2019 AHA/ACC/HRS Focused Update of the 2014 Guideline for Management of Patients with Atrial

GUIDELINES MADE SIMPLE - Focused Update Edition A Selection of Tables and Figures

ACC.org/GMSAF ©2018, American College of B18202 ©2018, American College of Cardiology 2019 AHA/ACC/HRS Focused Update of the 2014 Guideline for Management of Patients with

A report of the American College of Cardiology/American Association Task Force on Clinical Practice Guidelines, and the Heart Rhythm Society

Writing Committee: Craig T. January, MD, PhD, FACC, Chair L. Samuel Wann, MD, MACC, FAHA, Vice Chair

Hugh Calkins, MD, FACC, FAHA, FHRS Lin Y. Chen, MD, MS, FACC, FAHA, FHRS Joaquin E. Cigarroa, MD, FACC Joseph C. Cleveland, Jr, MD, FACC Patrick T. Ellinor, MD, PhD Michael Exekowitz, MBChB, DPhil, FACC, FAHA Michael E. field, MD, FACC, FAHA, FHRS Karen Furie, MD, MPH, FAHA Paul Heidenreich, MD, FACC, FAHA Katherine T. Murray, MD, FACC, FAHA, FHRS Julie B. Shea, MS, RNCS, FHRS Cynthia M. Tracy, MD Clyde W. Yancy, MD, MACC, FAHA

The purpose of the 2019 Focused Update is to update the “2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation” in areas where new evidence has emerged since its publication. The scope of this update of the 2014 AF guideline includes revisions to the section on anticoagulation due to the approval of new medications and thromboembolism protection devices, the section on of AF, revisions to the section on the management of AF complicating , and new sections on device detection of AF and weight loss.

The following resource contains recommendation tables from the 2019 AF Focused Update as well as a comparison tool that highlights the major new and modified recommendations in the 2019 Focused Update. The resource is only an excerpt from the document and the full publication should be reviewed for important context.

CITATION: 10.1016/j.jacc.2019.01.011. 2019 AHA/ACC/HRS Focused Update of the 2014 Guideline for Management of Patients with Atrial Fibrillation

Selected Table or Figure Page

AF Focused Update: 2014-2019 Comparison Tool…………………………………………………………… 4-5

Selecting an Regimen—Balancing Risks and Benefits… …………………………………… 6-8

Interruption and Bridging Anticoagulation ……………………………………………………………………… 9

Percutaneous Approaches to Occlude the LAA ……………………………………………………………… 10

Cardiac Surgery—LAA Occlusion/Excision …………………………………………………………………… 10

Prevention of Thromboembolism……………………………………………………………………………… 11

Ablation in HF…………………………………………………………………………………………………… 12

AF Complicating ACS…………………………………………………………………………………………… 13

Device Detection of AF and Atrial Flutter ……………………………………………………………………… 14

Weight Reduction in Patients with AF………………………………………………………………………… 14 GUIDELINES MADE SIMPLE Back to Table of Contents AF 2019 AHA/ACC/HRS Focused Update of the 2014 Guideline for Management of Patients with Atrial Fibrillation

2014-2019 Comparison Tool (1 of 2)

Change in Guideline Recommendations (Only major included) 2014 2019 The term “nonvalvular AF” is no longer used Section 4.1.1 - Selection of Antithrombotic Regimen Oral recommended for high risk patients now include edoxaban.

Exclusion criteria for CHA2DS2-VASc assessment and use of NOACs now defined as moderate to severe mitral stenosis or a mechanical heart valve. For patients with AF and end-stage chronic kidney disease, the direct thrombin inhibitor dabigatran, or the factor Xa inhibitors rivaroxaban OR edoxaban are not recommended. Section 6.1.1 - Prevention of Thromboembolism For patients with AF or atrial flutter of 48 hours’ duration or longer, or when the duration of AF is unknown, anticoagulation with (INR 2.0 Upgraded to Class I to 3.0), a factor Xa inhibitor, or direct thrombin Recommendation inhibitor is recommended for at least 3 weeks before and at least 4 weeks after .

For patients with AF or atrial flutter of <48 hours'

duration with a CHA2DS2-VASc score of ≥2 in men and ≥3 in women, administration of heparin, a Downgraded to Class IIa factor Xa inhibitor, or a direct thrombin inhibitor is Recommendation reasonable as soon as possible before cardioversion, followed by long term anticoagulation therapy.

Table will continue in the next page. I IIa IIb III

ACC.org/AFCompare

4 GUIDELINES MADE SIMPLE Back to Table of Contents AF 2019 AHA/ACC/HRS Focused Update of the 2014 Guideline for Management of Patients with Atrial Fibrillation

2014-2019 Comparison Tool (2 of 2)

New Recommendations Section 4.1.1 - Selection of Antithrombotic Regimen NOACs are recommended over warfarin where eligible except in those patients with moderate - severe mitral stenosis or a mechanical heart valve. Section 4.3 - Interruption and Bridging Anticoagulation Idarucizumab is the reversal agent for dabigatran in the event of life-threatening bleeding or an urgent procedure. Andexanet Alfa is the reversal agent for and rivaroxaban. Section 4.4.1 - Percutaneous Approaches to Occlude the Left Atrial Appendage Percutaneous LAAO should be considered for those AF patients at an increased risk of who have contraindications to long-term anticoagulation and who are at high risk of thromboembolic events. Section 6.3.4 - Catheter Ablation in HF Catheter ablation of AF is reasonable in symptomatic AF patients with HF and reduced LVEF. Section 7.4 - Complicating Acute Coronary Syndrome If triple therapy is prescribed post-stent placement, clopidogrel is preferred over prasugrel.

Double therapy with a P2Y12 inhibitor and dose adjusted vitamin K antagonist is reasonable post-stenting. Double therapy with clopidogrel and low-dose rivaroxaban (15 mg daily) may be reasonable post-stenting.

Double therapy with a P2Y12 inhibitor and dabigatran 150 mg twice daily is reasonable post-stenting. If triple therapy is prescribed for patients with AF who are at increased risk of stroke and who have undergone PCI with stenting for ACS, a transition to double therapy at 4-6 weeks may be considered. Section 7.12 - Device Detection of AF and Atrial Flutter In patients with cardiac implantable electronic devices, atrial high rate episodes (AHREs) should prompt further evaluation. In patients with cryptogenic stroke in whom long-term external ambulatory monitoring is inconclusive implantation of a cardiac monitor is reasonable to detect silent AF. Section 7.13 - Weight Loss Weight loss and risk factor modification is recommended for overweight/obese patients with AF.

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5 GUIDELINES MADE SIMPLE Back to Table of Contents AF 2019 AHA/ACC/HRS Focused Update of the 2014 Guideline for Management of Patients with Atrial Fibrillation

Recommendations for Selecting an Anticoagulant Regimen— RecommendationsBalancing for Selecting an Risks Anticoagulant and RegimenBenefits—Balancing(1 of Risks 3) and Benefits

COR LOE Recommendations A 1. For patients with AF and an elevated CHA2DS2-VASc score of 2 or greater in men or 3 or greater in women, oral anticoagulants are recommended. B Options include: • Warfarin (LOE: A) • Dabigatran (LOE: B) B • Rivaroxaban (LOE: B) • Apixaban (LOE: B) or • I B Edoxaban (LOE: B-R) MODIFIED: This recommendation has been updated in response to the approval of edoxaban, a new factor Xa inhibitor. More precision in the use of CHA2DS2- VASc scores is specified in subsequent recommendations. The LOEs for warfarin, dabigatran, rivaroxaban, and apixaban have not been updated for greater B-R granularity as per the new LOE system. (Section 4.1. in the 2014 AF Guideline) The original text can be found in Section 4.1 of the 2014 AF guideline. Additional information about the comparative effectiveness and bleeding risk of NOACs can be found in Section 4.2.2.2. 2. NOACs (dabigatran, rivaroxaban, apixaban, and edoxaban) are recommended over warfarin in NOAC-eligible patients with AF (except with moderate-to- severe mitral stenosis or a mechanical heart valve). NEW: Exclusion criteria are now defined as moderate-to-severe mitral stenosis I A or a mechanical heart valve. When the NOAC trials are considered as a group, the direct thrombin inhibitor and factor Xa inhibitors were at least noninferior and, in some trials, superior to warfarin for preventing stroke and systemic and were associated with lower risks of serious bleeding. 3. Among patients treated with warfarin, the international normalized ratio (INR) should be determined at least weekly during initiation of anticoagulant I A therapy and at least monthly when anticoagulation (INR in range) is stable. MODIFIED: “Antithrombotic” was changed to “anticoagulant.” 4. In patients with AF (except with moderate-to-severe mitral stenosis or a

mechanical heart valve), the CHA2DS2-VASc score is recommended for assessment of stroke risk. I B MODIFIED: Exclusion criteria are now defined as moderate-to-severe mitral stenosis or a mechanical heart valve. Patients with AF with bioprosthetic heart valves are addressed in the supportive text. (Section 4.1. in the 2014 AF guideline) 5. For patients with AF who have mechanical heart valves, warfarin is I B recommended. MODIFIED: New information is included in the supportive text. 6. Selection of anticoagulant therapy should be based on the risk of thromboembolism, irrespective of whether the AF pattern is paroxysmal, I B persistent, or permanent. MODIFIED: “Antithrombotic” was changed to “anticoagulant.” 7. Renal function and hepatic function should be evaluated before initiation of a Table Iwill continueB-NR in the next page. NOAC and should be reevaluated at least annually.

6 Recommendations for Selecting an Anticoagulant Regimen—Balancing Risks and Benefits

COR LOE Recommendations A 1. For patients with AF and an elevated CHA2DS2-VASc score of 2 or greater in men or 3 or greater in women, oral anticoagulants are recommended. B Options include: • Warfarin (LOE: A) • Dabigatran (LOE: B) B • Rivaroxaban (LOE: B) • Apixaban (LOE: B) or • I B Edoxaban (LOE: B-R) MODIFIED: This recommendation has been updated in response to the approval of edoxaban, a new factor Xa inhibitor. More precision in the use of CHA2DS2- VASc scores is specified in subsequent recommendations. The LOEs for warfarin, dabigatran, rivaroxaban, and apixaban have not been updated for greater B-R granularity as per the new LOE system. (Section 4.1. in the 2014 AF Guideline) The original text can be found in Section 4.1 of the 2014 AF guideline. Additional information about the comparative effectiveness and bleeding risk of NOACs can be found in Section 4.2.2.2. 2. NOACs (dabigatran, rivaroxaban, apixaban, and edoxaban) are recommended over warfarin in NOAC-eligible patients with AF (except with moderate-to- severe mitral stenosis or a mechanical heart valve). NEW: Exclusion criteria are now defined as moderate-to-severe mitral stenosis I A or a mechanical heart valve. When the NOAC trials are considered as a group, the direct thrombin inhibitor and factor Xa inhibitors were at least noninferior and, in some trials, superior to warfarin for preventing stroke and systemic embolism and were associated with lower risks of serious bleeding. 3. Among patients treated with warfarin, the international normalized ratio (INR) should be determined at least weekly during initiation of anticoagulant I A therapy and at least monthly when anticoagulation (INR in range) is stable. MODIFIED: “Antithrombotic” was changed to “anticoagulant.” GUIDELINES MADE4. SIMPLE In patients with AF (except with moderate-to-severe mitral stenosisBack to or Table a of Contents

AF 2019 AHA/ACC/HRS Focusedmechanical Update heartof the valve),2014 Guideline the CHA for2DS Management2-VASc score of is Patientsrecommended with Atrial for Fibrillation assessment of stroke risk. I B MODIFIED: Exclusion criteria are now defined as moderate-to-severe mitral stenosis or a mechanical heart valve. Patients with AF with bioprosthetic heart valves are addressed in the supportive text. (Section 4.1. in the 2014 AF guideline) 5. For patients with AF who have mechanical heart valves, warfarin is I B recommended. MODIFIED: New information is included in the supportive text. Recommendations6. Selection for of Selecting anticoagulant therapyan Anticoagulant should be based on Regimen— the risk of thromboembolism, irrespective of whether the AF pattern is paroxysmal, I B Balancingpersistent, or permanent.Risks and Benefits(2 of 3) MODIFIED: “Antithrombotic” was changed to “anticoagulant.” 7. Renal function and hepatic function should be evaluated before initiation of a I B-NR NOAC and should be reevaluated at least annually. MODIFIED: Evaluation of hepatic function was added. LOE was updated from B to B-NR. New evidence was added. (Section 4.1. in the 2014 AF Guideline) 8. In patients with AF, anticoagulant therapy should be individualized on the basis of shared decision-making after discussion of the absolute risks and relative I C risks of stroke and bleeding, as well as the patient’s values and preferences. MODIFIED: “Antithrombotic” was changed to “anticoagulant.” 9. For patients with atrial flutter, anticoagulant therapy is recommended I C according to the same risk profile used for AF. MODIFIED: “Antithrombotic” was changed to “anticoagulant.” 10. Reevaluation of the need for and choice of anticoagulant therapy at periodic I C intervals is recommended to reassess stroke and bleeding risks. MODIFIED: “Antithrombotic” was changed to “anticoagulant.” 11. For patients with AF (except with moderate-to-severe mitral stenosis or a mechanical heart valve) who are unable to maintain a therapeutic INR level with warfarin, use of a NOAC is recommended. I C-EO MODIFIED: Exclusion criteria are now defined as moderate-to-severe mitral stenosis or a mechanical heart valve, and this recommendation has been changed in response to the approval of edoxaban. (Section 4.1. in the 2014 AF Guideline) 12. For patients with AF (except with moderate-to-severe mitral stenosis or a mechanical heart valve) and a CHA2DS2-VASc score of 0 in men or 1 in women, IIa B it is reasonable to omit anticoagulant therapy. MODIFIED: Exclusion criteria are now defined as moderate-to-severe mitral stenosis or a mechanical heart valve. (Section 4.1. in the 2014 AF Guideline) 13. For patients with AF who have a CHA2DS2-VASc score of 2 or greater in men or 3 or greater in women and who have end-stage chronic kidney disease (CKD; creatinine clearance [CrCl] <15 mL/min) or are on dialysis, it might be IIb B-NR reasonable to prescribe warfarin (INR 2.0 to 3.0) or apixaban for oral anticoagulation. MODIFIED: New evidence has been added. LOE was updated from B to B-NR. (Section 4.1. in the 2014 AF Guideline) Table will continue in the 14.next Forpage. patients with AF (except with moderate-to-severe mitral stenosis or a mechanical heart valve) and moderate-to-severe CKD (serum creatinine ≥1.5 mg/dL [apixaban], CrCl 15 to 30 mL/min [dabigatran], CrCl <50 mL/min [rivaroxaban], or CrCl 15 to 50 mL/min [edoxaban]) with an elevated CHA2DS2- VASc score, treatment with reduced doses of direct thrombin or factor Xa IIb B-R inhibitors may be considered (e.g., dabigatran, rivaroxaban, apixaban, or edoxaban). MODIFIED: Exclusion criteria are now defined as moderate-to-severe mitral stenosis or a mechanical heart7 valve, and this recommendation has been changed in response to the approval of edoxaban. LOE was updated from C to B-R. (Section 4.1. in the 2014 AF Guideline) 15. For patients with AF (except with moderate-to-severe mitral stenosis or a mechanical heart valve) and a CHA2DS2-VASc score of 1 in men and 2 in IIb C- LD women, prescribing an oral anticoagulant to reduce thromboembolic stroke risk may be considered. MODIFIED: Evaluation of hepatic function was added. LOE was updated from B to B-NR. New evidence was added. (Section 4.1. in the 2014 AF Guideline) MODIFIED: Evaluation of hepatic function was added. LOE was updated from B 8. Into patients B-NR. New with evidence AF, anticoagulant was added. therapy (Section should 4.1. in be the individualized 2014 AF Guideline) on the basis of shared decision-making after discussion of the absolute risks and relative I C 8. Inrisks patients of stroke with AF,and anticoagulant bleeding, as well therapy as the should patient’s be individualized values and preferences. on the basis of shared decision-making after discussion of the absolute risks and relative I C MODIFIED: “Antithrombotic” was changed to “anticoagulant.” risks of stroke and bleeding, as well as the patient’s values and preferences. 9. For patients with atrial flutter, anticoagulant therapy is recommended MODIFIED: “Antithrombotic” was changed to “anticoagulant.” I C according to the same risk profile used for AF. 9. For patients with atrial flutter, anticoagulant therapy is recommended MODIFIED: “Antithrombotic” was changed to “anticoagulant.” I C according to the same risk profile used for AF. 10. Reevaluation of the need for and choice of anticoagulant therapy at periodic MODIFIED: “Antithrombotic” was changed to “anticoagulant.” I C intervals is recommended to reassess stroke and bleeding risks. 10.MODIFIED: Reevaluation “Antithrombotic” of the need for was and changed choice of to anticoagulant “anticoagulant.” therapy at periodic I C intervals is recommended to reassess stroke and bleeding risks. 11. For patients with AF (except with moderate-to-severe mitral stenosis or a MODIFIED: “Antithrombotic” was changed to “anticoagulant.” mechanical heart valve) who are unable to maintain a therapeutic INR level 11. For patients with AF (except with moderate-to-severe mitral stenosis or a with warfarin, use of a NOAC is recommended. I C-EO MODIFIED:mechanical Exclusionheart valve) criteria who are unable now defined to maintain as moderate a therapeutic-to-severe INR mitral level stenosiswith warfarin, or a mechanicaluse of a NOAC heart is recommended. valve, and this recommendation has been GUIDELINESI C MADE-EO SIMPLEchangedMODIFIED: in responseExclusion to criteria the approval are now of edoxaban. defined as (Sectionmoderate 4.1.-to in-severe theBack 2014 mitralto Table AF of Contents AF Guideline)stenosis or a mechanical heart valve, and this recommendation has been 2019 AHA/ACC/HRS Focusedchanged Update in response of the 2014 to the Guideline approval forof edoxaban.Management (Section of Patients 4.1. in thewith 2014 Atrial AF Fibrillation 12. For patients with AF (except with moderate-to-severe mitral stenosis or a Guideline) mechanical heart valve) and a CHA2DS2-VASc score of 0 in men or 1 in women, IIa B 12. it For is reasonable patients with to omit AF (except anticoagulant with moderate therapy.- to-severe mitral stenosis or a MODIFIEDmechanical: Exclusionheart valve) criteria and a areCHA now2DS2 -VASc defined score as ofmoderate 0 in men-to or- severe1 in women, mitral IIa B stenosisit is reasonable or a mechanical to omit heartanticoagulant valve. (Section therapy. 4.1. in the 2014 AF Guideline) MODIFIED: Exclusion criteria are now defined as moderate-to-severe mitral 13. For patients with AF who have a CHA2DS2-VASc score of 2 or greater in men or stenosis or a mechanical heart valve. (Section 4.1. in the 2014 AF Guideline) 3 or greater in women and who have end-stage chronic kidney disease (CKD; 13.creatinine For patients clearance with AF [CrCl] who have<15 mL/min) a CHA2DS or2- VAScare on score dialysis, of 2 itor might greater be in men or IIb B-NR reasonable3 or greater to in prescribewomen and warfarin who have (INR end 2.0 -tostage 3.0) chronic or apixaban kidney for disease oral (CKD; Recommendationscreatinine for clearance Selecting [CrCl] <15 mL/min)an Anticoagulant or are on dialysis, it might Regimen— be anticoagulation. IIb B-NR BalancingMODIFIEDreasonable: Ntoew prescribeRisks evidence warfarin and has been Benefits(INR added. 2.0 to LOE3.0) wasor(3 apixaban of updated 3) for from oral B to B-NR. (Sectionanticoagulation 4.1. in the. 2014 AF Guideline) MODIFIED: New evidence has been added. LOE was updated from B to B-NR. 14. For patients with AF (except with moderate-to-severe mitral stenosis or a (Section 4.1. in the 2014 AF Guideline) mechanical heart valve) and moderate-to-severe CKD (serum creatinine ≥1.5 14.mg/dL For patients [apixaban], with AFCrCl (except 15 to with 30 mL/min moderate [dabigatran],-to-severe mitral CrCl stenosis<50 mL/min or a mechanical heart valve) and moderate-to-severe CKD (serum creatinine ≥1.5 [rivaroxaban], or CrCl 15 to 50 mL/min [edoxaban]) with an elevated CHA2DS2- VAScmg/dL score, [apixaban], treatment CrCl with 15 toreduced 30 mL/min doses of [dabigatran], direct thrombin CrCl < or50 factor mL/min Xa IIb B-R inhibitors[rivaroxaban], may or be CrCl considered 15 to 50 mL/min (e.g., dabigatran,[edoxaban]) rivaroxaban,with an elevated apixaban, CHA2DS or2- edoxaban)VASc score,. treatment with reduced doses of direct thrombin or factor Xa

IIb B-R MODIFIEDinhibitors : mayExclusion be considered criteria are (e.g., now dabigatran, defined as rivaroxaban,moderate-to - apixaban,severe mitral or stenosisedoxaban) or .a mechanical heart valve, and this recommendation has been changed inMODIFIED response: toEx theclusion approval criteria of edoxaban. are now LOE defined was updated as moderate from -Cto to-severe B-R. (Section mitral 4.1.stenosis in the or 2014 a mechanical AF Guideline) heart valve, and this recommendation has been changed in response to the approval of edoxaban. LOE was updated from C to B-R. (Section 15. For patients with AF (except with moderate-to-severe mitral stenosis or a 4.1. in the 2014 AF Guideline) mechanical heart valve) and a CHA2DS2-VASc score of 1 in men and 2 in IIb C- LD 15. women,For patients prescribing with AF an (except oral anticoagulant with moderate to reduce-to-severe thromboembolic mitral stenosis stroke or a mechanical heart valve) and a CHA2DS2-VASc score of 1 in men and 2 in IIb C- LD risk may be considered. MODIFIEDwomen, prescribing: Exclusion an criteria oral anticoagulant are now defined to reduce as moderate thromboembolic-to-severe stroke mitral stenosisrisk may be or considered. a mechanical heart valve, and evidence was added to support separate risk scores by sex. LOE was updated from C to C-LD. (Section 4.1. in the 2014 AF Guideline) 16. In patients with AF and end-stage CKD or on dialysis, the direct thrombin inhibitor dabigatran or the factor Xa inhibitors rivaroxaban or edoxaban are III: not recommended because of the lack of evidence from clinical trials that No C-EO benefit exceeds risk. Benefit MODIFIED: New data have been included. Edoxaban received FDA approval and has been added to the recommendation. LOE was updated from C to C-EO. (Section 4.1. in the 2014 AF Guideline) 17. The direct thrombin inhibitor dabigatran should not be used in patients with III: AF and a mechanical heart valve. B-R Harm MODIFIED: Evidence was added. LOE was updated from B to B-R. Other NOACs are addressed in the supportive text. (Section 4.1. in the 2014 AF Guideline)

8 GUIDELINES MADE SIMPLE Back to Table of Contents AF 2019 AHA/ACC/HRS Focused Update of the 2014 Guideline for Management of Patients with Atrial Fibrillation

Recommendations for InterruptionRecommendations and for Interruption Bridging and AnticoagulationBridging Anticoagulation

COR LOE Recommendations 1. Bridging therapy with unfractionated heparin or low-molecular-weight heparin is recommended for patients with AF and a mechanical heart valve I C undergoing procedures that require interruption of warfarin. Decisions on bridging therapy should balance the risks of stroke and bleeding.

2. For patients with AF without mechanical heart valves who require interruption of warfarin for procedures, decisions about bridging therapy (unfractionated heparin or low-molecular-weight heparin) should balance I B-R the risks of stroke and bleeding and the duration of time a patient will not be anticoagulated. MODIFIED: LOE was updated from C to B-R because of new evidence. (Section 4.1. in the 2014 AF Guideline) 3. Idarucizumab is recommended for the reversal of dabigatran in the event of life-threatening bleeding or an urgent procedure. I B-NR NEW: New evidence has been published about idarucizumab to support LOE B-NR. 4. Andexanet alfa can be useful for the reversal of rivaroxaban and apixaban in the event of life-threatening or uncontrolled bleeding. IIa B-NR NEW: New evidence has been published about andexanet alfa to support LOE B-NR.

9 GUIDELINES MADE SIMPLE Back to Table of Contents AF 2019 AHA/ACC/HRS Focused Update of the 2014 Guideline for Management of Patients with Atrial Fibrillation

Recommendation for

PercutaneousRecommendation for PercutaneousApproaches Approaches to Occlude to Occlude thethe LAA LAA

COR LOE Recommendation 1. Percutaneous LAA occlusion may be considered in patients with AF at increased risk of stroke who have contraindications to long-term anticoagulation. IIb B-NR NEW: Clinical trial data and FDA approval of the Watchman device necessitated this recommendation.

RecommendationRecommendation for for Percutaneous Cardiac Surgery Approaches—LAA Occlusion/Excision to Occlude the LAA

COR LOE Recommendation 1.1. SurgicalPercutaneous occlusion LAA of occlusion the LAA maymay bebe consideredconsidered in in patients patients with with AF AF at undergoing increased riskcardiac of stroke surgery, who as have a component contraindications of an to overall long- term heart anticoagulation team approach. to the IIb B-NR managementNEW: Clinical oftrial AF. data and FDA approval of the Watchman device necessitated MODIFIEDthis recommendation.: RecommendationLOE was updated from C to B-NR for because of new evidence.

Cardiac Surgery—LAA Occlusion/Excision Recommendation for Cardiac Surgery—LAA Occlusion/Excision

COR LOE Recommendation 1. Surgical occlusion of the LAA may be considered in patients with AF undergoing cardiac surgery, as a component of an overall heart team approach to the IIb B-NR management of AF. MODIFIED: LOE was updated from C to B-NR because of new evidence.

10 GUIDELINES MADE SIMPLE Back to Table of Contents AF 2019 AHA/ACC/HRS Focused Update of the 2014 Guideline for Management of Patients with Atrial Fibrillation RecommendationsRecommendations for Prevention forof Thromboembolism Prevention of Thromboembolism Recommendations for Prevention of Thromboembolism COR LOE Recommendations 1. For patients with AF or atrial flutter of 48 hours’ duration or longer, or when COR LOE Recommendations the duration of AF is unknown, anticoagulation with warfarin (INR 2.0 to 1. For patients with AF or atrial flutter of 48 hours’ duration or longer, or when 3.0), a factor Xa inhibitor, or direct thrombin inhibitor is recommended the duration of AF is unknown, anticoagulation with warfarin (INR 2.0 to for at least 3 weeks before and at least 4 weeks after cardioversion, 3.0), a factor Xa inhibitor, or direct thrombin inhibitor is recommended regardless of the CHA2DS2-VASc score or the method (electrical or for at least 3 weeks before and at least 4 weeks after cardioversion, pharmacological) used to restore sinus rhythm. I B-R regardless of the CHA2DS2-VASc score or the method (electrical or MODIFIED: The 2014 AF Guideline recommendation for use of warfarin pharmacological) used to restore sinus rhythm. I B-R around the time of cardioversion was combined with the 2014 AF Guideline MODIFIED: The 2014 AF Guideline recommendation for use of warfarin recommendation for NOACs to create a single recommendation. This around the time of cardioversion was combined with the 2014 AF Guideline combined recommendation was updated to COR I/LOE B-R from COR IIa/LOE recommendation for NOACs to create a single recommendation. This C for NOACs in the 2014 AF Guideline on the basis of additional trials that have combined recommendation was updated to COR I/LOE B-R from COR IIa/LOE evaluated the use of NOACs with cardioversion. C for NOACs in the 2014 AF Guideline on the basis of additional trials that have 2. For patients with AF or atrial flutter of more than 48 hours’ duration or evaluated the use of NOACs with cardioversion. unknown duration that requires immediate cardioversion for hemodynamic I C 2. For patients with AF or atrial flutter of more than 48 hours’ duration or instability, anticoagulation should be initiated as soon as possible and unknown duration that requires immediate cardioversion for hemodynamic I C continued for at least 4 weeks after cardioversion unless contraindicated. instability, anticoagulation should be initiated as soon as possible and 3. After cardioversion for AF of any duration, the decision about long-term continued for at least 4 weeks after cardioversion unless contraindicated. anticoagulation therapy should be based on the thromboembolic risk 3. After cardioversion for AF of any duration, the decision about long-term profile and bleeding risk profile. I C-EO anticoagulation therapy should be based on the thromboembolic risk MODIFIED: The 2014 AF Guideline recommendation was strengthened with profile and bleeding risk profile. I C-EO the addition of bleeding risk profile to the long-term anticoagulation decision- MODIFIED: The 2014 AF Guideline recommendation was strengthened with making process. the addition of bleeding risk profile to the long-term anticoagulation decision- 4. For patients with AF or atrial flutter of less than 48 hours’ duration with a making process. CHA2DS2-VASc score of 2 or greater in men and 3 or greater in women, 4. For patients with AF or atrial flutter of less than 48 hours’ duration with a administration of heparin, a factor Xa inhibitor, or a direct thrombin CHA2DS2-VASc score of 2 or greater in men and 3 or greater in women, inhibitor is reasonable as soon as possible before cardioversion, followed by IIa B-NR administration of heparin, a factor Xa inhibitor, or a direct thrombin long-term anticoagulation therapy. inhibitor is reasonable as soon as possible before cardioversion, followed by IIa B-NR MODIFIED: Recommendation COR was changed from I in the 2014 AF long-term anticoagulation therapy. Guideline to IIa, and LOE was changed from C in the 2014 AF Guideline to B- MODIFIED: Recommendation COR was changed from I in the 2014 AF NR. In addition, a specific CHA2DS2-VASc score is now specified. Guideline to IIa, and LOE was changed from C in the 2014 AF Guideline to B- 5. For patients with AF or atrial flutter of 48 hours’ duration or longer or of NR. In addition, a specific CHA2DS2-VASc score is now specified. unknown duration who have not been anticoagulated for the preceding 3 5. For patients with AF or atrial flutter of 48 hours’ duration or longer or of weeks, it is reasonable to perform transesophageal echocardiography unknown duration who have not been anticoagulated for the preceding 3 IIa B before cardioversion and proceed with cardioversion if no left atrial weeks, it is reasonable to perform transesophageal echocardiography is identified, including in the LAA, provided that anticoagulation IIa B before cardioversion and proceed with cardioversion if no left atrial is achieved before transesophageal echocardiography and maintained after thrombus is identified, including in the LAA, provided that anticoagulation cardioversion for at least 4 weeks. is achieved before transesophageal echocardiography and maintained after 6. For patients with AF or atrial flutter of less than 48 hours’ duration with a cardioversion for at least 4 weeks. CHA2DS2-VASc score of 0 in men or 1 in women, administration of heparin, 6. For patients with AF or atrial flutter of less than 48 hours’ duration with a IIb B-NR a factor Xa inhibitor, or a direct thrombin inhibitor, versus no CHA2DS2-VASc score of 0 in men or 1 in women, administration of heparin, anticoagulant therapy, may be considered before cardioversion, without IIb B-NR a factor Xa inhibitor, or a direct thrombin inhibitor, versus no the need for postcardioversion oral anticoagulation. anticoagulant therapy, may be considered before cardioversion, without MODIFIED: Recommendation LOE was changed from C in the 2014 AF theGuideline need forto Bpostcardioversion-NR to reflect evi denceoral anticoagulation. from 2 registry studies and to include specific CHA2DS2-VASc scores derived from study results.

11 GUIDELINES MADE SIMPLE Back to Table of Contents AF 2019 AHA/ACC/HRS Focused Update of the 2014 Guideline for Management of Patients with Atrial Fibrillation

Recommendation for Catheter Ablation in HF Recommendation for Catheter Ablation in HF

COR LOE Recommendation 1. AF catheter ablation may be reasonable in selected patients with symptomatic AF and HF with reduced left ventricular (LV) ejection fraction (HFrEF) to potentially lower mortality rate and reduce hospitalization for HF. IIb B-R NEW: New evidence, including data on improved mortality rate, have been published for AF catheter ablation compared with medical therapy in patients with HF.

12 GUIDELINES MADE SIMPLE Back to Table of Contents AF 2019 AHA/ACC/HRS Focused Update of the 2014 Guideline for Management of Patients with Atrial Fibrillation Recommendations for AF Complicating ACS Recommendations for AF Complicating ACS COR LOE Recommendations 1. For patients with ACS and AF at increased risk of systemic thromboembolism (based on CHA2DS2-VASc risk score of 2 or greater), anticoagulation is recommended unless the bleeding risk exceeds the expected benefit. I B-R MODIFIED: New published data are available. LOE was updated from C in the 2014 AF Guideline to B-R. Anticoagulation options are described in supportive text. 2. Urgent direct-current cardioversion of new-onset AF in the setting of ACS is I C recommended for patients with hemodynamic compromise, ongoing , or inadequate rate control. 3. Intravenous beta blockers are recommended to slow a rapid ventricular I C response to AF in patients with ACS who do not display HF, hemodynamic instability, or bronchospasm. 4. If triple therapy (oral anticoagulant, aspirin, and P2Y12 inhibitor) is prescribed for patients with AF at increased risk of stroke (based on CHA2DS2-VASc risk score of 2 or greater) who have undergone percutaneous coronary intervention IIa B-NR (PCI) with stenting for ACS, it is reasonable to choose clopidogrel in preference to prasugrel. NEW: New published data are available. 5. In patients with AF at increased risk of stroke (based on CHA2DS2-VASc risk score of 2 or greater) who have undergone PCI with stenting for ACS, double therapy with a P2Y12 inhibitor (clopidogrel or ticagrelor) and dose-adjusted vitamin K IIa B-R antagonist is reasonable to reduce the risk of bleeding as compared with triple therapy. NEW: New RCT data and data from 2 registries and a retrospective cohort study are available. 6. In patients with AF at increased risk of stroke (based on CHA2DS2-VASc risk score of 2 or greater) who have undergone PCI with stenting for ACS, double therapy IIa B-R with P2Y12 inhibitors (clopidogrel) and low-dose rivaroxaban (15 mg daily) is reasonable to reduce the risk of bleeding as compared with triple therapy. NEW: New published data are available. 7. In patients with AF at increased risk of stroke (based on CHA2DS2-VASc risk score of 2 or greater) who have undergone PCI with stenting for ACS, double IIa B-R therapy with a P2Y12 inhibitor (clopidogrel) and dabigatran 150 mg twice daily is reasonable to reduce the risk of bleeding as compared with triple therapy. NEW: New published data are available. 8. If triple therapy (oral anticoagulant, aspirin, and P2Y12 inhibitor) is prescribed for patients with AF who are at increased risk of stroke (based on CHA2DS2-VASc risk score of 2 or greater) and who have undergone PCI with stenting (drug IIb B-R eluting or bare metal) for ACS, a transition to double therapy (oral anticoagulant and P2Y12 inhibitor) at 4 to 6 weeks may be considered. NEW: New published data are available. 9. Administration of amiodarone or may be considered to slow a rapid IIb C ventricular response in patients with ACS and AF associated with severe LV dysfunction and HF or hemodynamic instability. 10. Administration of nondihydropyridine calcium antagonists may be considered IIb C to slow a rapid ventricular response in patients with ACS and AF only in the absence of significant HF or hemodynamic instability.

13 GUIDELINES MADE SIMPLE Back to Table of Contents AF 2019 AHA/ACC/HRS Focused Update of the 2014 Guideline for Management of Patients with Atrial Fibrillation

Recommendations for Device Detection of AF and Atrial Flutter Recommendations for Device Detection of AF and Atrial Flutter

COR LOE Recommendations 1. In patients with cardiac implantable electronic devices (pacemakers or implanted cardioverter-defibrilators), the presence of recorded atrial high-rate episodes I B-NRRecommendations (AHREs) should for prompt Device further Detection evaluation of AF andto document Atrial Flutter clinically relevant AF to guide treatment decisions. COR LOE Recommendations 2.1. In In patientspatients with cardiac cryptogenic implantable stroke electronic (i.e., stroke devices of unknown (pacemakers cause) or inimplanted whom external ambulatory monitoring is inconclusive, implantation of a cardiac monitor IIa B-R cardioverter-defibrilators), the presence of recorded atrial high-rate episodes I B-NR (loop(AHREs) recorder) should is promptreasonable further to optimize evaluation detection to document of silent clinically AF. relevant AF to guide treatment decisions.

Recommendation2. In patients withfor Weight cryptogenic Reduction stroke in (i.e., Patients stroke with of AF unknown cause) in whom external ambulatory monitoring is inconclusive, implantation of a cardiac monitor IIa B-R COR LOE (loop recorder) is reasonableRecommendation to optimize detection of silent AF. 1. For overweightRecommendation and obese patients with AF, weightfor loss, combined with risk factor modification, is recommended. I B-R Weight Reduction in Patients with AF RecommendationNEW: New data for demonstrate Weight Reduction the beneficial in Patients effects ofwith weight AF loss and risk factor modification on controlling AF. COR LOE Recommendation 1. For overweight and obese patients with AF, weight loss, combined with risk factor modification, is recommended. I B-R NEW: New data demonstrate the beneficial effects of weight loss and risk factor modification on controlling AF.

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