Copyright © 2013, Canadian Cardiovascular Society 09/09/2015 1 2012 CCS Atrial Fibrillation...

Copyright © 2013, Canadian Cardiovascular Society23-04-21 1

2012 CCS Atrial Fibrillation Guidelines Update

Skanes AC, Healey JS et al., Can J Cardiol 2012 Mar;28(2): 125-136

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Copyright © 2013, Canadian Cardiovascular Society 223-04-21



Canadian Cardiovascular Society Guidelines

2012 UPDATE Atrial Fibrillation Guidelines:

Recommendations for Stroke Prevention and Rate / Rhythm Control




• Allan Skanes (co chair)

• Jeff Healey (co chair)

• John Cairns

• Stuart Connolly

• Jafna Cox

• Paul Dorian

• Anne Gillis

• Laurent Macle

• Sean McMurtry

• Gordon Gubitz

• Brent Mitchell

• Stanley Nattel

• Pierre Pagé

• Ratika Parkash

• P. Timothy Pollak

• Michael Stephenson

• Ian Stiell

• Mario Talajic

• Teresa Tsang

• Atul Verma

CCS Atrial Fibrillation Guidelines 2012 Update

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 Pagé

• Ratika Parkash

• P. Timothy Pollak

• Michael Stephenson

• Ian Stiell

• Mario Talajic

• Teresa Tsang

• Atul Verma

CCS AF Guidelines 2010Primary Panel




• Malcolm Arnold • David Bewick • Vidal Essebag• Milan Gupta• Brett Heilbron • Charles Kerr• Bob Kiaii • Jan Surkes • George Wyse

CCS AF Guidelines 2010 ∕ 2012 UpdateSecondary Panel




Canadian Cardiovascular Society Atrial Fibrillation Guidelines 2010: Implementing

GRADE and Achieving Consensus

Anne M Gillis MDAllan C Skanes MD

With special acknowledgement of Jan Brozek MD, PhD




A New Approach to Guideline Development & Evaluation

Grading of Recommendations, Assessment, Development and Evaluation

GRADE




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




Quality Comments

HighFuture research unlikely to change confidence in estimate of effect; e.g.

multiple well designed, well conducted clinical trails.

Moderate

Further research likely to have an important impact on confidence in

estimate of effect and may change the estimate e.g. limited clinical trials,

inconsistency of results or study limitations.

Low

Further research very likely to have a significant impact in the estimate of

effect and is likely to change the estimate e.g. small number of clinical

studies or cohort observations.

Very LowThe estimate of effect is very uncertain; e.g. case studies; consensus

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

GRADE: Rating Quality of Evidence




Factor CommentQuality of Evidence

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.

Difference between

desirable and

undesirable effects

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.

Values and

Preferences

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.

Cost 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.

Factors Determining the Strength of the Recommendation

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 MDRatika Parkash MD

P Timothy Pollak MDTeresa SM Tsang MD

Paul Dorian MD




Establish Pattern of Atrial Fibrillation

Paroxysmal Persistent

Permanent

Newly Diagnosed AF

Modified with permission from Fuster et al Circulation 2006;114:e257-354




HistoryEstablish 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




All patients with AF should have a complete history and physical examination, electrocardiogram, echocardiogram, basic laboratory investigations. Details are highlighted in Table 1.

Strong Recommendation Low QualityEvidence

Other ancillary tests should be considered under specific circumstances. Detailsincluded in Table 2.

Strong Recommendation Low Quality Evidence

RecommendationsEtiology and Investigations




Practical Tips

• Aggressive treatment of hypertension may prevent or reduce recurrences

• Choice of antihypertensive therapy should favor rate controlling drugs e.g. β-blockers and Ca2+ channel blockers vs inhibitors of renin angiotensin system.

• Identify and treat obstructive sleep apnea




CCSSAF Score

Impact on QOL

0 Asymptomatic

1 Minimal effect on QOL

2 Minor effect of QOL

3 Moderate effect on QOL

4 Severe effect on QOL

Establish AF SeverityUse to Guide Therapeutic Approach

Dorian et al Can J Cardiol 2006;22:383-386




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.

Strong RecommendationLow Quality of Evidence

We suggest that QOL of the AF patient can be assessed in routine care using the CCS‐SAF scale.

Conditional Recommendation Low Quality of Evidence

Recommendations Quality of Life

Values and Preferences: These recommendations recognize that improvement in QOL is a high priority for therapeutic decision making.




CCS SAF Score

Impact EHRA Class Impact

CCS SAF 0 Asymptomatic EHRA I No symptoms

CCS SAF 1Minimal effect on QOL

EHRA IIMild symptoms

CCS SAF 2Modest effect on QOL

EHRA III

Severe symptoms; daily activity affected

CCS SAF 3Moderate effect on QOL

EHRA IV

Disabling symptoms;Normal daily activity discontinued

CCS SAF 4Severe effect on QOL




Canadian Cardiovascular Society Atrial Fibrillation Guidelines 2012: AF/AFL

Rhythm Management

Anne M Gillis MDAtul Verma MD

Mario Talajic MDStanley Nattel MDPaul Dorian MD




Management of Arrhythmia

Rate Control

RhythmControl

Overview of AF Management

AF DetectedDetection and Treatment of

Precipitating Causes

No antithrombotic therapy may be appropriate in selected young patients with no stroke risk factors

ASAOAC

Assessment of Thromboembolic

Risk (CHADS2)




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




We recommend that the goals of ventricular rate control should be to improve symptoms and clinical outcomes which are attributable to excessive ventricular rates

Strong RecommendationLow Quality Evidence

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 RecommendationModerate Quality Evidence

Recommendations – Rx Goals

Values and PreferencesThese 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




Favours Rate Control Favours Rhythm Control

Persistent AF Paroxysmal AF

Newly Detected AF

Less Symptomatic More Symptomatic

> 65 years of age < 65 years of age

Hypertension No Hypertension

No History of Congestive

Heart Failure Congestive Heart Failure clearly exacerbated by AF

Previous Antiarrhythmic

Drug Failure

No Previous Antiarrhythmic

Drug Failure

Factors Influencing Decision of Rate vs Rhythm Control




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




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.

Strong Recommendation Moderate Quality Evidence

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 RecommendationHigh Quality Evidence

Values and PreferencesThese 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.

Ventricular Rate Control




We recommend β-blockers or non-dihydropyridine 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.

Conditional RecommendationModerate Quality Evidence

We suggest that digoxin be added to therapy with beta-blockers or calcium channel blockers in patients whose heart rate remains uncontrolled.






We recommend that dronedarone not be used in patients with permanent AF nor for the sole purpose of rate control.

Strong Recommendation High Quality Evidence

We recommend dronedarone not be used in patients with a history of heart failure or a left ventricular ejection fraction ≤ 0.40.


We suggest dronedarone be used with caution in patients taking digoxin.



Values and PreferencesThese recommendations recognize that the mechanism(s) for the differences between the results of the ATHENA and the PALLAS trials have notyet been determined. These recommendations are based on the known differences between the 2 patient populations and are also informed by the results of the ANDROMEDA trial.




RecommendationStrength /Class of Recommendation

Level or Quality of Evidence

2010 CCS Guidelines

We recommend that treatment for rate control of persistent/permanent AF or AFL should aim for a resting heart rate < 100 bpm

Strong High

2010 ESC Guidelines

Reasonable to initiate treatment with a lenient rate control protocol aimed at resting HR <110 bpm. Reasonable to adopt a stricter rate control strategy when symptoms persist or tachycardiomyopathy occurs, despite lenient rate control: HR <80

IIa B

2010 ACCF/AHA/HRS Focused Update

Treatment to achieve strict rate control of heart rate is not beneficial compared to achieving a resting heart rate < 110 bpm in patients with persistent AF who have stable ventricular function (LVEF > 0.40) and no or acceptable symptoms related to AF

III – no benefit B

2004 CCS Guidelines

HR <80 bpm at rest and <110 bpm during 6 min hallwalk IIa C




We recommend beta-blockers as initial therapy for rate control of AF/AFL in patients with myocardial infarction or left ventricular systolic dysfunction

Strong RecommendationHigh Quality Evidence

Ventricular Rate ControlPrevious MI or LV Systolic Dysfunction

Values and PreferencesThis 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.




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


Ventricular Rate ControlAV Junction Ablation

Values and PreferencesThis 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.




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.


Values and preferencesThis recommendation places a high value on the results of clinical studies demonstrating the efficacy and safety of intermittent antiarrhythmic drug therapy in selected patients.

Pill in the Pocket For Rhythm Control

– Single dose flecainide (200-300 mg) or propafenone (450-600 mg) as an oral dose

– Often prescribed with a short-acting beta-blocker at the same time (metoprolol 50-100 mg)




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)




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.


Values and preferencesThese 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.

Cardioversion 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

Conditional RecommendationHigh Quality Evidence

We suggest that, in patients with intact AV conduction, pacemakers be programmed to minimize ventricular pacing for prevention of AF


Pacing for Rhythm Control

Values and preferencesThese 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.




Danish

AAI vs VVI CTOPP

Extended

CTOPP MOST

Danish

AAI vs DDD

Number 225 2568 2568 2050 177

Age (yr) 71 ± 17 73 ± 10 73 ± 10 74 (67-80) 74 ± 9

Pacing Indication SND All pacemaker

patients

All pacemaker

patients

SND SND

Follow-up (yr) 5.5 3.1 6.4 2.7 2.9

Pacing Modes AAI vs VVI AAI/R or DDD/R

vs VVI/R

AAI/R or DDD/R

vs VVI/R

DDDR vs VVIR AAI vs DDDR-s

vs DDDR-l

AF Occurrence

(%/yr)

4.1 vs 6.6 5.3 vs 6.3 4.5 vs 5.7 7.9 vs 10.0 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

Pacing Mode and AF




Canadian Cardiovascular Society Atrial Fibrillation Guidelines 2012*: Catheter

Ablation of Atrial Fibrillation and Flutter

Atul Verma MDJafna L Cox MD

Laurent Macle MDAllan C Skanes MD

*Unchanged from 2010




Ablation Control OR 95% CI 28/32 13/35 11.85 3.4-41.4

12/15 6/15 6.0 1.2-30.7

46/53 13/59 23.3 8.5-63.6

85/99 24/99 19.0 9.2-39.3

38/68 6/69 13.3 5.1-34.9

266/344 102/346 15.8 10.1-24.7

Piccini JP et al. Circ Arrhythm 2009;2:626

• 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

Systematic Review of RCTs Ablation vs Drug Rx




Cappato R et al. Circ Arrhythm Electrophysiol. 2010;3:32-8

Type of Complication (n=14,218) No of Pts Rate%Femoral pseudoaneurysm 152 0.93AV fistulae 88 0.54Pneumothorax 15 0.09

Valve damage/requiring surgery 11/7 0.07

Tamponade 213 1.31Transient ischemic attack 115 0.71PV stenosis requiring intervention 48 0.29Stroke 37 0.23Permanent diaphragmatic paralysis 28 0.17Death 25 0.15Atrium-esophageal fistulae 3 0.02TOTAL 741 4.54%

Worldwide AF Ablation (’03-’06)




We recommend catheter ablation of AF in patients who remain symptomaticfollowing adequate trials of anti-arrhythmic drug therapy and in whom a rhythmcontrol strategy remains desired.

Strong RecommendationModerate QualityEvidence

We suggest catheter ablation to maintain sinus rhythm in select patients withsymptomatic AF and mild-moderate structural heart disease who arerefractory or intolerant to at least one anti-arrhythmic medication.

ConditionalRecommendationModerate Quality Evidence

We suggest catheter ablation to maintain sinus rhythm as first-line therapy for reliefof symptoms in highly selected patients with symptomatic, paroxysmal AF.

Conditional RecommendationLow 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 pre-excitation 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.

StrongRecommendationLow Quality Evidence

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.

Conditional Recommendation Very LowQuality Evidence

Recommendations Ablation




CCS Guidelines ESC Guidelines ACCF/AHA/HRS

StrengthLevel of

EvidenceClass

Level of Evidence

ClassLevel of

Evidence

Paroxysmal* Conditional ModerateIIa

(Conditional)A (High) I (Strong)¶ A (High)

Persistent* Conditional ModerateIIa

(Conditional)B

(Moderate)IIa

(Conditional)A (High)

Failed 1 drug Conditional Moderate -- -- I (Strong)¶ A (High)

Failed ≥ 2 drugs

Strong Moderate -- -- -- --

1st Line Conditional LowIIb

(Conditional)B

(Moderate)-- --

PAF / sign. structural heart disease

-- -- -- --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

Comparison of North American and European Guidelines




Canadian Cardiovascular Society Atrial Fibrillation Guidelines 2012*:

Management of recent onset atrial fibrillation and atrial flutter in the

emergency department

Ian G. Stiell, MD, MScLaurent Macle, MD





We recommend that in stable patients with recent-onset AF/AFL, a strategy of rate control or rhythm control could be selected


Values and PreferencesThis 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.

ED Management of Recent Onset AF/AFL




We recommend for patients with acute hemodynamic instability secondary to rapid recent-onset AF/AFL, immediate electrical conversion to sinus rhythm


Values and PreferencesThis 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.

Hemodynamically Unstable Patients with AF/AFL




We recommend that electrical cardioversion may be conducted in the ED with 150-200 joules biphasic waveform as the initial energy setting.


Values and PreferencesThis 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.

Electrical Cardioversion




We recommend that rate-slowing agents alone are acceptable while awaiting spontaneous conversion


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

Conditional RecommendationLow Quality Evidence

In hemodynamically stable patients with AF/AFL of known duration < 48 h in whom a strategy of rhythm control has been selected:

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.




Drug Dose Risks

Diltiazem* 0.25 mg/kg IV bolus over 10 min; repeat at

0.35 mg/kg IV

Hypertension, bradycardia

Metoprolol 2.5-5mg IV bolus over 2 min; up to 3 doses

Hypotension, bradycardia

Verapamil* 0.075-0.15mg/kg over 2 min

Hypotension, bradycardia

Digoxin 0.25 mg IV each 2 h; up to 1.5mg

Bradycardia, Digitalis toxicity

Rate Control: IV Therapy

*Calcium-channel blockers should not be used in patients with heart failure or left ventricular dysfunction




Pharmacologic CardioversionDrug Dose Efficacy Risks

Class 1AProcainamide

15-17 mg/kg IV over 60 min

++ 5% hypotension

Class IC*PropafenoneFlecainide

450-600 mg PO300-400 mg PO

++++++

Hypotension, 1:1 flutter, bradycardiaHypotension, 1:1 flutter, bradycardia

Class IIIIbutilide

1-2 mg IV over 10-20 minPre-treat with MgSO4 1-2 mg IV

++2-3% Torsades de pointes

*Class IC drugs should be used in combination with AV nodal blocking agents (beta-blockers or calcium-channel inhibitors). Class IC agents should also be avoided in patients with structural heart disease.




We recommend urgent electrical cardioversion if the patient is hemodynamically unstable


We recommend Intravenous antiarrhythmic agents procainamide or ibutilide in stable patients


We recommend that AV nodal blocking agents (digoxin, calcium channel blockers, beta-blockers, adenosine) are contra-indicated.


Wolff Parkinson White Syndrome

Values and PreferencesThese 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 2012: Prevention of Stroke and Systemic

Thromboembolism in Atrial Fibrillation and Flutter

John A Cairns, MD, FRCPC,

Stuart Connolly, MD, FRCPC,

Gordon Gubitz, MD, FRCPC

Sean McMurtry, MD, PhD, FRCPC,

Mario Talajic, MD, FRCPC

Carl Van Walraven, MD, FRCPC, MSc




Patients(n = 1733)

Adjusted Stroke Rate (%/yr) 95% CI

CHADS2 Score

120 1.9 (1.2 to 3.0) 0

463 2.8 (2.0 to 3.8) 1

523 4.0 (3.1 to 5.1) 2

337 5.9 (4.6 to 7.3) 3

220 8.5 (6.3 to 11.1) 4

65 12.5 (8.2 to 17.5) 5

5 18.2 (10.5 to 27.4) 6

CHADS2

Risk Factor ScoreCongestive Heart Failure

1

Hypertension 1

Age ≥ 75 1

Diabetes Mellitus 1

Stroke/TIA/Thromboembolism

2

Maximum Score 6

Predictive Index for Stroke


Copyright © 2013, Canadian Cardiovascular Society


23-04-21 67

Lip, GY, et al. Stroke 2010; 46: 2731




Patients (n = 7329)TE Rate assuming

no warfarinCHA2DS2VASc

Score

1 0 0

422 1.3 1

1230 2.2 2

1730 3.2 3

1718 4.0 4

1159 6.7 5

679 9.8 6

294 9.6 7

82 6.7 8

14 15.2 9




Letter Clinical Characteristic PointsH Hypertension 1

A Abnormal Liver or Renal Function1 point each

1 or 2

S Stroke 1

B Bleeding 1

L Labile INRs 1

E Elderly (age > 65 yr) 1

D Drugs or Alcohol 1 point each

1 or 2

Maximum 9 points

Bleeding Risk – HAS-BLED Score

Pisters R et al. Chest. 2010 Nov;138:1093-100




Hart Ann Int Med 1999;131:492

RRR = 64%




Hart Ann Int Med 1999;131:492

RRR = 19%




RCTs Warfarin vs ASA

Hart. Ann Int Med 2007;147:590

50% 0 -50% Warfarin Better Warfarin Worse RRR=39%




AF Patients: Risk of Stroke (white numbers) and of Stroke + Non-cerebral Major Bleed (black numbers)

Ev

ents

/10

00

pa

tie

nts

/ye

ar

10 12

13 18

17 24

19

28

40

7 11 10 17 14 23




23-04-21 77




23-04-21 78




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 OAC at therapeutic dose for 3 weeks before and at least 4 weeks post cardioversion


Cardioversion – AF ≥ 48 hr

Following attempted cardioversionIf 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.




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.


Cardioversion – AF < 48 hr

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.




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

Hemodynamically Unstable Patients Emergency Cardioversion




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

CardioversionCardioversion(TEE-Guided)




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 ⁄ rivaroxaban ⁄ apixaban for 2 days). Once post procedure hemostasis is established (about 24 hr) the antithrombotic therapy should be reinstated.

Conditional Recommendation Low Quality Evidence

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.


Antithrombotic Therapy Peri-Procedure




We recommend that patients with AF who are receiving OAC:

Have their renal function assessed at least annually by measuring serum creatinine and calculating eGFR.

Be regularly considered for the need for alteration of OAC drug and ∕ or dose changes based on eGFR.



Stroke Prevention in AF patients with CKD




For antithrombotic therapy of CKD patients, therapy should relate to eGFR as follows:

eGFR > 30 mL per minute: We recommend that such patients receive antithrombotic therapy according to their CHADS₂ score as detailed in recommendations for patients with normal renal function.

eGFR 15-30 mL per minute and not on dialysis: We suggest that such patients receive antithrombotic therapy according to their CHADS₂ score as for patients with normal renal function. The preferred agent for these patients is warfarin.


Conditional Recommendation Moderate Quality Evidence


Values and Preferences:This recommendation places a relatively higher value on prevention of ischemic stroke than on bleeding complications associated with antithrombotic therapy, as well as the limited data available for new OACs in CKD patients. No therapy may be appropriate for some patients with eGFR 15-30 mL per minute (not on dialysis), with a stronger preference for avoiding bleeding complications than preventing ischemic stroke.




For antithrombotic therapy of CKD patients, therapy should relate to eGFR as follows:

eGFR < 15 mL per minute (on dialysis): We suggest that such patients not routinely receive either OAC or

ASA for stroke prevention in AF.




Values and Preferences:

This recommendation places a relatively higher weight on observational data linking warfarin and ASA use with mortality in patients on dialysis, and relatively lower weight on the potential for these agents to prevent ischemic stroke. Therapy with OACs or antiplatelet drugs may be appropriate for some patients with eGFR < 15 mL per minute (on dialysis) in whom there is a stronger preference for avoiding ischemic stroke.





PRACTICAL TIP:

Patients with eGFR 30-50 mL per minute need more frequent measures of eGFR and may need OAC dose reductions with conditions that may transiently reduce eGFR. This is especially true in the elderly (age older than 75 years) as bleeding risk increases with age.




Canadian Cardiovascular Society Atrial Fibrillation Guidelines 2012*:

Prevention and treatment of atrial fibrillation following cardiac surgery

L. Brent Mitchell MD





COMPLICATIONS RATES – no POAF versus POAF

Post Operative AF (POAF)

Steinberg ed. Atrial Fibrillation after Cardiac Surgery pp37-50, 2000

%5.5

4.14.7

1.9

6.4

3.4

5.3

3.03.6

1.7

9.3

4.0




TREATMENTS WITH GOOD EVIDENCE OF EFFICACY

THERAPY N n RR (95% CI)

beta-blockers 31 4452 0.36 (0.28 – 0.47)

sotalol 9 1382 0.34 (0.26 – 0.45)

amiodarone 18 3296 0.48 (0.40 – 0.57)

IV magnesium 22 2896 0.54 (0.40 – 0.74)

biatrial pacing 10 754 0.44 (0.31 – 0.64)

0.40.2 0.6 0.8 1.0 1.41.2 1.6

Relative Risk

Burgess DC et al. Eur Heart J 27:2846-57, 2006


beta-blockers 31 4452 0.36 (0.28 – 0.47)

BB withdrawal 25 2600 0.30 (0.22 – 0.40)

no BB withdrawal 3 1163 0.69 (0.54 – 0.87)

sotalol 9 1382 0.34 (0.26 – 0.45)

amiodarone 18 3296 0.48 (0.40 – 0.57)

IV magnesium 22 2896 0.54 (0.40 – 0.74)

biatrial pacing 10 754 0.44 (0.31 – 0.64)

POAF Prevention




COMPARISONS OF TREATMENT EFFICACIES


amio vs AP 1 74 0.50 (0.30 – 0.82)

BB vs magnesium 1 134 0.53 (0.36 – 0.80)

sotalol vs BB 4 900 0.50 (0.34 – 0.74)

amio vs BB 1 102 0.53 (0.37 – 0.93)

amio vs sotalol 1 160 0.77 (0.54 – 1.12)

0.40.2 0.6 0.8 1.0 1.41.2 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.

ConditionalRecommendation Low Quality Evidence

POAF Prevention

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 beta-blocker therapy without personal benefit.




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.


POAF Prevention

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.




We suggest that patients who have a contra-indication 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.

ConditionalRecommendation Low to Moderate Quality Evidence

POAF Prevention

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.




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 beta-blocker, amiodarone, IV magnesium, or biatrial pacing.

ConditionalRecommendation Low to Moderate Quality Evidence

POAF Prevention

Values and Preferences: This recommendation recognizes that data confirming the superiority of combinations of prophylactic therapies is sparse.




Comparison - PreventionCCS Guidelines ESC Guidelines

Strength LOE Class LOE

BB continued if on Strong High I A

BB started if not on Cond Low I A

Amio if BB contraindicated Strong High IIa A

Sotalol may be considered Cond Mod IIb A

Bi-A Pace may be considered Cond Low IIb A

IV Mag may be considered Cond Low -- --

Corticosteriods considered -- -- IIb B




0 10 20

Pts

in h

osp

ital

Days Post-Op

raterhythm

5 15 25

Lee JK et al. Am Heart J 2000;140:9:871-7.

p = 0.27

30 35

RCT of Rate- vs Rhythm-Control Treatment of PAOF (N=50)

9.0 ± 0.7 days

13.2 ± 2.0 days

p = 0.05

raterhythm

NSR at 8 weeks

91%96%

POAF - Treatment




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 post-operative bleeding.


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.




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 establishventricular rate control. The specific agent chosen will be individualized for each patient but a beta-blocker is usually preferred.

StrongRecommendation High Quality Evidence

POAF - Treatment

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.




We suggest that post operative AF may be appropriately treated with either a ventricular response rate-control strategy or a rhythm-control strategy.


POAF - Treatment

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.




We recommend that, when anticoagulation therapy, rate-control therapy and/or rhythm-control therapy has been prescribed for post-operative AF, formal reconsideration of the ongoing need for such therapy should be undertaken six to twelve weeks later.


POAF - Treatment

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 ESC GuidelinesStrength LOE Class LOE

epicardial V-Pace wires at OR Strong Low -- --

Rate control with BB, CA, dig Strong High I B

Rate control in that order Strong High

AF control AAD considered Cond Low IIa C

anticoag considered at 72hr Cond Low IIa (48hr) A (48 hr)

consider DC Rx at 6-12 weeks Strong Mod -- --

agree in text




Canadian Cardiovascular Society Atrial Fibrillation Guidelines 2010:

Surgical Therapy

Pierre Pagé MD




Values and Preferences: This recommendation recognizesthat individual institutional experience and patient considerations best determine for whom the surgical procedure is performed.

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.





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.

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.






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.

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 .






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 closure (excision or obliteration) of the left atrial appendage be undertaken as part of the surgical ablation of AF associated with mitral valve surgery.

StrongRecommendation Low Quality Evidence

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.






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.

We recommend that oral anticoagulant therapy be continued following surgical AF ablation in patients with a CHADS2 score ≥ 2.

StrongRecommendation Moderate Quality Evidence

We suggest that oral anticoagulant therapy be continued following surgical AF ablation in patients who have undergone mechanical or bioprosthetic mitral valve replacement.






Cox MAZE III Ablation Pattern




Recommended Type-specific Surgical Strategies*

Cardiac status or type of AF Paroxysmal

Persistent, mixed or continuous

Lone AF PVI PVI +

Mitral Valve surgery PVI +Bi-atrial full Cox MAZE

or PVI +

Aortic valve / CABG surgery

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




Thank you and questions

Copyright © 2013, Canadian Cardiovascular Society 09/09/2015 1 2012 CCS Atrial Fibrillation...

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