recommendation Low Quality Evidence
Values and Preferences These recommendations recognize that selection of rate control therapy needs to be individualized based on the presence or absence of underlying structural heart disease, the activity level of the patient and other individual considerations.
Recommendation
We recommend that treatment for rate 2010 CCS control of persistent/permanent AF or AFL should aim for a resting heart rate Guidelines < 100 bpm Reasonable to initiate treatment with a lenient rate control protocol aimed at resting HR <110 bpm. Reasonable to 2010 ESC adopt a stricter rate control strategy Guidelines when symptoms persist or tachycardiomyopathy occurs, despite lenient rate control: HR <80 Treatment to achieve strict rate control of heart rate is not beneficial compared 2010 to achieving a resting heart rate < 110 ACCF/AHA/HRS bpm in patients with persistent AF who Focused have stable ventricular function (LVEF > Update 0.40) and no or acceptable symptoms related to AF HR <80 bpm at rest and <110 bpm 2004 CCS during 6 min hallwalk
Strength /Class of Recommendation
Level or Quality of Evidence

High
Strong
IIa
III no benefit
Guidelines
IIa
Ventricular Rate Control Previous MI or LV Systolic Dysfunction

We recommend beta-blockers as initial therapy for rate control of AF/AFL in patients with myocardial infarction or left ventricular systolic dysfunction Strong Recommendation High Quality Evidence
Values and Preferences This recommendation places a high value on the results of multiple randomized clinical trials reporting the benefit of beta-blockers to improve survival and decrease the risk of recurrent myocardial infarction and prevent new-onset heart failure following myocardial infarction as well as the adverse effects of calcium channel blockers in the setting of heart failure.
Ventricular Rate Control AV Junction Ablation

We recommend AV junction ablation and implantation of a permanent pacemaker in symptomatic patients with uncontrolled ventricular rates during AF despite maximally tolerated combination pharmacologic therapy Strong Recommendation Moderate Quality Evidence
Values and Preferences This recommendation places a high value on the results of many small randomized trials and one systematic review reporting significant improvements in quality of life and functional capacity as well as a decrease in hospitalizations for AF following AV junction ablation in highly symptomatic patients.
-blockers for Rate Control

Drug
atenolol bisoprolol metoprolol
Dose
50 150 mg p.o. daily 2.5 10 mg p.o. daily 25 mg- 200mg p.o. bid 20 160 mg p.o. daily - bid 80 240 mg p.o. tid
Adverse Effects
bradycardia, hypotension, fatigue, depression as per atenolol as per atenolol
nadolol
propranolol*
as per atenolol
as per atenolol
* Sustained release preparations are available
Ca2+ Channel Blockers or Digoxin for Rate Control

Drug verapamil * Dose 120 mg p.o. daily 240 mg p.o. bid 120-280 mg p.o. daily - bid 0.125 0.25 mg p.o. daily Adverse Effects bradycardia, hypotension, constipation bradycardia, hypotension, ankle swelling bradycardia, nausea, vomiting, visual disturbances
diltiazem *
digoxin
* Sustained release preparations are available
Rhythm Control Recommendations

We recommend use of maintenance oral antiarrhythmic therapy as first-line therapy for patients with recurrent AF in whom long-term rhythm control is desired (see flow charts). We recommend that oral antiarrhythmic drug therapy should be avoided in patients with AF/AFL and advanced sinus or AV nodal disease unless the patient has a pacemaker/implantable defibrillator Strong Recommendation Moderate Quality Evidence Strong Recommendation Low Quality Evidence
We recommend that an AV blocking agent should be used in patients with AF/AFL being treated with a class I antiarrhythmic drug (e.g. propafenone or flecainide) in the absence of advanced AV node disease.
Values and preferences These recommendations place a high value on the decision of individual patients to balance relief of symptoms and improvement in QOL and other clinical outcomes with the potential greater adverse effects of Class I/III antiarrhythmic drugs compared to rate control therapy.
Rhythm Control Strategy

We recommend the optimal treatment of precipitating or reversible predisposing conditions of AF prior to attempts to restore/maintain sinus rhythm. We recommend a rhythm control strategy for patients with AF/AFL who remain symptomatic with rate control therapy or in whom rate control therapy is unlikely to control symptoms. Strong Recommendation Low Quality Evidence Strong Recommendation Moderate Quality Evidence
We recommend that the goal of rhythm control therapy should be improvement in patient symptoms and clinical outcomes, and not necessarily the elimination of all AF.
Strong Recommendation Moderate Quality Evidence
Values and Preferences These recommendations place a high value on the decision of individual patients to balance relief of symptoms and improvement in QOL and other clinical outcomes with the potential greater adverse effects of the addition of Class I/III antiarrhythmic drugs to rate control therapy.
Antiarrhythmic Drug Choices Normal Ventricular Function
Dronedarone Flecainide* Propafenone* Sotalol Catheter Ablation Amiodarone

* Class I agents should be AVOIDED in CAD
They should be combined with AV-nodal blocking agents Sotalol contraindicated in women >65 yrs taking diuretics Drugs listed in alphabetical order
Antiarrhythmic Drug Choices Abnormal Left Ventricular Function
EF > 35%
EF 35%
Amiodarone Dronedarone Sotalol*
Amiodarone
Catheter Ablation
* Sotalol should be used with caution with EF 35-40% Contraindicated in women >65 yrs taking diuretics
Pill in the Pocket For Rhythm Control

We recommend intermittent antiarrhythmic drug therapy ("pill in pocket") in symptomatic patients with infrequent, longer-lasting episodes of AF/AFL as an alternative to daily antiarrhythmic therapy. Strong Recommendation Moderate Quality Evidence
Single dose flecainide (200-300 mg) or propafenone (450-600 mg) as an oral dose Often prescribed with a short-acting betablocker at the same time (metoprolol 50-100 mg)
Values and preferences This recommendation places a high value on the results of clinical studies demonstrating the efficacy and safety of intermittent antiarrhythmic drug therapy in selected patients.
Class IC Drugs
Drug
Flecainide 50-150 mg BID
Efficacy
30-50%
Toxicity
Ventricular tachycardia Bradycardia
Comments
Contraindicated in patients with CAD or LV dysfunction
Rapid ventricular response Should be combined with an to AF or atrial flutter (1:1 conduction) AV nodal blocking agent
Propafenone 30-50% 150-300 mg TID
Ventricular tachycardia Bradycardia
Contraindicated in patients with CAD or LV dysfunction
Rapid ventricular response Should be combined with an to AF or atrial flutter (1:1 conduction) Abnormal taste AV nodal blocking agent
Class III Drug

Amiodarone 100- 200 mg OD (after 10gm loading)
Efficacy
60-70%
Toxicity
Photosensitivity Bradycardia GI upset Thyroid dysfunction Hepatic toxicity Neuropathy, tremor Pulmonary toxicity Torsades de pointes (rare) GI upset Bradycardia
Comments
Low risk of proarrhythmia Limited by systemic side effects Most side effects are dose & duration related
Dronedarone
400 mg BID
40%
Sotalol
30-50%
80-160 mg BID
Torsades de pointes Bradycardia Beta-blocker side effects
Only antiarrhythmic shown to reduce hospitalizations and cardiovascular mortality May increase mortality in patients with recently decompensated heart failure, EF <35% Effective rate control agent New drug limited experience outside trials Should be avoided in patients at high risk of Torsades de pointes VT especially women >65 years taking diuretics or those with renal insufficiency QT interval should be monitored 1 week after starting Use cautiously when EF<40%
Rhythm Control Does Not Replace Anticoagulation

No evidence that AF reduction via antiarrhythmic therapy reduces the risk of stroke/thromboembolism Patients must continue on appropriate anticoagulation according to their individual embolic risk (CHADS2 score)
Cardioversion for Rhythm Control

We recommend electrical or pharmacologic cardioversion for restoration of sinus rhythm in patients with AF/AFL selected for rhythm control therapy who are unlikely to convert spontaneously. We recommend pre-treatment with antiarrhythmic drugs prior to electrical cardioversion in patients who have had AF recurrence post-cardioversion without antiarrhythmic drug pre-treatment. Strong Recommendation Low Quality Evidence Strong Recommendation Moderate Quality Evidence
Values and preferences These recommendations place a high value on the decision of individual patients to pursue a rhythm control strategy for improvement in quality of life and functional capacity.
Pacing for Rhythm Control

We suggest that, in patients requiring pacing for the treatment of symptomatic bradycardia secondary to sinus node dysfunction, atrial or dual chamber pacing be generally used for the prevention of AF We suggest that, in patients with intact AV conduction, pacemakers be programmed to minimize ventricular pacing for prevention of AF Conditional Recommendation High Quality Evidence Conditional Recommendation Moderate Quality Evidence
Values and preferences These recommendations recognize a potential benefit of atrial or dual chamber pacing programmed to minimize ventricular pacing to reduce the probability of AF development following pacemaker implantation.
Pacing Mode and AF

Danish AAI vs VVI CTOPP Extended CTOPP MOST Danish AAI vs DDD
Number Age (yr) Pacing Indication
225 71 17 SND
2568 73 10 All pacemaker patients
2568 73 10 All pacemaker patients 6.4
2050 74 (67-80) SND
177 74 9 SND
Follow-up (yr) Pacing Modes
5.5
3.1
2.7
2.9 AAI vs DDDR-s vs DDDR-l
AAI vs VVI AAI/R or DDD/R AAI/R or DDD/R DDDR vs VVIR vs VVI/R vs VVI/R 4.5 vs 5.7 7.9 vs 10.0
AF Occurrence (%/yr)
4.1 vs 6.6
5.3 vs 6.3
2.4 vs 8.3 vs 6.2
Risk Reduction (%)
46
18
20
21
73
P value
0.012
0.05
0.009
0.008
0.02
Canadian Cardiovascular Society Atrial Fibrillation Guidelines 2010: Catheter Ablation of Atrial Fibrillation and Flutter
Atul Verma MD Jafna L Cox MD Laurent Macle MD Allan C Skanes MD
Systematic Review of RCTs Ablation vs Drug Rx

Ablation 28/32 12/15 46/53 85/99 Control 13/35 6/15 13/59 24/99 OR 11.85 6.0 23.3 19.0 95% CI 3.4-41.4 1.2-30.7 8.5-63.6 9.2-39.3
38/68
266/344
6/69
102/346
13.3
15.8
5.1-34.9
10.1-24.7
9 RCTs / 3 systematic reviews in 1274 patients who have failed 1 drug uniformly demonstrate large differences in recurrence of AF (OR 9.74 95% CI, 3.98 to 23.87) in favour of ablation vs AAD Piccini JP et al. Circ Arrhythm 2009;2:626
Worldwide AF Ablation (03-06)

Type of Complication (n=14,218) Femoral pseudoaneurysm AV fistulae Pneumothorax Valve damage/requiring surgery Tamponade Transient ischemic attack PV stenosis requiring intervention Stroke Permanent diaphragmatic paralysis Death Atrium-esophageal fistulae No of Pts 152 88 15 11/7 213 115 48 37 28 25 3 Rate% 0.93 0.54 0.09 0.07 1.31 0.71 0.29 0.23 0.17 0.15 0.02
TOTAL
741
4.54%
Cappato R et al. Circ Arrhythm Electrophysiol. 2010;3:32-8
Recommendations Ablation
We recommend catheter ablation of AF in patients who remain symptomatic following adequate trials of anti-arrhythmic drug therapy and in whom a rhythm control strategy remains desired. We suggest catheter ablation to maintain sinus rhythm in select patients with symptomatic AF and mild-moderate structural heart disease who are refractory or intolerant to at least one antiarrhythmic medication. Strong Recommendation Moderate Quality Evidence
Conditional 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 AF.
Conditional Recommendation Low Quality Evidence
Values and Preferences: These recommendations recognize that the balance of risk with ablation and benefit in symptom relief and improvement in quality of life must be individualized. They also recognize that patients may have relative or absolute cardiac or non-cardiac contra-indications to specific medications.
Recommendations Ablation
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. In patients with evidence of ventricular preexcitation during AF, we recommend catheter ablation of the accessory pathway, especially if AF is associated with rapid ventricular rates, syncope, or a pathway with a short refractory period. In young patients with lone, paroxysmal AF, we suggest an electrophysiological study to exclude a reentrant tachycardia as a cause of AF; if present, we suggest curative ablation of the tachycardia. Strong Recommendation Moderate Quality Evidence Strong Recommendation Low Quality Evidence Conditional Recommendation Very Low Quality Evidence
Comparison of North American and European Guidelines

CCS Guidelines
Strength Paroxysmal* Persistent* Failed 1 drug Failed 2 drugs 1st Line PAF / sign. structural heart disease Conditional Conditional Conditional Strong Conditional Level of Evidence Moderate Moderate Moderate Moderate Low
ESC Guidelines
Class IIa (Conditional) IIa (Conditional) --IIb (Conditional) Level of Evidence A (High) B (Moderate) --B (Moderate)
ACCF/AHA/HRS
Class I (Strong) IIa (Conditional) I (Strong) --Level of Evidence A (High) A (High) A (High) ---
--
--
--
--
IIb (Conditional)
A (High)
* Applies to patients with symptomatic AF and failed at least one anti-arrhythmic drug. Dictates ablation performed in experienced centre in patient with minimal heart disease -- Not directly addressed. Often this group is incorporated into other recommendations
Canadian Cardiovascular Society Atrial Fibrillation Guidelines 2010: Management of recent onset atrial fibrillation and atrial flutter in the emergency department
Ian G. Stiell, MD, MSc Laurent Macle, MD
ED Management of Recent Onset AF/AFL

We recommend that in stable patients with recent-onset AF/AFL, a strategy of rate control or rhythm control could be selected Strong Recommendation High Quality Evidence
Values and Preferences This recommendation places a high value on the randomized control trials investigating rate control as an alternative to rhythm control for AF/AFL, recognizing that these trials did not specifically address the ED environment.
Hemodynamically Unstable Patients with AF/AFL

We recommend for patients with acute hemodynamic instability secondary to rapid recent-onset AF/AFL, immediate electrical conversion to sinus rhythm Strong Recommendation Low Quality Evidence
Values and Preferences This recommendation places a high value on the immediate management of hemodynamic instability and a lower value on anticoagulation status under these circumstances. It is also recognized that this is a relatively rare circumstance and that in most cases, stroke risk and anticoagulation status can be considered prior to immediate cardioversion.
Electrical Cardioversion
We recommend that electrical cardioversion may be conducted in the ED with 150-200 joules biphasic waveform as the initial energy setting. Strong Recommendation Low Quality Evidence
Values and Preferences This recommendation places a high value on the avoidance of repeated shocks and the avoidance of ventricular fibrillation that can occur with synchronized cardioversion of AF at lower energy levels. It is recognized that the induction of VF is a rare but easily avoidable event.
In hemodynamically stable patients with AF/AFL of known duration < 48 h in whom a strategy of rhythm control has been selected: We recommend that rate-slowing agents alone are acceptable while awaiting spontaneous conversion Strong Recommendation Moderate Quality Evidence Strong Recommendation Moderate Quality Evidence Conditional Recommendation Low Quality Evidence
We recommend that synchronized electrical cardioversion or pharmacological cardioversion may be used when a decision is made to cardiovert patients in the emergency department. See Tables for drug recommendations. We suggest that antiarrhythmic drugs may be used to pre-treat patients before electrical cardioversion in ED in order to decrease early recurrence of AF and to enhance cardioversion efficacy
Values and Preferences These recommendations place a high value on determination of the duration of AF/AFL as a determinant of stroke risk with cardioversion. Also, individual considerations of the patient and treating physician are recognized in making specific decisions about method of cardioversion.
Strategy of rhythm-control for recent-onset AF/AFL

Known duration < 48 h (and not high-risk patients1) Duration > 48 h or unknown or high-risk patients1
Failed CV
Hemodynamically unstable
Hemodynamically stable
Ratecontrol
Urgent electrical cardioversion2
Pharmacological or electrical cardioversion2
Therapeutic OAC for 3 weeks before cardioversion
TEE-guided cardioversion (OAC initiated with heparin bridging)3
Successful CV
Antithrombotic therapy
-In general, no prior or subsequent anticoagulation is required. -If AF/AFL persists or recurs or if AF/AFL has been recurrent, antithrombotic therapy as appropriate (CHADS2 score) should be initiated and continued indefinitely. -Early follow-up to review antithrombotic strategy.
1Patients 2150-200J
Antithrombotic therapy
-OAC continued for 4 consecutive weeks. -If AF/AFL persists or recurs or if AF/AFL has been recurrent, antithrombotic therapy as appropriate (per CHADS2 score) should be continued indefinitely. -Early follow-up should be arrange to review ongoing antithrombotic strategy.
at particularly high risk of stroke (e.g. mechanical valve, rheumatic heart disease, recent stroke/TIA) biphasic waveform preferred 3Heparin must be initiated and continued until a therapeutic level of oral anticoagulation has been established.
Rate Control: IV Therapy

Drug
Diltiazem*
Dose
0.25 mg/kg IV bolus over 10 min; repeat at 0.35 mg/kg IV 2.5-5mg IV bolus over 2 min; up to 3 doses
0.075-0.15mg/kg over 2 min 0.25 mg IV each 2 h; up to 1.5mg
Risks
Hypertension, bradycardia Hypotension, bradycardia
Hypotension, bradycardia Bradycardia, Digitalis toxicity
Metoprolol
Verapamil*
Digoxin
*Calcium-channel blockers should not be used in patients with heart failure or left ventricular dysfunction
Pharmacologic Cardioversion
Drug
Class 1A Procainamide Class IC* Propafenone Flecainide
Dose
15-17 mg/kg IV over 60 min 450-600 mg PO 300-400 mg PO
Efficacy
++
Risks
5% hypotension Hypotension, 1:1 flutter, bradycardia Hypotension, 1:1 flutter, bradycardia 2-3% Torsades de pointes
+++ +++
Class III Ibutilide
1-2 mg IV over 10-20 min Pre-treat with MgSO4 1-2 mg IV
++
*Class IC drugs should be used in combination with AV nodal blocking agents (beta-blockers or calciumchannel inhibitors). Class IC agents should also be avoided in patients with structural heart disease.
Wolff Parkinson White Syndrome

We recommend urgent electrical cardioversion if the patient is hemodynamically unstable
Strong Recommendation Low Quality Evidence Strong Recommendation Low Quality Evidence
We recommend Intravenous antiarrhythmic agents procainamide or ibutilide in stable patients
We recommend that AV nodal blocking agents (digoxin, calcium channel blockers, betablockers, adenosine) are contra-indicated.
Values and Preferences These recommendations place a high value on avoidance of the degeneration of pre-excited AF to ventricular fibrillation. It is recognized that degeneration can occur spontaneously or it can be facilitated by the administration of specific agents that in the absence of ventricular pre-excitation would be the appropriate therapy for rate control of AF.
CCS Atrial Fibrillation Guidelines 2010: Prevention of Stroke and Systemic Thromboembolism in Atrial Fibrillation and Flutter
John A Cairns, MD, FRCPC, Stuart Connolly, MD, FRCPC, Sean McMurtry, MD, PhD, FRCPC, Michael Stephenson, MD, FCFP, Mario Talajic, MD, FRCPC
Risk Stratification
Stroke Prevention Bleeding Risk
We recommend that all patients with AF or AFL (paroxysmal, persistent or permanent), should be stratified using a predictive index for stroke (e.g. CHADS2) and for the risk of bleeding (e.g. HAS-BLED), and that most patients should receive antithrombotic therapy. Strong Recommendation High Quality Evidence
Predictive Index for Stroke

CHADS2
Risk Factor
Congestive Heart Failure
Hypertension Age 75 Diabetes Mellitus Stroke/TIA/ Thromboembolism Maximum Score
Score
1
1 1 1 2 6
Patients (n = 1733) 120 463 523
Adjusted Stroke Rate (%/yr) 95% CI 1.9 (1.2 to 3.0) 2.8 (2.0 to 3.8) 4.0 (3.1 to 5.1)
CHADS2 Score 0 1 2
337
220 65 5
5.9 (4.6 to 7.3)

8.5 (6.3 to 11.1) 12.5 (8.2 to 17.5) 18.2 (10.5 to 27.4)
3
4 5 6
CHADS2
Risk Factor
CHA2DS2-VASc
Score
1
Risk Factor
Score
1
Hypertension
Age 75 Diabetes Mellitus Stroke/TIA/Thromboembolism
1
1 1 2
Hypertension
Age 75 Diabetes Mellitus Stroke/TIA/Thromboembolism Vascular Disease Age 65-74 Female
1
2 1 2 1 1 1 9
Maximum Score
Maximum Score
Patients (n = 7329)
1
422 1230 1730 1718 1159 679 294 82 14
Adjusted Stroke Rate (%/yr) 95% CI

0
0.46 (0.10 to 1.34) 0.78 (0.44 to 1.29) 1.16 (0.79 to 1.64) 1.43 (1.01 to 1.95) 2.42 (1.75 to 3.26) 3.54 (2.49 to 4.87) 3.44 (1.94 to 5.62) 2.41 (0.53 to 6.88) 5.47 (0.91 to 27.0)
TE Rate assuming no warfarin

0
1.3 2.2 3.2 4.0 6.7 9.8 9.6 6.7 15.2
CHA2DS2VASc Score
0
1 2 3 4 5 6 7 8 9
Bleeding Risk HAS-BLED Score

Letter
H A S B L E D
Clinical Characteristic
Hypertension Abnormal Liver or Renal Function 1 point each Stroke Bleeding Labile INRs Elderly (age > 65 yr) Drugs or Alcohol 1 point each
Points
1 1 or 2 1 1 1 1 1 or 2
Maximum 9 points
Pisters R et al. Chest. 2010 Nov;138:1093-100
Overview of Thromboembolic Management

Assess Thromboembolic Risk (CHADS2) and Bleeding Risk (HAS-BLED)
CHADS2 = 0
CHADS2 = 1
CHADS2 2
aspirin
No antithrombotic may be appropriate in selected young patients with no stroke risk factors
OAC*
*Aspirin is a reasonable alternative in some as indicated by risk/benefit
OAC
Dabigatran is preferred OAC over warfarin in most patients.
RRR = 64%
Hart Ann Int Med 1999;131:492
RRR = 19%
Hart Ann Int Med 1999;131:492
RCTs Warfarin vs ASA
RRR=39%
Hart. Ann Int Med 2007;147:590
50% Warfarin Better
-50% Warfarin Worse
40
40 35
Events/1000 patients/year
17 24 28
30 25
19
13 18
20 15 10 5 0 CHADS 0 CHADS 1 CHADS 2

7 11 10 17 14 23 10 12
NoRx Warfarin Aspirin
Risk of Stroke + Non-cerebral Major Bleed among AF Patients
ASA for Stroke Prevention

We recommend that patients at very low risk Strong of stroke (CHADS2 = 0) should receive aspirin Recommendation (75-325 mg/day). High Quality Evidence
We suggest that some young persons with no standard risk factors for stroke may not require any antithrombotic therapy. Conditional Recommendation Moderate Quality Evidence
Anticoagulant Therapy for Stroke Prevention

We recommend that patients at low risk of stroke (CHADS2 = 1) should receive OAC therapy (either warfarin [INR 2 3] or dabigatran). We suggest, based on individual risk/benefit considerations, that aspirin is a reasonable alternative for some. We recommend that patients at moderate risk of stroke (CHADS2 2) should receive OAC therapy (either warfarin [INR 2 3] or dabigatran). Strong Recommendation High Quality Evidence Conditional Recommendation Moderate Quality Evidence Strong Recommendation High Quality Evidence
Values and preferences: These recommendations place relatively greater weight on the absolute reduction of stroke risk with both warfarin and dabigatran compared to aspirin and less weight on the absolute increased risk for major hemorrhage with an oral anticoagulant compared to aspirin.
Dabigatran vs Warfarin
We suggest, that when OAC therapy is indicated, most patients should receive dabigatran in preference to warfarin. In general, the dose of dabigatran 150 mg po bid is preferable to a dose of 110 mg po bid. Conditional Recommendation High Quality Evidence
Values and preferences: This recommendation places a relatively high value on the greater efficacy of dabigatran over a relatively short time of follow-up, particularly among patients who have not previously received an oral anticoagulant, the lower incidence of intracranial hemorrhage and its ease of use, and less value on the long safety experience with warfarin.
Antithrombotic Management of AF/AFL in CAD

Stable CAD Recent ACS PCI
Choose antithrombotic based on stroke risk
Choose antithrombotic based on balance of risks and benefits
Choose antithrombotic based on balance of risks and benefits
CHADS2 =0
CHADS2 1
CHADS2 1
CHADS2 2
CHADS2 1
CHADS2 2
Aspirin
OAC* monotherapy
aspirin + clopidogrel
Triple antithrombotic Rx
aspirin + clopidogrel
Triple antithrombotic Rx
* Warfarin is preferred over dabigatran for patients at high risk of coronary events
We suggest that patients with AF/AFL who have stable CAD should receive antithrombotic therapy selected based upon their risk of stroke (aspirin for CHADS2 = 0 and OAC for CHADS2 1). Warfarin is preferred over dabigatran for those at high risk of coronary events. We suggest that patients with AF/AFL who have experienced ACS or who have undergone PCI, should receive antithrombotic therapy selected based on a balanced assessment of their risks of stroke, of recurrent coronary artery events and of hemorrhage associated with the use of combinations of antithrombotic therapies, which in patients at higher risk of stroke may include aspirin plus clopidogrel plus OAC.
Conditional Recommendation Moderate Quality Evidence
Cardioversion AF 48 hr
We recommend that hemodynamically stable patients with AF/AFL of 48 hours or uncertain duration for whom electrical or pharmacological cardioversion is planned should receive therapeutic OAC therapy (warfarin [INR 2-3] or dabigatran) for 3 weeks before and at least 4 weeks post cardioversion Strong Recommendation Moderate Quality Evidence
Following attempted cardioversion If AF/AFL persists or recurs or if symptoms suggest that the presenting AF/AFL has been recurrent, the patient should have antithrombotic therapy continued indefinitely (using either OAC or aspirin as appropriate ). If sinus rhythm is achieved and sustained for 4 weeks, the need for ongoing antithrombotic therapy should be determined based upon the risk of stroke and in selected cases expert consultation may be required.
Cardioversion AF < 48 hr
We recommend that hemodynamically stable patients with AF/AFL of known duration < 48 hours may undergo cardioversion without prior or subsequent anticoagulation. However, if the patient is at particularly high risk of stroke (e.g. mechanical valve, rheumatic heart disease, recent stroke or TIA), cardioversion should be delayed and the patient should receive OAC for 3 weeks before and at least 4 weeks post cardioversion. Strong Recommendation Moderate Quality Evidence
If AF or AFL persists, recurs, or if symptoms suggest that the presenting AF/AFL has been recurrent, antithrombotic therapy (OAC or aspirin as appropriate) should be commenced and continued indefinitely. If NSR is achieved and sustained for 4 weeks, the need for ongoing antithrombotic therapy should be determined based on the risk of stroke (CHADS2) score and in selected cases expert consultation may be required.
Hemodynamically Unstable Patients Emergency Cardioversion

We suggest if the AF/AFL is of known duration < 48 hr, the patient may undergo cardioversion without prior anticoagulation. If the patient is at high risk of stroke (e.g. mechanical valve, rheumatic heart disease, recent stroke or TIA), the patient should receive IV UFH or LMWH before cardioversion if possible, or immediately thereafter and then be converted to OAC for at least 4 weeks post cardioversion. If the AF/AFL is of 48 hr or uncertain duration, we suggest the patient receive IV UFH or LMWH before cardioversion or immediately thereafter if even a brief delay is unacceptable. Such a patient should then be converted to OAC for at least 4 weeks post cardioversion. Conditional Recommendation Moderate Quality Evidence
Cardioversion (TEE-Guided)
We suggest that hemodynamically stable patients with AF/AFL of duration 48 hr or unknown, may undergo cardioversion guided by TEE (following the protocol from the ACUTE trial as detailed in the text). Conditional Recommendation High Quality Evidence
Patient with AF undergoing Surgical or Diagnostic Procedure with Major Bleeding Risk
Very low to Moderate Stroke Risk*
High Stroke Risk**
Low Bleeding Risk
High Bleeding Risk
Low Bleeding Risk
High Bleeding Risk
Continue antithrombotic (INR < 3 if warfarin)
Stop antithrombotic pre-procedure Re-institure when risk of bleeding reduced
Continue OAC or stop OAC and bridge with UFH or LMWH perioperatively
Stop OAC and bridge with UFH or LMWH perioperatively
* CHADS2 2 ** mechanical valve, recent stroke or TIA, rheumatic valve disease, CHADS 2 3 stop 12-24hr pre-procedure, restart when hemostasis secure and bridge to therapeutic OAC
Antithrombotic Therapy Peri-Procedure

If there is a very low to moderate risk of stroke (CHADS2 2), the patient should have their antithrombotic agent discontinued before the procedure (aspirin or clopidogrel for 7-10 days, warfarin for 5 days if the INR was in the range 2- 3, and dabigatran for 2 days). Once post procedure hemostasis is established (about 24 hr) the antithrombotic therapy should be reinstated. If there is a particularly high risk of stroke (e.g. mechanical valve, recent stroke or TIA, rheumatic valve disease, CHADS2 3) or of other thromboembolism (e.g. Fontan procedure): a) if there is an acceptable perioperative bleeding risk (i.e. risk of stroke outweighs risk of bleeding) the patient should have OAC therapy continued perioperatively or have their OAC discontinued before the procedure and be bridged with LMWH or UFH perioperatively, or alternatively, b) if there is a substantial risk of major and potentially problematic bleeding (i.e. risk of bleeding and risk of stroke are both substantial) the patient should have their OAC discontinued before the procedure with LMWH or UFH bridging until 12-24 pre procedure. Once post procedure hemostasis is established (about 24 hr) the OAC should be reinstated with LMWH or UFH bridging. Conditional Recommendation Low Quality Evidence
Canadian Cardiovascular Society Atrial Fibrillation Guidelines 2010: Prevention and treatment of atrial fibrillation following cardiac surgery
L. Brent Mitchell MD
Post Operative AF (POAF)

COMPLICATIONS RATES no POAF versus POAF
10 8
6.4 9.3
5.3 4.7 3.4 1.9 3.6 1.7 4.0 4.1
5.5
4 2 0 CVA
3.0
CHF
MI
PPM
VT/VF
MORT
Steinberg ed. Atrial Fibrillation after Cardiac Surgery pp37-50, 2000
POAF Prevention
TREATMENTS WITH GOOD EVIDENCE OF EFFICACY
THERAPY beta-blockers BB withdrawal no BB withdrawal sotalol amiodarone IV magnesium biatrial pacing N 31 25 3 9 18 22 10 n 4452 2600 1163 1382 3296 2896 754 RR (95% CI) 0.36 (0.28 0.47) 0.30 (0.22 0.40) 0.69 (0.54 0.87) 0.34 (0.26 0.45) 0.48 (0.40 0.57) 0.54 (0.40 0.74) 0.44 (0.31 0.64)
0.2 0.4 0.6 0.8 1.0 1.2 1.4 1.6
Relative Risk
Burgess DC et al. Eur Heart J 27:2846-57, 2006
POAF Prevention
COMPARISONS OF TREATMENT EFFICACIES
THERAPY amio vs AP BB vs magnesium sotalol vs BB amio vs BB
N 1 1 4 1
n 74 134 900 102
RR (95% CI) 0.50 (0.30 0.82) 0.53 (0.36 0.80) 0.50 (0.34 0.74) 0.53 (0.37 0.93)
amio vs sotalol
160
0.77 (0.54 1.12)
0.2
0.4
0.6
0.8
1.0
1.2
1.4
1.6
Relative Risk
Mitchell LB et al. Can J Cardiol 21:45B-50B, 2005
POAF Prevention
We recommend that patients who have been receiving a beta-blocker before cardiac surgery have that therapy continued through the operative procedure in the absence of the development of a new contraindication. We suggest that patients who have not been receiving a beta-blocker before cardiac surgery have beta-blocker therapy initiated just before or immediately after the operative procedure in the absence of a contraindication. Strong Recommendation High Quality Evidence Conditional Recommendation Low Quality Evidence
Values and Preferences: These recommendations place a high value on reducing post-operative AF and a lower value on adverse hemodynamic effects of beta-blockade during or after cardiac surgery. It is also noted that inherent to a strategy of prophylaxis, a number of patients will receive betablocker therapy without personal benefit.
POAF Prevention
We recommend that patients who have a contra-indication to beta-blocker therapy before or after cardiac surgery be considered for prophylactic therapy with amiodarone to prevent postoperative AF. Strong Recommendation High Quality Evidence
Values and Preferences: This recommendation places a high value on minimizing the potential adverse effects of amiodarone and a lower value on data suggesting that amiodarone is more effective than beta-blockers for this purpose.
POAF Prevention
We suggest that patients who have a contraindication to beta-blocker therapy and to amiodarone therapy before or after cardiac surgery be considered for prophylactic therapy to prevent postoperative AF with IV magnesium or with biatrial pacing. Conditional Recommendation Low to Moderate Quality Evidence
Values and Preferences: This recommendation places a high value on preventing post-operative AF using more novel therapies that are supported by lower quality data. A high value is placed on the low probability of adverse effects from magnesium. The use of bi-atrial pacing needs to be individualized by patient and institution, as the potential for adverse effects may outweigh potential benefit based on local expertise.
POAF Prevention
We suggest that patients at high risk of postoperative AF be considered for prophylactic therapy to prevent postoperative AF with sotalol or combination therapy including two or more of a betablocker, amiodarone, IV magnesium, or biatrial pacing. Conditional Recommendation Low to Moderate Quality Evidence
Values and Preferences: This recommendation recognizes that data confirming the superiority of combinations of prophylactic therapies is sparse.
Comparison - Prevention
CCS Guidelines
Strength
BB continued if on BB started if not on Strong Cond
ESC Guidelines
Class
I I
LOE
High Low
LOE
A A
Amio if BB contraindicated
Sotalol may be considered
Strong
Cond
High
Mod
IIa
IIb
A
A
Bi-A Pace may be considered

IV Mag may be considered Corticosteriods considered
Cond
Cond --
Low
Low --
IIb
-IIb
A
-B
POAF - Treatment
RCT of Rate- vs Rhythm-Control Treatment of PAOF (N=50)
1.00
9.0 0.7 days
96% 91%
0.80
Pts in hospital
13.2 2.0 days p = 0.05
0.60 0.40
rhythm rate
0.20 0.00
0
p = 0.27
10
15
20
25
30
35
rhythm
rate
Days Post-Op Lee JK et al. Am Heart J 2000;140:9:871-7.
NSR at 8 weeks
POAF - Treatment
We suggest that consideration be given to anticoagulation therapy if post-operative continuous atrial fibrillation persists for more than 72 hours. This consideration will include individualized assessment of the risks of a thromboembolic event and the risk of postoperative bleeding. Conditional Recommendation Low Quality Evidence
Values and Preferences: This recommendation places a higher value on minimizing the risk of thromboembolic events and a lower value on the potential for post-operative bleeding. Because the risk of post-operative bleeding decreases with time the benefit to risk ratio favours a longer period without anticoagulation in the post-operative setting than that suggested in other settings.
POAF - Treatment
We recommend that temporary epicardial pacing electrode wires be placed at the time of cardiac surgery to allow backup ventricular pacing as necessary. We recommend that post operative AF with a rapid ventricular response be treated with a beta-blocker, a non-dihydropyridine calcium antagonist, or amiodarone to establish ventricular rate control. The specific agent chosen will be individualized for each patient but a beta-blocker is usually preferred. Strong Recommendation Low Quality Evidence Strong Recommendation High 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, recognizing that these trials did not specifically address the post-operative period.
POAF - Treatment
We suggest that post operative AF may be appropriately treated with either a ventricular response rate-control strategy or a rhythmcontrol strategy. Conditional Recommendation Low 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, recognizing that these trials did not specifically address the post-operative period.
POAF - Treatment
We recommend that, when anticoagulation therapy, rate-control therapy and/or rhythmcontrol therapy has been prescribed for postoperative AF, formal reconsideration of the ongoing need for such therapy should be undertaken six to twelve weeks later. Strong Recommendation Moderate Quality Evidence
Values and Preferences: This recommendation reflects the high probability that post-operative AF will be a self-limiting process that does not require long-term therapy.
Comparison - Treatment
CCS Guidelines
Strength
epicardial V-Pace wires at OR Rate control with BB, CA, dig Rate control in that order AF control AAD considered anticoag considered at 72hr consider DC Rx at 6-12 weeks Strong Strong Strong Cond Cond Strong
ESC Guidelines
Class
--
LOE
Low High High Low Low Mod
LOE
--
agree in text
IIa IIa (48hr) -C A (48 hr) --
Patient for CV Surgery Low Risk On Beta-Blocker? No Beta-Blocker Contraindicated?
Assess AF Risk Factors?
High Risk
On Beta-Blocker? Yes Continue BB No Beta-Blocker Contraindicated? Yes Sotalol or Amiodarone or BB and another
No
Beta-Blocker
Yes
Amiodarone Contraindicated?
No
Sotalol or Amiodarone or BB and another No Amiodarone
Yes
Amiodarone Contraindicated?
No Amiodarone
Yes IV Magnesium or Biatrial Pacing
Yes IV Magnesium and Biatrial Pacing
Canadian Cardiovascular Society Atrial Fibrillation Guidelines 2010: Surgical Therapy

Pierre Pag MD
Surgical Treatment of AF
We recommend that a surgical AF ablation procedure be undertaken in association with mitral valve surgery in patients with AF when there is a strong desire to maintain sinus rhythm, the likelihood of success of the procedure is deemed to be high, and the additional risk is low. Strong Recommendation Moderate Quality Evidence
Values and Preferences: This recommendation recognizes that individual institutional experience and patient considerations best determine for whom the surgical procedure is performed.
We recommend that patients with asymptomatic lone AF, in whom AF is not expected to affect cardiac outcome, should not be considered for surgical therapy for AF. Strong Recommendation Low Quality Evidence
Values and Preferences: This recommendation recognizes that patients with lone AF are at low risk for stroke or other adverse cardiovascular outcomes. Thus, elimination of AF in the absence of a high number of symptoms is unlikely to result in an improvement in quality of life.
In patients with AF who are undergoing aortic valve surgery or coronary artery bypass surgery, we suggest that a surgical AF ablation procedure be undertaken when there is a strong desire to maintain sinus rhythm, the success of the procedure is deemed to be high, and the additional risk low . Conditional Recommendation Low Quality Evidence
Values and Preferences: This recommendation recognizes that left atrial endocardial access is not routinely required for aortic or coronary surgery. This limits ablation to newer epicardial approaches.
We recommend that closure (excision or obliteration) of the left atrial appendage be undertaken as part of the surgical ablation of AF associated with mitral valve surgery. We suggest that closure of the left atrial appendage be undertaken as part of the surgical ablation of persistent AF in patients undergoing aortic valve surgery or coronary artery bypass surgery if this does not increase the risk of the surgery. Strong Recommendation Low Quality Evidence Conditional Recommendation Low Quality Evidence
Values and Preferences: These recommendations place a high value on stroke reduction and a lower value on any concomitant loss of atrial transport with left atrial appendage closure.
We recommend that oral anticoagulant therapy be continued following surgical AF ablation in patients with a CHADS2 score 2. We suggest that oral anticoagulant therapy be continued following surgical AF ablation in patients who have undergone mechanical or bioprosthetic mitral valve replacement. Strong Recommendation Moderate Quality Evidence Conditional Recommendation Low Quality Evidence
Values and Preferences: These recommendations place a high value on minimizing the risk of stroke and a lower value in the utility of long-term monitoring to document the absence of AF. Atrial Fibrillation Guidelines
Cox MAZE III Ablation Pattern
Recommended Type-specific Surgical Strategies*

Cardiac status or type of AF
Lone AF Mitral Valve surgery Aortic valve / CABG surgery
Paroxysmal
PVI PVI + PVI
Persistent, mixed or continuous

PVI + Bi-atrial full Cox MAZE or PVI + PVI +
PVI + is PVI plus connecting lesions to LAA and mitral valve * All procedures must include exclusion or resection of the left atrial appendage

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Canadian Cardiovascular Society 2010 Atrial Fibrillation Guidelines

CCS AF Guidelines 2010 Primary Panel

Atrial Fibrillation Guidelines

CCS AF Guidelines 2010 Secondary Panel

Atrial Fibrillation Guidelines

A New Approach to Guideline Development & Evaluation

Atrial Fibrillation Guidelines

2. Strength of Recommendations: 2 Grades

Atrial Fibrillation Guidelines

GRADE: Rating Quality of Evidence

Modified with permission from: Guyatt GH, et al. BMJ 2008;336:926

Atrial Fibrillation Guidelines

Factors Determining the Strength of the Recommendation

Difference between desirable and undesirable effects Values and Preferences

Modified with permission from: Guyatt GH, et al. BMJ 2008;336:926

Atrial Fibrillation Guidelines

Establish Pattern of Atrial Fibrillation

Atrial Fibrillation Guidelines

Determine thromboembolic risk (e.g. CHADS2 Score)

Atrial Fibrillation Guidelines

Atrial Fibrillation Guidelines

Atrial Fibrillation Guidelines

Atrial Fibrillation Guidelines

Recommendations Etiology and Investigations

Strong Recommendation Low Quality Evidence

Atrial Fibrillation Guidelines

Atrial Fibrillation Guidelines

Minimal effect on QOL

Severe effect on QOL

Atrial Fibrillation Guidelines

Recommendations Quality of Life

Atrial Fibrillation Guidelines

CCS SAF Score CCS SAF 0 CCS SAF 1

EHRA Class EHRA I EHRA II

Impact No symptoms Mild symptoms

Minimal effect on QOL

Moderate effect on QOL Severe effect on QOL

Atrial Fibrillation Guidelines

Assessment of Thromboembolic Risk (CHADS2)

Atrial Fibrillation Guidelines

Goals of AF Arrhythmia Management

Atrial Fibrillation Guidelines

Atrial Fibrillation Guidelines

Referral for Specialty Care

Atrial Fibrillation Guidelines

Rate or Rhythm Control?

Factors Influencing Decision of Rate vs Rhythm Control

Favours Rhythm Control

Less Symptomatic > 65 years of age

More Symptomatic < 65 years of age

Atrial Fibrillation Guidelines

What is Optimal Target Heart Rate?

Atrial Fibrillation Guidelines

Ventricular Rate Control

Atrial Fibrillation Guidelines

Rate Control Drug Choices

No Heart Disease Hypertension -blocker Diltiazem Verapamil Combination Rx Digitalis

-blocker* Diltiazem Verapamil

*-blockers preferred in CAD Digitalis may be considered as monotherapy in sedentary individuals

Atrial Fibrillation Guidelines