1 January ACC AHA HRS 2014 Afib Guidelines.Pdf
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JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY VOL.64,NO.21,2014 ª 2014 BY THE AMERICAN HEART ASSOCIATION, INC., ISSN 0735-1097/$36.00 THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION, http://dx.doi.org/10.1016/j.jacc.2014.03.022 AND THE HEART RHYTHM SOCIETY PUBLISHED BY ELSEVIER INC. CLINICAL PRACTICE GUIDELINE: FULL TEXT 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society Developed in Collaboration With the Society of Thoracic Surgeons Writing Craig T. January, MD, PHD, FACC, Chair William G. Stevenson, MD, FACC, FAHA, FHRS*{ Committee L. Samuel Wann, MD, MACC, FAHA, Vice Chair* Patrick J. Tchou, MD, FACCz Members* Cynthia M. Tracy, MD, FACC, FAHAy Joseph S. Alpert, MD, FACC, FAHA*y Clyde W. Yancy, MD, FACC, FAHAy Hugh Calkins, MD, FACC, FAHA, FHRS*zx Joaquin E. Cigarroa, MD, FACCy *Writing committee members are required to recuse themselves from Joseph C. Cleveland JR, MD, FACCjj voting on sections to which their specific relationships with industry and Jamie B. Conti, MD, FACC, FHRS*y other entities may apply; see Appendix 1 for recusal information. Patrick T. Ellinor, MD, PHD, FAHAz yACC/AHA Representative. zHeart Rhythm Society Representative. x k Michael D. Ezekowitz, MB, CHB, FACC, FAHA*y ACC/AHA Task Force on Performance Measures Liaison. Society of { Michael E. Field, MD, FACC, FHRSy Thoracic Surgeons Representative. ACC/AHA Task Force on Practice Guidelines Liaison. Katherine T. Murray, MD, FACC, FAHA, FHRSy Ralph L. Sacco, MD, FAHAy ACC/AHA Task Jeffrey L. Anderson, MD, FACC, FAHA, Chair Judith S. Hochman, MD, FACC, FAHA# Force Members Jonathan L. Halperin, MD, FACC, FAHA, Chair-Elect Richard J. Kovacs, MD, FACC, FAHA E. Magnus Ohman, MD, FACC Nancy M. Albert, PhD, RN, FAHA Susan J. Pressler, PhD, RN, FAHA Biykem Bozkurt, MD, PhD, FACC, FAHA Frank W. Sellke, MD, FACC, FAHA Ralph G. Brindis, MD, MPH, MACC Win-Kuang Shen, MD, FACC, FAHA Mark A. Creager, MD, FACC, FAHA# William G. Stevenson, MD, FACC, FAHA# Lesley H. Curtis, PhD, FAHA Clyde W. Yancy, MD, FACC, FAHA# David DeMets, PhD# Robert A. Guyton, MD, FACC# #Former Task Force member; current member during the writing effort. This document was approved by the American College of Cardiology Board of Trustees, the American Heart Association Science Advisory and Coordinating Committee, and the Heart Rhythm Society Board of Trustees in March 2014. The American College of Cardiology Foundation requests that this document be cited as follows: January CT, Wann LS, Alpert JS, Calkins H, Cigarroa JE, Cleveland JC Jr, Conti JB, Ellinor PT, Ezekowitz MD, Field ME, Murray KT, Sacco RL, Stevenson WG, Tchou PJ, Tracy CM, Yancy CW. 2014 AHA/ACC/ HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol 2014;64:e1–76. This article is copublished in Circulation. Copies: This document is available on the World Wide Web sites of the American Heart Association (my.americanheart.org), the American College of Cardiology (www.cardiosource.org), and the Heart Rhythm Society (www.hrsonline.org). For copies of this document, please contact the Elsevier Inc. Reprint Department via fax (212) 633–3820 or e-mail [email protected]. Permissions: Multiple copies, modification, alteration, enhancement, and/or distribution of this document are not permitted without the express permission of the American College of Cardiology. Requests may be completed online via the Elsevier site (http://www.elsevier.com/authors/ obtainingpermission-to-re-useelsevier-material). Downloaded From: http://content.onlinejacc.org/ by Lea Binder on 10/04/2016 e2 January et al. JACC VOL. 64, NO. 21, 2014 AHA/ACC/HRS Practice Guideline DECEMBER 2, 2014:e1– 76 TABLE OF CONTENTS PREAMBLE ......................................e3 4.2.2.3. Considerations in Selecting Anticoagulants .................e23 4.2.2.4. Silent AF and Stroke .............e25 1. INTRODUCTION ...............................e6 4.3. Interruption and Bridging Anticoagulation .....e25 1.1. Methodology and Evidence Review ............e6 4.4. Nonpharmacological Stroke Prevention ........e26 1.2. Organization of the Writing Committee .........e6 4.4.1. Percutaneous Approaches to Occlude the ............... 1.3. Document Review and Approval e6 LAA ................................e26 1.4. Scope of the Guideline .......................e6 4.4.2. Cardiac Surgery—LAA Occlusion/Excision: Recommendation .....................e26 2. BACKGROUND AND PATHOPHYSIOLOGY ........e6 2.1. Definitions and Pathophysiology of AF ..........e8 5. RATE CONTROL: RECOMMENDATIONS ..........e27 2.1.1. AF Classification .......................e9 5.1. Specific Pharmacological Agents for Rate Control ..e29 2.1.1.1. Associated Arrhythmias ............ e9 5.1.1. Beta-Adrenergic Receptor Blockers ....... e29 2.1.1.2. Atrial Flutter and Macroreentrant Atrial Tachycardia ................ e9 5.1.2. Nondihydropyridine Calcium Channel Blockers ............................. e29 2.2. Mechanisms of AF and Pathophysiology ....... e11 5.1.3. Digoxin ............................. e29 2.2.1. Atrial Structural Abnormalities .......... e11 5.1.4. Other Pharmacological Agents for Rate ........ 2.2.2. Electrophysiological Mechanisms e12 Control .............................e30 2.2.2.1. Triggers of AF .................. e12 2.2.2.2. Maintenance of AF .............. e12 5.2. AV Nodal Ablation .........................e30 2.2.2.3. Role of the Autonomic Nervous 5.3. Selecting and Applying a Rate-Control Strategy ..e31 System ....................... e12 5.3.1. Broad Considerations in Rate Control ..... e31 2.2.3. Pathophysiological Mechanisms ......... e13 ........ 2.2.3.1. Atrial Tachycardia Remodeling ..... e13 5.3.2. Individual Patient Considerations e31 2.2.3.2. Inflammation and Oxidative ........................ Stress e13 6. RHYTHM CONTROL ...........................e32 2.2.3.3. The Renin-Angiotensin-Aldosterone System ....................... e13 6.1. Electrical and Pharmacological Cardioversion ..................... 2.2.3.4. Risk Factors and Associated of AF and Atrial Flutter e33 Heart Disease .................. e13 6.1.1. Prevention of Thromboembolism: Recommendations ....................e33 3. CLINICAL EVALUATION: RECOMMENDATION ....e14 6.1.2. Direct-Current Cardioversion: 3.1. Basic Evaluation of the Patient With AF ........e14 Recommendations ....................e33 3.1.1. Clinical History and Physical 6.1.3. Pharmacological Cardioversion: Examination ......................... e14 Recommendations ....................e33 3.1.2. Investigations ........................ e14 6.2. Pharmacological Agents for Preventing AF and 3.1.3. Rhythm Monitoring and Stress Testing ... e15 Maintaining Sinus Rhythm ..................e35 6.2.1. Antiarrhythmic Drugs to Maintain Sinus 4. PREVENTION OF THROMBOEMBOLISM .......... e15 Rhythm: Recommendations ............e35 4.1. Risk-Based Antithrombotic Therapy: 6.2.1.1. Specific Drug Therapy ............e38 Recommendations .........................e15 6.2.1.2. Outpatient Initiation of ...... 4.1.1. Selecting an Antithrombotic Regimen— Antiarrhythmic Drug Therapy e40 Balancing Risks and Benefits ............e17 6.2.2. Upstream Therapy: Recommendations ...e40 4.1.1.1. Risk Stratification Schemes (CHADS2, CHA2DS2-VASc, 6.3. AF Catheter Ablation to Maintain Sinus Rhythm: and HAS-BLED) ................. e17 Recommendations .........................e41 6.3.1. Patient Selection .....................e41 4.2. Antithrombotic Options .....................e18 6.3.2. Recurrence After Catheter Ablation ......e42 4.2.1. Antiplatelet Agents ...................e18 6.3.3. Anticoagulation Therapy Periablation ....e42 4.2.2. Oral Anticoagulants ...................e20 4.2.2.1. Warfarin ......................e20 6.3.4. Catheter Ablation in HF ...............e43 4.2.2.2. New Target-specific Oral 6.3.5. Complications Following AF Catheter Anticoagulants .................e22 Ablation ............................e43 Downloaded From: http://content.onlinejacc.org/ by Lea Binder on 10/04/2016 JACC VOL. 64, NO. 21, 2014 January et al. e3 DECEMBER 2, 2014:e1– 76 AHA/ACC/HRS Practice Guideline 6.4. Pacemakers and Implantable Cardioverter- strategies. An organized and directed approach to a Defibrillators for Prevention of AF ............e43 thorough review of evidence has resulted in the pro- 6.5. Surgical Maze Procedures: Recommendations .. e44 duction of clinical practice guidelines that assist clini- cians in selecting the best management strategy for an 7. SPECIFIC PATIENT GROUPS AND AF ............e45 individual patient. Moreover, clinical practice guidelines can provide a foundation for other applications, such as 7.1. Athletes .................................e45 performance measures, appropriate use criteria, and 7.2. Elderly ..................................e45 both quality improvement and clinical decision support 7.3. Hypertrophic Cardiomyopathy: tools. Recommendations ........................e45 The American College of Cardiology (ACC) and the American Heart Association (AHA) have jointly 7.4. AF Complicating ACS: Recommendations ......e47 engaged in the production of guidelines in the area ......... 7.5. Hyperthyroidism: Recommendations e48 of cardiovascular disease since 1980. The ACC/AHA 7.6. Acute Noncardiac Illness ...................e49 Task Force on Practice Guidelines