Managementul Fia

Canadian Cardiovascular Society
2010 Atrial Fibrillation Guidelines

Atrial Fibrillation Guidelines

Anne Gillis (co chair)
Allan Skanes (co chair)
John Cairns
Stuart Connolly
Jafna Cox
Paul Dorian
Jeff Healey
Laurent Macle
Sean McMurtry

Brent Mitchell
Stanley Nattel
Pierre Pag
Ratika Parkash
P. Timothy Pollak
Michael Stephenson
Ian Stiell
Mario Talajic
Teresa Tsang
Atul Verma

CCS AF Guidelines 2010
Primary Panel

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

CCS AF Guidelines 2010
Secondary Panel

Canadian Cardiovascular Society Atrial
Fibrillation Guidelines 2010:
Implementing GRADE and Achieving
Consensus
Anne M Gillis MD
Allan C Skanes MD

With special acknowledgement of
Jan Brozek MD, PhD

A New Approach to Guideline
Development & Evaluation
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
High
Future 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 Low
The 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 Comment
Quality 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

Jeff S Healey MD
Ratika Parkash MD
P Timothy Pollak MD
Teresa SM Tsang MD
Paul Dorian MD
Atrial Fibrillation Guidelines 2010:
Etiology and Investigation
Establish Pattern of Atrial Fibrillation
Paroxysmal Persistent
Permanent
Newly Diagnosed AF
Modified with permission from Fuster et al Circulation 2006;114:e257-354.
History
Establish Severity (including impact on QOL)
Identify Etiology
Identify reversible causes (hyperthyroidism, ventricular pacing, SVT,
exercise)
Identify factors whose treatment could reduce recurrent AF or
improve overall prognosis (i.e. hypertension, sleep apnea, left
ventricular dysfunction)
Identify potential triggers (i.e. alcohol, intensive aerobic training)
Identify potentially heritable causes of AF (particularly in lone AF)
Determine thromboembolic risk (e.g. CHADS
2
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 Quality
Evidence
Other ancillary tests should be considered
under specific circumstances. Details
included in Table 2.
Strong
Recommendation
Low Quality
Evidence
Recommendations
Etiology and Investigations
Practical Tips
Aggressive treatment of hypertension may prevent
or reduce recurrences
Choice of antihypertensive therapy should favor rate
controlling drugs e.g. -blockers and Ca
2+
channel
blockers vs inhibitors of renin angiotensin system.
Identify and treat obstructive sleep apnea
CCS
SAF 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 Severity
Use 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
Recommendation
Low Quality of
Evidence
We suggest that QOL of the AF patient can
be assessed in routine care using the
CCSSAF 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 1
Minimal effect
on QOL
EHRA II Mild symptoms
CCS SAF 2
Modest effect
on QOL
EHRA III
Severe
symptoms;
daily activity
affected
CCS SAF 3
Moderate effect
on QOL
EHRA IV
Disabling
symptoms;
Normal daily
activity
discontinued
CCS SAF 4
Severe effect
on QOL
AF/AFL Rhythm Management

Anne M Gillis MD
Atul Verma MD
Mario Talajic MD
Stanley Nattel MD
Paul Dorian MD

Management of
Arrhythmia
Rate
Control
Rhythm
Control
Overview of AF Management
AF Detected
Detection and
Treatment of
Precipitating Causes
No antithrombotic therapy may be appropriate in
selected young patients with no stroke risk factors
ASA
OAC
Assessment of
Thromboembolic
Risk (CHADS
2
)
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
Recommendation
Low 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
Recommendation
Moderate Quality
Evidence

Recommendations Rx Goals
Values and Preferences
These recommendations place a high value on the decision of individual patients
to balance relief of symptoms and improvement in QOL and other clinical
outcomes with the potential greater adverse effects of Class I/III antiarrhythmic
drugs compared to rate control therapy.
Referral for Specialty Care
Most patients with AF/AFL should be considered for referral to
a cardiologist or an internist with an interest in cardiovascular
disease for an expert opinion on management.
Patients 35 yr old with symptomatic AF should be referred to
an arrhythmia specialist to rule out other forms of SVT that may
trigger AF and that would be best treated by radiofrequency
ablation.
Patients who remain highly symptomatic despite multiple trials
of antiarrhythmic drug therapy, or who remain unresponsive to,
or intolerant of rate controlling therapies should be referred to
an arrhythmia specialist for an expert opinion on management
alternatives.

Rate or Rhythm Control?
How do you decide if you are going to
pursue rate or rhythm control for a
patient with AF?
No right or wrong answer
Often, the two are simultaneous:
Rhythm control requires good rate
control when patient goes back into AF
Need to continuously re-evaluate the
strategy as the AF progresses
What may have been a good initial
strategy may no longer be warranted
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.
Strong
Recommendation
Moderate Quality
Evidence
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
Recommendation
High Quality
Evidence
These recommendations place a high value on the randomized clinical trials and
other clinical studies demonstrating that ventricular rate control of AF is an
effective treatment approach for many patients with AF.

Ventricular Rate Control
Rate Control Drug Choices
No Heart
Disease
Hypertension
CAD Heart Failure
-blocker
Diltiazem
Verapamil
Combination Rx
Digitalis

-blocker*
Diltiazem
Verapamil

-blocker

digitalis
*-blockers preferred in CAD
Digitalis may be considered as

monotherapy in sedentary individuals
Dronedarone
We recommend -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.
Strong
Recommendation
Moderate Quality
Evidence
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
Recommendation
Moderate Quality
Evidence
We suggest that digoxin be added to therapy
with beta-blockers or calcium channel blockers
in patients whose heart rate remains
uncontrolled.
Conditional
Recommendation
Moderate Quality
Evidence
We suggest that dronedarone may be added for
additional rate control in patients with
uncontrolled ventricular rates despite therapy
with -blockers, calcium channel blockers
and/or digoxin.
Conditional
Recommendation
Moderate Quality
Evidence
We suggest that amiodarone for rate control
should be reserved for exceptional cases in
which other means are not feasible or are
insufficient.
Conditional
Recommendation
Low Quality
Evidence
These recommendations recognize that selection of rate control therapy needs
to be individualized based on the presence or absence of underlying structural
heart disease, the activity level of the patient and other individual
considerations.

Recommendation
Strength /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
Recommendation
High Quality
Evidence
Previous MI or LV Systolic Dysfunction
This recommendation places a high value on the results of multiple randomized
clinical trials reporting the benefit of beta-blockers to improve survival and
decrease the risk of recurrent myocardial infarction and prevent new-onset heart
failure following myocardial infarction as well as the adverse effects of calcium
channel blockers in the setting of heart failure.

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

Drug Dose
Adverse Effects
atenolol 50 150 mg p.o. daily
bradycardia,
hypotension, fatigue,
depression
bisoprolol 2.5 10 mg p.o. daily as per atenolol
metoprolol 25 mg- 200mg p.o. bid as per atenolol
nadolol
20 160 mg p.o. daily - bid
as per atenolol
propranolol* 80 240 mg p.o. tid as per atenolol
-blockers for Rate Control
* Sustained release preparations are available
Drug Dose Adverse Effects
verapamil *
120 mg p.o. daily -
240 mg p.o. bid
bradycardia,
hypotension,
constipation
diltiazem *
120-280 mg p.o.
daily - bid
bradycardia,
hypotension,
ankle swelling
digoxin
0.125 0.25 mg p.o.
daily
bradycardia,
nausea, vomiting,
visual
disturbances
Ca
2+
Channel Blockers or Digoxin
for Rate Control
* Sustained release preparations are available
We recommend use of maintenance oral
antiarrhythmic therapy as first-line therapy for patients
with recurrent AF in whom long-term rhythm control is
desired (see flow charts).
Strong
Recommendation
Moderate Quality
Evidence
We recommend that oral antiarrhythmic drug therapy
should be avoided in patients with AF/AFL and
advanced sinus or AV nodal disease unless the patient
has a pacemaker/implantable defibrillator
Strong
Recommendation
Low Quality
Evidence
We recommend that an AV blocking agent should be
used in patients with AF/AFL being treated with a class
I antiarrhythmic drug (e.g. propafenone or flecainide)
in the absence of advanced AV node disease.
Strong
Recommendation
Low Quality
Evidence
Rhythm Control Recommendations
Values and preferences
outcomes with the potential greater adverse effects of Class I/III antiarrhythmic
drugs compared to rate control therapy.

We recommend the optimal treatment of precipitating
or reversible predisposing conditions of AF prior to
attempts to restore/maintain sinus rhythm.
Strong
Recommendation
Low Quality
Evidence
We recommend a rhythm control strategy for patients
with AF/AFL who remain symptomatic with rate
control therapy or in whom rate control therapy is
unlikely to control symptoms.
Strong
Recommendation
Moderate Quality
Evidence
We recommend that the goal of rhythm control
therapy should be improvement in patient symptoms
and clinical outcomes, and not necessarily the
elimination of all AF.
Strong
Recommendation
Moderate Quality
Evidence
Rhythm Control Strategy
outcomes with the potential greater adverse effects of the addition of Class I/III
antiarrhythmic drugs to rate control therapy.

Antiarrhythmic Drug Choices
Normal Ventricular Function
Dronedarone
Flecainide*
Propafenone*
Sotalol
Amiodarone
Catheter Ablation
* Class I agents should be AVOIDED in CAD
They should be combined with AV-nodal blocking agents
Sotalol contraindicated in women >65 yrs taking diuretics
Drugs listed in alphabetical order
Antiarrhythmic Drug Choices
Abnormal Left Ventricular Function
EF > 35%
Amiodarone
Dronedarone
Sotalol*
Amiodarone
Catheter Ablation
* Sotalol should be used with caution with EF 35-40%
Contraindicated in women >65 yrs taking diuretics
EF 35%
We recommend intermittent antiarrhythmic
drug therapy ("pill in pocket") in symptomatic
patients with infrequent, longer-lasting
episodes of AF/AFL as an alternative to daily
antiarrhythmic therapy.
Strong
Recommendation
Moderate Quality
Evidence
This recommendation places a high value on the results of clinical studies
demonstrating the efficacy and safety of intermittent antiarrhythmic drug
therapy in selected patients.

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)
Drug Efficacy Toxicity Comments
Flecainide
50-150 mg
BID

30-50% Ventricular tachycardia
Bradycardia
Rapid ventricular response
to AF or atrial flutter (1:1
conduction)
Contraindicated in patients
with CAD or LV dysfunction
Should be combined with an
AV nodal blocking agent
Propafenone
150-300 mg
TID

30-50% Ventricular tachycardia
Bradycardia
Rapid ventricular response
to AF or atrial flutter (1:1
conduction)
Abnormal taste
Contraindicated in patients
with CAD or LV dysfunction
Should be combined with an
AV nodal blocking agent

Class IC Drugs
Class III
Drug
Efficacy Toxicity Comments
Amiodarone
100- 200 mg OD
(after 10gm
loading)

60-70%
Photosensitivity
Bradycardia
GI upset
Thyroid dysfunction
Hepatic toxicity
Neuropathy, tremor
Pulmonary toxicity
Torsades de pointes (rare)
Low risk of proarrhythmia
Limited by systemic side effects
Most side effects are dose & duration
related

Dronedarone
400 mg BID

40%
GI upset
Bradycardia
Only antiarrhythmic shown to reduce
hospitalizations and cardiovascular
mortality
May increase mortality in patients
with recently decompensated heart
failure, EF <35%
Effective rate control agent
New drug limited experience
outside trials
Sotalol
80-160 mg BID

30-50%
Torsades de pointes
Bradycardia
Beta-blocker side effects
Should be avoided in patients at high
risk of Torsades de pointes VT
especially women >65 years taking
diuretics or those with renal
insufficiency
QT interval should be monitored 1
week after starting
Use cautiously when EF<40%
Rhythm Control Does Not
Replace Anticoagulation

No evidence that AF reduction via antiarrhythmic
therapy reduces the risk of stroke/thromboembolism
Patients must continue on appropriate
anticoagulation according to their individual embolic
risk (CHADS
2
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.
Strong
Recommendation
Low Quality
Evidence
We recommend pre-treatment with
antiarrhythmic drugs prior to electrical
cardioversion in patients who have had AF
recurrence post-cardioversion without
antiarrhythmic drug pre-treatment.
Strong
Recommendation
Moderate Quality
Evidence
These recommendations place a high value on the decision of individual
patients to pursue a rhythm control strategy for improvement in quality of
life and functional capacity.

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
Recommendation
High Quality
Evidence
We suggest that, in patients with intact AV
conduction, pacemakers be programmed to
minimize ventricular pacing for prevention of
AF
Conditional
Recommendation
Moderate Quality
Evidence
Pacing for Rhythm Control
These recommendations recognize a potential benefit of atrial or dual
chamber pacing programmed to minimize ventricular pacing to reduce the
probability of AF development following pacemaker implantation.

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
Catheter Ablation of Atrial
Fibrillation and Flutter
Atul Verma MD
Jafna L Cox MD
Laurent Macle MD
Allan C Skanes MD
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 0.93
AV fistulae 88 0.54
Pneumothorax 15 0.09

Valve damage/requiring surgery 11/7 0.07

Tamponade 213 1.31
Transient ischemic attack 115 0.71
PV stenosis requiring intervention 48 0.29
Stroke 37 0.23
Permanent diaphragmatic paralysis 28 0.17
Death 25 0.15
Atrium-esophageal fistulae 3 0.02
TOTAL 741 4.54%
Worldwide AF Ablation (03-06)
We recommend catheter ablation of AF in
patients who remain symptomatic
following adequate trials of anti-arrhythmic
drug therapy and in whom a rhythm
control strategy remains desired.
Strong Recommendation
Moderate Quality
Evidence

We suggest catheter ablation to maintain
sinus rhythm in select patients with
symptomatic AF and mild-moderate
structural heart disease who are
refractory or intolerant to at least one anti-
arrhythmic medication.
Conditional
Recommendation
Moderate Quality
Evidence

We suggest catheter ablation to maintain
sinus rhythm as first-line therapy for relief
of symptoms in highly selected patients
with symptomatic, paroxysmal AF.
Conditional
Recommendation
Low Quality Evidence
Values and Preferences:
These recommendations recognize that the balance of risk with ablation and benefit in symptom
relief and improvement in quality of life must be individualized. They also recognize that patients
may have relative or absolute cardiac or non-cardiac contra-indications to specific medications.

Recommendations Ablation
We recommend curative catheter ablation for
symptomatic patients with typical atrial flutter as
first line therapy or as a reasonable alternative to
pharmacologic rhythm or rate control therapy.
Strong
Recommendation
Moderate Quality
Evidence

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.
Strong
Recommendation
Low 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 Low
Quality Evidence

Recommendations Ablation
CCS Guidelines ESC Guidelines ACCF/AHA/HRS
Strength
Level of
Evidence
Class
Level of
Evidence
Class
Level of
Evidence
Paroxysmal* Conditional Moderate
IIa
(Conditional)
A (High) I (Strong) A (High)
Persistent* Conditional Moderate
IIa
(Conditional)
B
(Moderate)
IIa
(Conditional)
A (High)
Failed 1 drug Conditional Moderate -- -- I (Strong) A (High)
Failed 2
drugs
Strong Moderate -- -- -- --
1
st
Line Conditional Low
IIb
(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
Management of recent onset atrial
fibrillation and atrial flutter in the
emergency department

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

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

Strong
Recommendation
Low Quality
Evidence
This recommendation places a high value on the immediate management of
hemodynamic instability and a lower value on anticoagulation status under
these circumstances. It is also recognized that this is a relatively rare
circumstance and that in most cases, stroke risk and anticoagulation status
can be considered prior to immediate cardioversion.

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.

Strong
Recommendation
Low Quality
Evidence
This recommendation places a high value on the avoidance of
repeated shocks and the avoidance of ventricular fibrillation that
can occur with synchronized cardioversion of AF at lower energy
levels. It is recognized that the induction of VF is a rare but easily
avoidable event.

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

Strong
Recommendation
Moderate Quality
Evidence
We recommend that synchronized electrical
cardioversion or pharmacological cardioversion may be
used when a decision is made to cardiovert patients in
the emergency department. See Tables for drug
recommendations.
Strong
Recommendation
Moderate Quality
Evidence
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
Recommendation
Low Quality
Evidence
In hemodynamically stable patients with AF/AFL of known duration
< 48 h in whom a strategy of rhythm control has been selected:

These recommendations place a high value on determination of the duration of AF/AFL as a
determinant of stroke risk with cardioversion. Also, individual considerations of the patient and
treating physician are recognized in making specific decisions about method of cardioversion.

Strategy of rhythm-control for recent-onset AF/AFL
Duration > 48 h or unknown
or high-risk patients
1

Therapeutic OAC
for 3 weeks
before
cardioversion

Rate-
control
TEE-guided
cardioversion
(OAC initiated with
heparin bridging)
3

Antithrombotic therapy
-OAC continued for 4 consecutive weeks.
-If AF/AFL persists or recurs or if AF/AFL has been
recurrent, antithrombotic therapy as appropriate (per
CHADS
2
score) should be continued indefinitely.
-Early follow-up should be arrange to review ongoing
antithrombotic strategy.

1
Patients at particularly high risk of stroke (e.g. mechanical valve, rheumatic heart disease, recent stroke/TIA)
2
150-200J biphasic waveform preferred
3
Heparin must be initiated and continued until a therapeutic level of oral anticoagulation has been established.

Known duration < 48 h
(and not high-risk patients
1
)
Hemodynamically
stable
Pharmacological
or electrical
cardioversion
2

Hemodynamically
unstable
Urgent electrical
cardioversion
2

Failed CV
Successful CV
Antithrombotic therapy
-In general, no prior or subsequent anticoagulation
is required.
-If AF/AFL persists or recurs or if AF/AFL has been
recurrent, antithrombotic therapy as appropriate
(CHADS
2
score) should be initiated and continued
indefinitely.
-Early follow-up to review antithrombotic strategy.

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 Cardioversion
Drug Dose Efficacy Risks
Class 1A
Procainamide
15-17 mg/kg IV
over 60 min
++ 5% hypotension
Class IC*
Propafenone
Flecainide

450-600 mg PO
300-400 mg PO

+++
+++
Hypotension, 1:1
flutter, bradycardia
Hypotension, 1:1
flutter, bradycardia

Class III
Ibutilide

1-2 mg IV over
10-20 min
Pre-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

Strong
Recommendation
Low Quality
Evidence
We recommend Intravenous antiarrhythmic
agents procainamide or ibutilide in stable
patients
Strong
Recommendation
Low Quality
Evidence
We recommend that AV nodal blocking agents
(digoxin, calcium channel blockers, beta-
blockers, adenosine) are contra-indicated.
Strong
Recommendation
Low Quality
Evidence
Wolff Parkinson White Syndrome
These recommendations place a high value on avoidance of the degeneration of pre-excited
AF to ventricular fibrillation. It is recognized that degeneration can occur spontaneously or it
can be facilitated by the administration of specific agents that in the absence of ventricular
pre-excitation would be the appropriate therapy for rate control of AF.

CCS Atrial Fibrillation Guidelines 2010:
Prevention of Stroke and Systemic
Thromboembolism in
Atrial Fibrillation and Flutter

John A Cairns, MD, FRCPC,
Stuart Connolly, MD, FRCPC,
Sean McMurtry, MD, PhD, FRCPC,
Michael Stephenson, MD, FCFP,
Mario Talajic, MD, FRCPC
We recommend that all patients with AF or
AFL (paroxysmal, persistent or permanent),
should be stratified using a predictive index
for stroke (e.g. CHADS
2
) and for the risk of
bleeding (e.g. HAS-BLED), and that most
patients should receive antithrombotic
therapy.
Strong
Recommendation
High Quality
Evidence
Risk Stratification
Stroke Prevention
Bleeding Risk
Patients
(n = 1733)
Adjusted Stroke
Rate (%/yr) 95% CI
CHADS
2

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
CHADS
2

Risk Factor Score
Congestive Heart
Failure
1
Hypertension 1
Age 75 1
Diabetes Mellitus 1
Stroke/TIA/
Thromboembolism
2
Maximum Score 6
Predictive Index for Stroke
CHA
2
DS
2
-VASc
Risk Factor Score
Congestive Heart Failure 1
Hypertension 1
Age 75 2
Diabetes Mellitus 1
Stroke/TIA/Thrombo-
embolism
2
Vascular Disease 1
Age 65-74 1
Female 1
Maximum Score 9
Risk Factor Score
Congestive Heart Failure 1
Hypertension 1
Age 75 1
Diabetes Mellitus 1
Stroke/TIA/Thrombo-
embolism

2
Maximum Score 6
CHADS
2

Patients (n =
7329)
Adjusted
Stroke
Rate (%/yr)
95% CI
TE Rate
assuming no
warfarin
CHA
2
DS
2
VASc
Score
1 0 0 0
422 0.46 (0.10 to 1.34) 1.3 1
1230 0.78 (0.44 to 1.29) 2.2 2
1730 1.16 (0.79 to 1.64) 3.2 3
1718 1.43 (1.01 to 1.95) 4.0 4
1159 2.42 (1.75 to 3.26) 6.7 5
679 3.54 (2.49 to 4.87) 9.8 6
294 3.44 (1.94 to 5.62) 9.6 7
82 2.41 (0.53 to 6.88) 6.7 8
14 5.47 (0.91 to 27.0) 15.2 9
Letter Clinical Characteristic Points
H Hypertension 1
A Abnormal Liver or Renal Function
1 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
Overview of Thromboembolic Management
CHADS
2
= 0
No antithrombotic may be
appropriate in selected young
patients with no stroke risk
factors
aspirin
*Aspirin is a reasonable
alternative in some as
indicated by risk/benefit
Dabigatran is preferred OAC over warfarin in most patients.
CHADS
2
= 1 CHADS
2
2
OAC* OAC
Assess Thromboembolic
Risk (CHADS
2
) and
Bleeding Risk (HAS-BLED)
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%
0
5
10
15
20
25
30
35
40
CHADS 0 CHADS 1 CHADS 2
NoRx
Warfarin
Aspirin
Risk of Stroke + Non-cerebral Major Bleed among AF Patients
E
v
e
n
t
s
/
1
0
0
0

p
a
t
i
e
n
t
s
/
y
e
a
r

10 12

13 18
17 24
19
28
40
7 11 10 17 14 23
We recommend that patients at very low risk
of stroke (CHADS
2
= 0) should receive aspirin
(75-325 mg/day).
Strong
Recommendation
High Quality
Evidence
We suggest that some young persons with
no standard risk factors for stroke may not
require any antithrombotic therapy.
Conditional
Recommendation
Moderate Quality
Evidence
ASA for Stroke Prevention
We recommend that patients at low risk of
stroke (CHADS
2
= 1) should receive OAC
therapy (either warfarin [INR 2 3] or
dabigatran).
Strong
Recommendation
High Quality
Evidence
We suggest, based on individual risk/benefit
considerations, that aspirin is a reasonable
alternative for some.
Conditional
Recommendation
Moderate Quality
Evidence
We recommend that patients at moderate
risk of stroke (CHADS
2
2) should receive
OAC therapy (either warfarin [INR 2 3] or
dabigatran).
Strong
Recommendation
High Quality
Evidence
Values and preferences: These recommendations place relatively greater
weight on the absolute reduction of stroke risk with both warfarin and
dabigatran compared to aspirin and less weight on the absolute increased
risk for major hemorrhage with an oral anticoagulant compared to aspirin.

Anticoagulant Therapy for Stroke Prevention
We suggest, that when OAC therapy is
indicated, most patients should receive
dabigatran in preference to warfarin. In
general, the dose of dabigatran 150 mg po
bid is preferable to a dose of 110 mg po bid.
Conditional
Recommendation
High Quality
Evidence
Values and preferences: This recommendation places a relatively high
value on the greater efficacy of dabigatran over a relatively short time of
follow-up, particularly among patients who have not previously received
an oral anticoagulant, the lower incidence of intracranial hemorrhage and
its ease of use, and less value on the long safety experience with
warfarin.

Dabigatran vs Warfarin
Choose
antithrombotic
based on stroke risk
PCI Recent ACS Stable CAD
Antithrombotic Management of AF/AFL in CAD
* Warfarin is preferred over dabigatran for patients at high risk of coronary events
Choose antithrombotic
based on balance of risks
and benefits
Choose antithrombotic
based on balance of risks
and benefits
CHADS
2
= 0
CHADS
2
1
CHADS
2
2
CHADS
2
1
CHADS
2
2
CHADS
2
1
Aspirin
OAC*
monotherapy
aspirin +
clopidogrel
aspirin +
clopidogrel
Triple anti-
thrombotic
Rx
Triple anti-
thrombotic
Rx
We suggest that patients with AF/AFL who
have stable CAD should receive
antithrombotic therapy selected based upon
their risk of stroke (aspirin for CHADS
2
= 0 and
OAC for CHADS
2
1). Warfarin is preferred
over dabigatran for those at high risk of
coronary events.
Conditional
Recommendation
Moderate Quality
Evidence
We suggest that patients with AF/AFL who
have experienced ACS or who have undergone
PCI, should receive antithrombotic therapy
selected based on a balanced assessment of
their risks of stroke, of recurrent coronary
artery events and of hemorrhage associated
with the use of combinations of antithrombotic
therapies, which in patients at higher risk of
stroke may include aspirin plus clopidogrel
plus OAC.
Conditional
Recommendation
Low Quality
Evidence

We recommend that hemodynamically stable
patients with AF/AFL of 48 hours or
uncertain duration for whom electrical or
pharmacological cardioversion is planned
should receive therapeutic OAC therapy
(warfarin [INR 2-3] or dabigatran) for 3 weeks
before and at least 4 weeks post
cardioversion
Strong
Recommendation
Moderate Quality
Evidence
Cardioversion AF 48 hr
Following attempted cardioversion
If AF/AFL persists or recurs or if symptoms suggest that the presenting
AF/AFL has been recurrent, the patient should have antithrombotic therapy
continued indefinitely (using either OAC or aspirin as appropriate ).

If sinus rhythm is achieved and sustained for 4 weeks, the need for
ongoing antithrombotic therapy should be determined based upon the risk
of stroke and in selected cases expert consultation may be required.

We recommend that hemodynamically stable
patients with AF/AFL of known duration < 48
hours may undergo cardioversion without
prior or subsequent anticoagulation. However,
if the patient is at particularly high risk of
stroke (e.g. mechanical valve, rheumatic heart
disease, recent stroke or TIA), cardioversion
should be delayed and the patient should
receive OAC for 3 weeks before and at least 4
weeks post cardioversion.
Strong
Recommendation
Moderate Quality
Evidence
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
(CHADS
2
) 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
Cardioversion

Cardioversion
(TEE-Guided)
High Stroke Risk**
Very low to Moderate Stroke
Risk*
High Bleeding
Risk
Stop antithrombotic
pre-procedure
Re-institure when
risk of bleeding
reduced
Low Bleeding
Risk
Continue
antithrombotic
(INR < 3 if
warfarin)
High Bleeding
Risk
Stop OAC and
bridge
with UFH or LMWH
perioperatively

Low Bleeding
Risk
Continue OAC or
stop OAC and
bridge with UFH or
LMWH
perioperatively
* CHADS
2
2
** mechanical valve, recent stroke or TIA, rheumatic valve disease, CHADS
2
3
stop 12-24hr pre-procedure, restart when hemostasis secure and bridge to therapeutic OAC
Patient with AF undergoing Surgical or
Diagnostic Procedure with Major Bleeding Risk
If there is a very low to moderate risk of stroke (CHADS
2
2), the
patient should have their antithrombotic agent discontinued before
the procedure (aspirin or clopidogrel for 7-10 days, warfarin for 5
days if the INR was in the range 2- 3, and dabigatran for 2 days).
Once post procedure hemostasis is established (about 24 hr) the
antithrombotic therapy should be reinstated.
Conditional
Recommendation
If there is a particularly high risk of stroke (e.g. mechanical valve,
recent stroke or TIA, rheumatic valve disease, CHADS
2
3) or of
other thromboembolism (e.g. Fontan procedure):

a) if there is an acceptable perioperative bleeding risk (i.e. risk of
stroke outweighs risk of bleeding) the patient should have OAC
therapy continued perioperatively or have their OAC discontinued
before the procedure and be bridged with LMWH or UFH
perioperatively, or alternatively,
b) if there is a substantial risk of major and potentially problematic
bleeding (i.e. risk of bleeding and risk of stroke are both
substantial) the patient should have their OAC discontinued before
the procedure with LMWH or UFH bridging until 12-24 pre
procedure. Once post procedure hemostasis is established (about
24 hr) the OAC should be reinstated with LMWH or UFH bridging.
Conditional
Recommendation

Antithrombotic Therapy Peri-Procedure
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
0
2
4
6
8
10
CVA CHF MI PPM VT/VF MORT
%
5.5
4.1
4.7
1.9
6.4
3.4
5.3
3.0
3.6
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)
0.4 0.2 0.6 0.8 1.0 1.4 1.2 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)

0.4 0.2 0.6 0.8 1.0 1.4 1.2 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.
Strong
Recommendation
High Quality
Evidence
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.
Conditional
Recommendation
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.
Strong
Recommendation
High Quality
Evidence
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.
Conditional
Recommendation
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.
Conditional
Recommendation
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 - Prevention
CCS 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
0.00
0.20
0.40
0.60
0.80
1.00
0 10 20
P
t
s

i
n

h
o
s
p
i
t
a
l

Days Post-Op
rate rhythm
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
rate rhythm
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.
Conditional
Recommendation
Low Quality
Evidence
Values and Preferences: This recommendation places a higher value on
minimizing the risk of thromboembolic events and a lower value on the potential
for post-operative bleeding. Because the risk of post-operative bleeding
decreases with time the benefit to risk ratio favours a longer period without
anticoagulation in the post-operative setting than that suggested in other
settings.
We recommend that temporary epicardial
pacing electrode wires be placed at the time
of cardiac surgery to allow backup
ventricular pacing as necessary.
Strong
Recommendation
Low Quality
Evidence
We recommend that post operative AF with a
rapid ventricular response be treated with a
beta-blocker, a non-dihydropyridine calcium
antagonist, or amiodarone to establish
ventricular rate control. The specific agent
chosen will be individualized for each patient
but a beta-blocker is usually preferred.
Strong
Recommendation
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.
Conditional
Recommendation
Low 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 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.
Strong
Recommendation
Moderate Quality
Evidence
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 Guidelines
Strength 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
Patient for CV Surgery Assess AF Risk Factors?
Low Risk High Risk
On Beta-Blocker?
No
Beta-Blocker
Contraindicated?
Continue BB
Beta-Blocker
Amiodarone
Contraindicated?
Amiodarone
IV Magnesium or
Biatrial Pacing
On Beta-Blocker?
Sotalol or
Amiodarone or
BB and another
Beta-Blocker
Contraindicated?
Sotalol or
Amiodarone or
BB and another
Amiodarone
Contraindicated?
Amiodarone IV Magnesium and
Biatrial Pacing
Yes
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Surgical Therapy

Pierre Pag MD

Values and Preferences: This recommendation recognizes
that 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.
Strong
Recommendation
Moderate Quality
Evidence

Values and Preferences: This recommendation recognizes that
patients with lone AF are at low risk for stroke or other adverse
cardiovascular outcomes. Thus, elimination of AF in the absence of
a high number of symptoms is unlikely to result in an improvement in
quality of life.
We recommend that patients with
asymptomatic lone AF, in whom AF is not
expected to affect cardiac outcome, should
not be considered for surgical therapy for AF.
Strong
Recommendation
Low Quality
Evidence

Values and Preferences: This recommendation recognizes that 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 .
Conditional
Recommendation
Low Quality
Evidence

Values and Preferences: These recommendations place a high
value on stroke reduction and a lower value on any concomitant loss
of atrial transport with left atrial appendage closure.
We recommend that closure (excision or
obliteration) of the left atrial appendage be
undertaken as part of the surgical ablation of
AF associated with mitral valve surgery.
Strong
Recommendation
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.
Conditional
Recommendation
Low Quality
Evidence


Values and Preferences: These recommendations place a high
value on minimizing the risk of stroke and a lower value in the utility
of long-term monitoring to document the absence of AF.
We recommend that oral anticoagulant
therapy be continued following surgical AF
ablation in patients with a CHADS
2
score 2.
Strong
Recommendation
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.
Conditional
Recommendation
Low Quality
Evidence
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

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Canadian Cardiovascular Society

2010 Atrial Fibrillation Guidelines

Digitalis may be considered as

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