2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation

BySteven Lome, MD

Year released: 2014

Societies: American College of Cardiology (ACC), American Heart Association (AHA), Heart Rhythm Society (HRS)

Collaboration: Society of Thoracic Surgeons (STS)

Summary:

The ACC, AHA and HRS made evidence-based recommendations on how to better assess and treat patients with atrial fibrillation (AF).

The committee was tasked with establishing revised guidelines for the optimum management of patients with AF.

The updated guideline incorporates new and existing knowledge derived from published clinical trials, basic science and comprehensive review articles, along with evolving treatment strategies and new drugs, according to the writing committee. This guideline replaces the 2006 ACC/AHA/ESC Guidelines for the Management of Patients With Atrial Fibrillation.

Some recommendations from previous guidelines — including the 2006 guidelines — have either been eliminated or updated as warranted by new evidence or a better understanding of earlier evidence.

Clinical characteristics and evaluation of AF

AF occurs when structural and/or electrophysiological abnormalities alter atrial tissue to promote abnormal impulse formation and/or propagation, the committee wrote. These abnormalities are caused by diverse pathophysiological mechanisms, such that AF represents a final common phenotype for multiple disease pathways and mechanisms that are incompletely understood.

The committee recommends electrocardiographic documentation to establish the diagnosis of AF.

Thromboembolic risk and treatment

The panel placed recommendations into various classes to help identify the strength of each recommendation. Anything labeled as class I was considered strong, recommended and should be performed or administered. Anything labeled class III had no benefit or the risk outweighs the benefit.

A class I recommendation suggests antithrombotic therapy should be individualized based on shared decision-making after a discussion of the absolute and relative risks for stroke and bleeding, as well as the patient’s values and preferences, according to the guidelines.

Antithrombotic therapy should be based on the risk for thromboembolism regardless of whether the AF pattern is paroxysmal, persistent or permanent, according to the committee.

An additional class I recommendation indicates that renal function should be evaluated before initiation of direct thrombin or factor Xa inhibitors and should be re-evaluated when clinically indicated, and at least every year.

Specific patient groups and AF

The panel organized the class recommendations into specific patient groups as well.

The committee wrote that anticoagulation is indicated in patients with hypertrophic cardiomyopathy with AF independent of the CHA₂DS₂-VASc score.

An additional class I recommendation indicates that urgent direct-current cardioversion of new-onset AF in the setting of acute coronary syndromes (ACS) is recommended for patients with hemodynamic compromise, ongoing ischemia or inadequate rate control.

Evidence gaps and future research directions

The committee wrote that the hope is that a better understanding of tissue and cellular mechanisms will lead to more defined approaches to treating and abolishing AF. Those new approaches for AF ablation, according to the committee, would favorably affect survival, thromboembolism and quality of life across different patient profiles.

Additionally, the committee wrote that new pharmacological therapies are needed, including antiarrhythmic drugs that have atrial selectivity and drugs that target fibrosis, which will hopefully reach clinical evaluation.