Review Of Resources And Guidelines On The Management Of Atrial Fibrillation

Note to myself: Be sure and review Links To And Excerpts From “CAEP Acute Atrial Fibrillation/Flutter Best Practices Checklist” And From “2019 AHA/ACC/HRS focused update of the 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation”. Posted on January 19, 2020 by Tom Wade MD

The above post is basically the “how to do it for atrial fibrillation diagnosis and management.”

For this post, I reviewed the following resources on the management of atrial fibrillation:

  1. Pearls And Pitfalls of CHADS₂ Score for Atrial Fibrillation Stroke Risk
    Estimates stroke risk in patients with atrial fibrillation from MDCalc.

    1. Bottom line is — Don’t use this risk score. Rather use the CHA₂DS₂-VASc Score
  2. Pearls and Pitfalls of CHA₂DS₂-VASc Score for Atrial Fibrillation Stroke Risk
    Calculates stroke risk for patients with atrial fibrillation, possibly better than the CHADS₂ Score from MDCalc. For the risk based on the risk score, see Evidence from MDCalc.

    1. Use this calculator to get an estimate of the patient’s stroke risk from atrial fibrillation when not on anticoagulant.
  3. Pearls and Pitfalls of HAS-BLED Score for Major Bleeding Risk
    Estimates risk of major bleeding for patients on anticoagulation to assess risk-benefit in atrial fibrillation care from MDCalc. For the risk based on the risk score, see Evidence from MDCalc.

    1. “Clinical factors that contribute to stroke risk and support anticoagulation in patients with atrial fibrillation are frequently risk factors for bleeding as well. The HAS-BLED Score was developed as a practical risk score to estimate the 1-year risk for major bleeding in patients with atrial fibrillation.” From Pearls and Pitfalls.
  4. Dr. Clare Atzema’s podcast and show notes on the latest guidelines for anticoagulation in atrial fibrillation from EM Quick Hits 6, July 2019 from 8:53 – 19:07. What follows are quotes from Dr. Atzema’s show notes.
    1. “Rather than considering cardioversion of atrial fibrillation within 48 hours of onset of atrial fibrillation without anticoagulation for all patients, guidelines recommend safe cardioversion without anticoagulation only for the patients with the lowest risk profile for stroke – those with a CHADS-2 <2. If CHADS-2 is ≥2 only cardiovert if onset of atrial fibrillation is within 12 hrs. The longer the duration of atrial fibrillation the higher the risk of stroke if cardioverted.”
    2. “The CCS Guidelines recommend anticoagulating all patients who are cardioverted regardless of stroke risk for a minimum of 4 weeks based on expert opinion only, while the CAEP checklist and AHA guidelines do not make this recommendation. While the risk of major bleeding is extraordinarily low for patients who are anticoagulated for only 4 weeks and the risk of stroke is also extraordinarily low for patients who are CHADS-65 negative or CHADS-2 <2, short term anticoagulation after cardioversion should be considered in low risk patients on an individual basis, incorporating shared decision making.”
    3. “All patients who are CHADS-65 positive or CHADS-2 ≥2 should be anticoagulated immediately for cardioversion or attempted cardioversion in the ED.”
  5. Dr. Ian Stiell on atrial fibrillation rate vs rhythm control controversy from EM Quick Hits 7, August 2019 from 20:55 – 26:37. A and B below are quotes from the show notes.
    1. “Dr. Stiell feels that there is an argument to support rhythm over rate control.”
    2. “With regards to recent atrial fibrillation guidelines’ suggestion to consider anticoagulating all patients who are cardioverted in the ED for 4 weeks regardless of CHADS-65 score, this suggestion is based on low quality evidence and should be applied on a case by case basis employing shared decision making, patient preference and bleeding risk.”
    3. Stiell, Ian G. et al. Safe Cardioversion for Patients with Acute-Onset Atrial Fibrillation and Flutter: Practical Concerns and Considerations [PubMed Abstract] . Canadian Journal of Cardiology. Published online June 13, 2019.
  6. Dr. Dorion’s podcast notes on atrial fibrillation – rate vs rhythm control from EM Quick Hits 12, January 2020 from 00:32 – 10:20. A through E below are quotes from Dr. Dorion’s show notes.
    1.  “For stable patients who present to the ED with the primary diagnosis of rapid atrial fibrillation with moderate to severe symptoms and no complications mandating immediate cardioversion (heart failure, cardiac ischemia, shock) options include electrical or chemical cardioversion or rate control with delayed cardioversion.”
    2. “Arguments for immediate electrical cardioversion include high success rate and prompt resolution of symptoms.”
    3. “Arguments against immediate cardioversion include high ED resource utilization, potential rare complications associated with procedural sedation and that most patients spontaneously convert without intervention within 36hrs (about 70%).”
    4. “Support for withholding immediate cardioversion comes from a 2019 NEJM study which compared immediate ED cardioversion to rate control and reassessment within 36hrs for consideration of delayed cardioversion (going home with a rate control agent) if still in atrial fibrillation. 91% of patients in the delayed cardioversion group were in sinus rhythm at 1 month and 94% in the immediate cardioversion group, showing non-inferiority. There was no differences in potential risks or patient-reported quality of life between the two strategies.”
    5. “Practical considerations such as availability of follow up within 36hrs limits the “delayed” cardioversion strategy.”
    6. Early or Delayed Cardioversion in Recent-Onset Atrial Fibrillation [PubMed Abstract] [Full Text HTML]. N Engl J Med. 2019 Apr 18;380(16):1499-1508. doi: 10.1056/NEJMoa1900353. Epub 2019 Mar 18. Points i through iv are excerpts from the article’s Abstract:
      1. Background: Patients with recent-onset atrial fibrillation commonly undergo immediate restoration of sinus rhythm by pharmacologic or electrical cardioversion. However, whether immediate restoration of sinus rhythm is necessary is not known, since atrial fibrillation often terminates spontaneously.
      2. Methods: In a multicenter, randomized, open-label, noninferiority trial, we randomly assigned patients with hemodynamically stable, recent-onset (<36 hours), symptomatic atrial fibrillation in the emergency department to be treated with a wait-and-see approach (delayed-cardioversion group) or early cardioversion.
      3. Results: The presence of sinus rhythm at 4 weeks occurred in 193 of 212 patients (91%) in the delayed-cardioversion group and in 202 of 215 (94%) in the early-cardioversion group (between-group difference, −2.9 percentage points; 95% confidence interval [CI], −8.2 to 2.2; P=0.005 for noninferiority). In the delayed-cardioversion group, conversion to sinus rhythm within 48 hours occurred spontaneously in 150 of 218 patients (69%) and after delayed cardioversion in 61 patients (28%). In the early-cardioversion group, conversion to sinus rhythm occurred spontaneously before the initiation of cardioversion in 36 of 219 patients (16%) and after cardioversion in 171 patients (78%). Among the patients who completed remote monitoring during 4 weeks of follow-up, a recurrence of atrial fibrillation occurred in 49 of 164 patients (30%) in the delayed-cardioversion group and in 50 of 171 (29%) in the early-cardioversion group. Within 4 weeks after randomization, cardiovascular complications occurred in 10 patients and 8 patients, respectively.
      4. Conclusions: In patients presenting to the emergency department with recent-onset, symptomatic atrial fibrillation, a wait-and-see approach was noninferior to early cardioversion in achieving a return to sinus rhythm at 4 weeks.
  7. CAEP Acute Atrial Fibrillation/Flutter Best Practices Checklist [Full Text PDF]. CJEM 2018;20(3):334-342. This guideline is, for me, the go-to guide on the management of atrial fibrillation.
    1. I’ve posted a direct link and some excerpts from this great resource: Link To And Excerpts From CAEP Acute Atrial Fibrillation/Flutter Best Practices Checklist.
    2. The guideline recommends using the CHAD-65 score. However, see the article, CHAD65 and CHA2DS2-VASc Risk Stratification Tools for Patients with Atrial Fibrillation: A Review of Clinical Effectiveness and Guidelines, Last updated: May 12, 2017. This article has thoughtful comments on the use of the two different risk stratification tool.
  8. January CT, Wann LS, Calkins H, et al. 2019 AHA/ACC/HRS focused update of the 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Heart Rhythm. 2019 Jan 28. [PubMed Abstract] [Full Text HTML] [Full Text PDF].
    1. See and review the Table and Supplementary Data “Recommendations for Selecting an Anticoagulant Regimen—Balancing Risks and Benefits
      Referenced studies that support new or modified recommendations are summarized in Online Data Supplements 1 and 2.” This table is on pages e71 and e72 of the PDF.
    2. Resources (9) and (10) summarize this resource. However, I think that the Table in this article, A above, is better and clearer.
  9.  Update to the Atrial Fibrillation Guideline: A Focus on Anticoagulation Strategies, January 29, 2019 from NEJM Journal Watch.
    1. This article is a great quick summary of Resource (10) below.
  10. Atrial Fibrillation Clinical Practice Guidelines (2019)  Summary by Medscape from the ACC/AHA and Heart Rhythm Society: “This is a quick summary of the guidelines without analysis or commentary.” See the next resource, Resource (6), for links to the complete 2019 Guidelines.
    1. This article is also a great quick summary of Resource (10) below.



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