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2019 AHA/ACC/HRS Focused Updateof the 2014 Guideline for Managementof Patients with Atrial FibrillationGUIDELINES MADE SIMPLE - Focused Update EditionACC.org/GMSAF 2018, American College of Cardiology B18202A Selection of Tables and Figures
2019 AHA/ACC/HRS Focused Update of the 2014 Guidelinefor Management of Patients with Atrial FibrillationA report of the American College of Cardiology/American Heart Association Task Forceon Clinical Practice Guidelines, and the Heart Rhythm SocietyWriting Committee:Craig T. January, MD, PhD, FACC, ChairL. Samuel Wann, MD, MACC, FAHA, Vice ChairHugh Calkins, MD, FACC, FAHA, FHRSLin Y. Chen, MD, MS, FACC, FAHA, FHRSJoaquin E. Cigarroa, MD, FACCJoseph C. Cleveland, Jr, MD, FACCPatrick T. Ellinor, MD, PhDMichael Exekowitz, MBChB, DPhil, FACC, FAHAMichael E. field, MD, FACC, FAHA, FHRSKaren Furie, MD, MPH, FAHAPaul Heidenreich, MD, FACC, FAHAKatherine T. Murray, MD, FACC, FAHA, FHRSJulie B. Shea, MS, RNCS, FHRSCynthia M. Tracy, MDClyde W. Yancy, MD, MACC, FAHAThe purpose of the 2019 Focused Update is to update the “2014 AHA/ACC/HRS Guideline forthe Management of Patients With Atrial Fibrillation” in areas where new evidence has emergedsince its publication. The scope of this update of the 2014 AF guideline includes revisions to thesection on anticoagulation due to the approval of new medications and thromboembolism protectiondevices, the section on catheter ablation of AF, revisions to the section on the management of AFcomplicating acute coronary syndrome, and new sections on device detection of AF and weight loss.The following resource contains recommendation tables from the 2019 AF Focused Updateas well as a comparison tool that highlights the major new and modified recommendationsin the 2019 Focused Update. The resource is only an excerpt from the document and the fullpublication should be reviewed for important context.CITATION: 10.1016/j.jacc.2019.01.011.
2019 AHA/ACC/HRS Focused Update of the 2014 Guidelinefor Management of Patients with Atrial FibrillationSelected Table or FigurePageAF Focused Update: 2014-2019 Comparison Tool 4-5Selecting an Anticoagulant Regimen—Balancing Risks and Benefits 6-8Interruption and Bridging Anticoagulation 9Percutaneous Approaches to Occlude the LAA 10Cardiac Surgery—LAA Occlusion/Excision 10Prevention of Thromboembolism 11Ablation in HF 12AF Complicating ACS 13Device Detection of AF and Atrial Flutter 14Weight Reduction in Patients with AF 14
Back to Table of ContentsGUIDELINES MADE SIMPLEAF 2019 AHA/ACC/HRS Focused Update of the 2014 Guideline for Management of Patients with Atrial Fibrillation2014-2019 Comparison Tool (1 of 2)Change in Guideline Recommendations (Only major included)20142019The term “nonvalvular AF” is no longer usedSection 4.1.1 - Selection of Antithrombotic RegimenOral anticoagulants recommended for high risk patients now include edoxaban.Exclusion criteria for CHA2DS2-VASc assessment and use of NOACs now defined as moderate tosevere 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 ThromboembolismFor patients with AF or atrial flutter of 48 hours’duration or longer, or when the duration of AF isunknown, anticoagulation with warfarin (INR 2.0to 3.0), a factor Xa inhibitor, or direct thrombininhibitor is recommended for at least 3 weeksbefore and at least 4 weeks after cardioversion.For patients with AF or atrial flutter of 48 hours'duration with a CHA2DS2-VASc score of 2 in menand 3 in women, administration of heparin, afactor Xa inhibitor, or a direct thrombin inhibitor isreasonable as soon as possible before cardioversion,followed by long term anticoagulation therapy.IIIaIIbUpgraded to Class IRecommendationDowngraded to Class IIaRecommendationTable will continue in the next page.IIIACC.org/AFCompare4
Back to Table of ContentsGUIDELINES MADE SIMPLEAF 2019 AHA/ACC/HRS Focused Update of the 2014 Guideline for Management of Patients with Atrial Fibrillation2014-2019 Comparison Tool (2 of 2)New RecommendationsSection 4.1.1 - Selection of Antithrombotic RegimenNOACs are recommended over warfarin where eligible except in those patients with moderate - severemitral stenosis or a mechanical heart valve.Section 4.3 - Interruption and Bridging AnticoagulationIdarucizumab is the reversal agent for dabigatran in the event of life-threatening bleeding or an urgent procedure.Andexanet Alfa is the reversal agent for apixaban and rivaroxaban.Section 4.4.1 - Percutaneous Approaches to Occlude the Left Atrial AppendagePercutaneous LAAO should be considered for those AF patients at an increased risk of stroke who havecontraindications to long-term anticoagulation and who are at high risk of thromboembolic events.Section 6.3.4 - Catheter Ablation in HFCatheter ablation of AF is reasonable in symptomatic AF patients with HF and reduced LVEF.Section 7.4 - Complicating Acute Coronary SyndromeIf 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 haveundergone 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 FlutterIn patients with cardiac implantable electronic devices, atrial high rate episodes (AHREs) should promptfurther evaluation.In patients with cryptogenic stroke in whom long-term external ambulatory monitoring isinconclusive implantation of a cardiac monitor is reasonable to detect silent AF.Section 7.13 - Weight LossWeight loss and risk factor modification is recommended for overweight/obese patients with AF.IIIaIIbIIIACC.org/AFCompare5
Back to Table of ContentsGUIDELINES MADE SIMPLEAF 2019 AHA/ACC/HRS Focused Update of the 2014 Guideline for Management of Patients with Atrial FibrillationRecommendations for Selecting an Anticoagulant Regimen—Balancingand Regimen—BalancingBenefits (1 ofRisks3) and BenefitsRecommendationsfor Selecting anRisksAnticoagulantCORLOEARecommendations1. For patients with AF and an elevated CHA2DS2-VASc score of 2 or greater inmen or 3 or greater in women, oral anticoagulants are recommended.BOptions include: Warfarin (LOE: A) Dabigatran (LOE: B)B Rivaroxaban (LOE: B) Apixaban (LOE: B) or Edoxaban (LOE: B-R)BIMODIFIED: This recommendation has been updated in response to the approvalof edoxaban, a new factor Xa inhibitor. More precision in the use of CHA2DS2VASc scores is specified in subsequent recommendations. The LOEs for warfarin,dabigatran, rivaroxaban, and apixaban have not been updated for greatergranularity as per the new LOE system. (Section 4.1. in the 2014 AF Guideline)B-RThe original text can be found in Section 4.1 of the 2014 AF guideline. Additionalinformation about the comparative effectiveness and bleeding risk of NOACscan be found in Section 4.2.2.2.2. NOACs (dabigatran, rivaroxaban, apixaban, and edoxaban) are recommendedover warfarin in NOAC-eligible patients with AF (except with moderate-tosevere mitral stenosis or a mechanical heart valve).NEW: Exclusion criteria are now defined as moderate-to-severe mitral stenosisIAor a mechanical heart valve. When the NOAC trials are considered as a group,the direct thrombin inhibitor and factor Xa inhibitors were at least noninferiorand, in some trials, superior to warfarin for preventing stroke and systemicembolism 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 anticoagulantIAtherapy 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 amechanical heart valve), the CHA2DS2-VASc score is recommended forassessment of stroke risk.MODIFIED: Exclusion criteria are now defined as moderate-to-severe mitralIBstenosis or a mechanical heart valve. Patients with AF with bioprosthetic heartvalves are addressed in the supportive text. (Section 4.1. in the 2014 AFguideline)5. For patients with AF who have mechanical heart valves, warfarin isIBrecommended.MODIFIED: New information is included in the supportive text.6. Selection of anticoagulant therapy should be based on the risk ofthromboembolism, irrespective of whether the AF pattern is paroxysmal,IBpersistent, or permanent.MODIFIED: “Antithrombotic” was changed to “anticoagulant.”RenalTable Iwill continuein the 7.nextpage.function and hepatic function should be evaluated before initiation of aB-NRNOAC and should be reevaluated at least annually.6
should be determined at least weekly during initiation of anticoagulanttherapy and at least monthly when anticoagulation (INR in range) is stable.MODIFIED: “Antithrombotic” was changed to “anticoagulant.”Back toorTableIn patients with AF (except with moderate-to-severe mitral stenosisa of ContentsGUIDELINES MADE4.SIMPLEmechanicalthe CHAfor2DS2-VASc score is recommended for2019 AHA/ACC/HRS FocusedUpdate heartof the valve),2014 GuidelineManagement of Patients with Atrial Fibrillationassessment of stroke risk.MODIFIED: Exclusion criteria are now defined as moderate-to-severe mitralIBstenosis or a mechanical heart valve. Patients with AF with bioprosthetic heartvalves are addressed in the supportive text. (Section 4.1. in the 2014 AFguideline)5. For patients with AF who have mechanical heart valves, warfarin isIBrecommended.MODIFIED: New information is included in the supportive text.6. Selection of anticoagulant therapy should be based on the risk ofthromboembolism, irrespective of whether the AF pattern is paroxysmal,IB(2 of 3)persistent, or permanent.MODIFIED: “Antithrombotic” was changed to “anticoagulant.”7. Renal function and hepatic function should be evaluated before initiation of aIB-NRNOAC and should be reevaluated at least annually.MODIFIED: Evaluation of hepatic function was added. LOE was updated from Bto 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 basisof shared decision-making after discussion of the absolute risks and relativeICrisks 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 recommendedICaccording 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 periodicICintervals 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 amechanical heart valve) who are unable to maintain a therapeutic INR levelwith warfarin, use of a NOAC is recommended.IC-EOMODIFIED: Exclusion criteria are now defined as moderate-to-severe mitralstenosis or a mechanical heart valve, and this recommendation has beenchanged in response to the approval of edoxaban. (Section 4.1. in the 2014 AFGuideline)12. For patients with AF (except with moderate-to-severe mitral stenosis or amechanical heart valve) and a CHA2DS2-VASc score of 0 in men or 1 in women,it is reasonable to omit anticoagulant therapy.IIaBMODIFIED: Exclusion criteria are now defined as moderate-to-severe mitralstenosis 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 or3 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 bereasonable to prescribe warfarin (INR 2.0 to 3.0) or apixaban for oralIIbB-NRanticoagulation.MODIFIED: New evidence has been added. LOE was updated from B to B-NR.(Section 4.1. in the 2014 AF Guideline)14. For patients with AF (except with moderate-to-severe mitral stenosis or aTable will continue in the next page.mechanical heart valve) and moderate-to-severe CKD (serum creatinine 1.5mg/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 CHA2DS2VASc score, treatment with reduced doses of direct thrombin or factor Xainhibitors may be considered (e.g., dabigatran, rivaroxaban, apixaban, orIIbB-Redoxaban).MODIFIED: Exclusion criteria are now defined as moderate-to-severe mitralstenosis or a mechanical heart7 valve, and this recommendation has been changedin response to the approval of edoxaban. LOE was updated from C to B-R. (SectionIAFARecommendations for Selecting an Anticoagulant Regimen—Balancing Risks and Benefits
AF11.withFor patientsAFa (exceptmoderate-to-severe mitral stenosis or awarfarin,withuse ofNOAC eto maintaina therapeutic INRmitrallevelIC-EOMODIFIED: Exclusion criteria are now definedas nded.stenosis or a mechanical heart valve, and this recommendation has beenIC-EOMODIFIED:Exclusiontocriteriaare nowdefined as (Sectionmoderate-to-severemitralBackto Tablechangedin responsethe approvalof edoxaban.4.1. in the2014AF of ContentsGUIDELINES MADE mendationhasbeenGuideline)2019 AHA/ACC/HRS FocusedUpdateof the 2014Managementof Patientswith2014AtrialAFFibrillationchangedin responseto theGuidelineapproval forof edoxaban.(Section4.1. in the12. For patients with AF (except with moderate-to-severe mitral stenosis or aGuideline)mechanical heart valve) and a CHA2DS2-VASc score of 0 in men or 1 in women,12. itForpatients withAF (exceptwith moderate-to-severemitral stenosis or ais reasonableto andaCHA2DS2-VASc score of 0 in men or 1 in women,MODIFIED: Exclusion criteria are now defined as moderate-to-severe mitralit is reasonableto omit heartanticoagulanttherapy.IIaBstenosisor a mechanicalvalve. (Section4.1. in the 2014 AF Guideline)MODIFIED: Exclusion criteria are now defined as moderate-to-severe mitral13. For patients with AF who have a CHA2DS2-VASc score of 2 or greater in men orstenosis 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.creatinineFor patientswith AF[CrCl]who havea CHA2DSor2-VAScof 2 itormightgreaterclearance 15 mL/min)are onscoredialysis,bein men ydiseasereasonable to prescribe warfarin (INR 2.0 to 3.0) or apixaban for oral (CKD;IIbB-NRcreatinine clearance[CrCl] 15 mL/min) or are on dialysis, it might R2.0 to LOE3.0) wasororalB to B-NR.IIbB-NR(3apixabanof3) forfromMODIFIED: New evidencehas beenadded.updatedanticoagulation.(Section 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 1.514.mg/dLFor patientswith AFmoderate-to-severeor a[apixaban],CrCl(except15 to with30 mL/min[dabigatran],mitralCrCl stenosis 50 D(serumcreatinine 1.5[rivaroxaban], or CrCl 15 to 50 mL/min [edoxaban]) with an elevated CHA2DS2mg/dLscore,[apixaban],CrClwith15 to30 mL/min[dabigatran],CrCl 50mL/minVASctreatmentreduceddoses ofdirect thrombinor factorXa[rivaroxaban],CrCl15 to 50 mL/min[edoxaban]) rivaroxaban,with an elevatedCHA2DSor2inhibitorsmayorbeconsidered(e.g., ibitors maybe ncriteria arenowdabigatran,defined as osis or a mechanical heart valve, and this recommendation has been changedMODIFIED:Exclusioncriteriaare now LOEdefinedas moderate-to-severemitralinresponse tothe approvalof edoxaban.was updatedfrom C to B-R. (Sectionstenosisor2014a mechanicalheart valve, and this recommendation has been changed4.1.in theAF Guideline)in response to the approval of edoxaban. LOE was updated from C to B-R. (Section15. For patients with AF (except with moderate-to-severe mitral stenosis or a4.1. in the 2014 AF Guideline)mechanical heart valve) and a CHA2DS2-VASc score of 1 in men and 2 inIIbC- LD 15. For patients with AF (except with moderate-to-severe mitral stenosis or awomen, prescribing an oral anticoagulant to reduce thromboembolic strokemechanicalheart valve) and a CHA2DS2-VASc score of 1 in men and 2 inriskmay be considered.IIbC- LDwomen,prescribingoral anticoagulantto reducethromboembolic strokeMODIFIED: Exclusionancriteriaare now definedas is or a mechanical heart valve, and evidence was added to supportseparate risk scores by sex. LOE was updated from C to C-LD. (Section 4.1. in the2014 AF Guideline)16. In patients with AF and end-stage CKD or on dialysis, the direct thrombininhibitor dabigatran or the factor Xa inhibitors rivaroxaban or edoxaban arenot recommended because of the lack of evidence from clinical trials thatIII:benefit exceeds risk.NoC-EOMODIFIED: New data have been included. Edoxaban received FDA approval andBenefithas 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 withIII:AF and a mechanical heart valve.B-RMODIFIED: Evidence was added. LOE was updated from B to B-R. Other NOACsHarmare addressed in the supportive text. (Section 4.1. in the 2014 AF Guideline)Recommendations for Selecting an Anticoagulant Regimen—Balancing Risks and Benefits8
Back to Table of ContentsGUIDELINES MADE SIMPLEAF 2019 AHA/ACC/HRS Focused Update of the 2014 Guideline for Management of Patients with Atrial FibrillationRecommendations forRecommendationsandfor Interruptionand AnticoagulationBridging NRIIaB-NRRecommendations1. Bridging therapy with unfractionated heparin or low-molecular-weightheparin is recommended for patients with AF and a mechanical heart valveundergoing procedures that require interruption of warfarin. Decisions onbridging therapy should balance the risks of stroke and bleeding.2. For patients with AF without mechanical heart valves who requireinterruption of warfarin for procedures, decisions about bridging therapy(unfractionated heparin or low-molecular-weight heparin) should balancethe risks of stroke and bleeding and the duration of time a patient will notbe 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 oflife-threatening bleeding or an urgent procedure.NEW: New evidence has been published about idarucizumab to support LOEB-NR.4. Andexanet alfa can be useful for the reversal of rivaroxaban and apixaban inthe event of life-threatening or uncontrolled bleeding.NEW: New evidence has been published about andexanet alfa to support LOEB-NR.9
Back to Table of ContentsGUIDELINES MADE SIMPLEAF 2019 AHA/ACC/HRS Focused Update of the 2014 Guideline for Management of Patients with Atrial FibrillationRecommendation forPercutaneousApproaches to Occlude the LAARecommendation for Percutaneous Approaches to Occlude the LAACORLOEIIbB-NRRecommendation1. Percutaneous LAA occlusion may be considered in patients with AF at increasedrisk of stroke who have contraindications to long-term anticoagulation.NEW: Clinical trial data and FDA approval of the Watchman device necessitatedthis roachesto Occlude the LAARecommendationCardiac AAocclusionmayincreased1. Surgical occlusion of the LAA cationstolong-termanticoagulation.cardiac surgery, as a component of an overall heart team approach to theNEW: Clinical oftrialmanagementAF.data and FDA approval of the Watchman device necessitatedthisrecommendation.MODIFIED: LOE was updated from C to B-NR because of new evidence.Recommendation forCardiac Surgery—LAA Occlusion/ExcisionRecommendation for Cardiac Surgery—LAA Occlusion/ExcisionCORLOEIIbB-NRRecommendation1. Surgical occlusion of the LAA may be considered in patients with AF undergoingcardiac surgery, as a component of an overall heart team approach to themanagement of AF.MODIFIED: LOE was updated from C to B-NR because of new evidence.10
Back to Table of ContentsGUIDELINES MADE SIMPLEAF 2019 AHA/ACC/HRS Focused Update of the 2014 Guideline for Management of Patients with Atrial FibrillationRecommendations for Prevention of ThromboembolismRecommendations for Prevention of ThromboembolismRecommendations for Prevention of 1. For patients with AF or atrial flutter of 48 hours’ duration or longer, or whenRecommendationsthe duration of AF is unknown, anticoagulation with warfarin (INR 2.0 to1. For patients with AF or atrial flutter of 48 hours’ duration or longer, or when3.0), a factor Xa inhibitor, or direct thrombin inhibitor is recommendedthe duration of AF is unknown, anticoagulation with warfarin (INR 2.0 tofor at least 3 weeks before and at least 4 weeks after cardioversion,3.0), a factor Xa inhibitor, or direct thrombin inhibitor is recommendedregardless of the CHA2DS2-VASc score or the method (electrical orfor at least 3 weeks before and at least 4 weeks after cardioversion,pharmacological) used to restore sinus rhythm.regardless of the CHA2DS2-VASc score or the method (electrical orMODIFIED: The 2014 AF Guideline recommendation for use of warfarinpharmacological) used to restore sinus rhythm.around the time of cardioversion was combined with the 2014 AF GuidelineMODIFIED: The 2014 AF Guideline recommendation for use of warfarinrecommendation for NOACs to create a single recommendation. Thisaround the time of cardioversion was combined with the 2014 AF Guidelinecombined recommendation was updated to COR I/LOE B-R from COR IIa/LOErecommendation for NOACs to create a single recommendation. ThisC for NOACs in the 2014 AF Guideline on the basis of additional trials that havecombined recommendation was updated to COR I/LOE B-R from COR IIa/LOEevaluated the use of NOACs with cardioversion.C for NOACs in the 2014 AF Guideline on the basis of additional trials that have2. For patients with AF or atrial flutter of more than 48 hours’ duration orevaluated the use of NOACs with cardioversion.unknown duration that requires immediate cardioversion for hemodynamic2. For patients with AF or atrial flutter of more than 48 hours’ duration orinstability, anticoagulation should be initiated as soon as possible andunknown duration that requires immediate cardioversion for hemodynamiccontinued for at least 4 weeks after cardioversion unless contraindicated.instability, anticoagulation should be initiated as soon as possible and3. After cardioversion for AF of any duration, the decision about long-termcontinued for at least 4 weeks after cardioversion unless contraindicated.anticoagulation therapy should be based on the thromboembolic risk3. After cardioversion for AF of any duration, the decision about long-termprofile and bleeding risk profile.anticoagulation therapy should be based on the thromboembolic riskMODIFIED: The 2014 AF Guideline recommendation was strengthened withprofile and bleeding risk profile.the addition of bleeding risk profile to the long-term anticoagulation decisionMODIFIED: The 2014 AF Guideline recommendation was strengthened withmaking process.the addition of bleeding risk profile to the long-term anticoagulation decision4. For patients with AF or atrial flutter of less than 48 hours’ duration with amaking 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 aadministration of heparin, a factor Xa inhibitor, or a direct thrombinCHA2DS2-VASc score of 2 or greater in men and 3 or greater in women,inhibitor is reasonable as soon as possible before cardioversion, followed byadministration of heparin, a factor Xa inhibitor, or a direct thrombinlong-term anticoagulation therapy.inhibitor is reasonable as soon as possible before cardioversion, followed byMODIFIED: Recommendation COR was changed from I in the 2014 AFlong-term anticoagulation therapy.Guideline to IIa, and LOE was changed from C in the 2014 AF Guideline to BMODIFIED: Recommendation COR was changed from I in the 2014 AFNR. 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 B5. For patients with AF or atrial flutter of 48 hours’ duration or longer or ofNR. In addition, a specific CHA2DS2-VASc score is now specified.unknown duration who have not been anticoagulated for the preceding 35. For patients with AF or atrial flutter of 48 hours’ duration or longer or ofweeks, it is reasonable to perform transesophageal echocardiographyunknown duration who have not been anticoagulated for the preceding 3before cardioversion and proceed with cardioversion if no left atrialweeks, it is reasonable to perform transesophageal echocardiographythrombus is identified, including in the LAA, provided that anticoagulationbefore cardioversion and proceed with cardioversion if no left atrialis achieved before transesophageal echocardiography and maintained afterthrombus is identified, including in the LAA, provided that anticoagulationcardioversion for at least 4 weeks.is achieved before transesophageal echocardiography and maintained after6. For patients with AF or atrial flutter of less than 48 hours’ duration with acardioversion 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 aa factor Xa inhibitor, or a direct thrombin inhibitor, versus noCHA2DS2-VASc score of 0 in men or 1 in women, administration of heparin,anticoagulant therapy, may be considered before cardioversion, withouta factor Xa inhibitor, or a direct thrombin inhibitor, versus nothe need for postcardioversion oral anticoagulation.anticoagulant therapy, may be considered before cardioversion, withoutMODIFIED: Recommendation LOE was changed from C in the 2014 AFthe need for postcardioversion oral anticoagulation.Guideline to B-NR to reflect evidence from 2 registry studies and to includespecific CHA2DS2-VASc scores derived from study results.11
Back to Table of ContentsGUIDELINES MADE SIMPLEAF 2019 AHA/ACC/HRS Focused Update of the 2014 Guideline for Management of Patients with Atrial FibrillationRecommendation for Catheter Ablation in HFRecommendation for Catheter Ablation in HFCORLOEIIbB-RRecommendation1. AF catheter ablation may be reasonable in selected patients with symptomaticAF and HF with reduced left ventricular (LV) ejection fraction (HFrEF) topotentially lower mortality rate and reduce hospitalization for HF.NEW: New evidence, including data on improved mortality rate, have beenpublished for AF catheter ablation compared with medical therapy in patientswith HF.12
Back to Table of ContentsGUIDELINES MADE SIMPLEAF 2019 AHA/ACC/HRS Focused Update of the 2014 Guideline for Management of Patients with Atrial FibrillationRecommendations for AF Complicating ACSRecommendationsfor AF Complicating bCIIbCRecommendations1. For patients with ACS and AF at increased risk of systemic thromboembolism(based on CHA2DS2-VASc risk score of 2 or greater), anticoagulation isrecommended unless the bleeding risk exceeds the expected benefit.MODIFIED: New published data are available. LOE was updated from C in the2014 AF Guideline to B-R. Anticoagulation options are described in supportivetext.2. Urgent direct-current cardioversion of new-onset AF in the setting of ACS isrecommended for patients with hemodynamic compromise, ongoing ischemia,or inadequate rate control.3. Intravenous beta blockers are recommended to slow a rapid ventricularresponse to AF in patients with ACS who do not display HF, hemodynamicinstability, or bronchospasm.4. If triple therapy (oral anticoagulant, aspirin, and P2Y12 inhibitor) is prescribedfor patients with AF at increased risk of stroke (based on CHA2DS2-VASc riskscore of 2 or greater) who have undergone percutaneous coronary intervention(PCI) with stenting for ACS, it is reasonable to choose clopidogrel in preferenceto prasugrel.NEW: New published data are available.5. In patients with AF at increased risk of stroke (based on CHA2DS2-VASc risk scoreof 2 or greater) who have undergone PCI with stenting for ACS,
AF 2019 AHA/ACC/HRS Focused Update of the 2014 Guideline for Management of Patients with Atrial Fibrillation 5 Back to Table of Contents Section 4.1.1 - Selection of Antithrombotic Regimen Section 4.3 - Interruption and Bridging Anticoagulation Section 4.4.1 - Percutaneous Approac
