2019 AHA/ACC/HRS Focused Update

of the 2014 Guideline for Management

of Patients with Atrial Fibrillation
GUIDELINES MADE SIMPLE - Focused Update Edition
A Selection of Tables and Figures

©2018, American College of Cardiology B18202

ACC.org/GMSAF
2019 AHA/ACC/HRS Focused Update of the 2014 Guideline
for 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

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

Hugh Calkins, MD, FACC, FAHA, FHRS

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

The purpose of the 2019 Focused Update is to update the “2014 AHA/ACC/HRS Guideline for
the Management of Patients With Atrial Fibrillation” in areas where new evidence has emerged
since its publication. The scope of this update of the 2014 AF guideline includes revisions to the
section on anticoagulation due to the approval of new medications and thromboembolism protection
devices, the section on catheter ablation of AF, revisions to the section on the management of AF
complicating 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 Update
as well as a comparison tool that highlights the major new and modified recommendations
in the 2019 Focused Update. The resource is only an excerpt from the document and the full
publication should be reviewed for important context.

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

Selected Table or Figure Page

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

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

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

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

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

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

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

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

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

Weight Reduction in Patients with AF………………………………………………………………………… 14

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

2014-2019 Comparison Tool (1 of 2)

Change in Guideline Recommendations (Only major included)
2014 2019
The term “nonvalvular AF” is no longer used
Section 4.1.1 - Selection of Antithrombotic Regimen
Oral anticoagulants recommended for high risk patients now include edoxaban.
Exclusion criteria for CHA2DS2-VASc assessment and use of NOACs now defined as moderate to
severe mitral stenosis or a mechanical heart valve.
For patients with AF and end-stage chronic kidney disease, the direct thrombin inhibitor dabigatran,
or the factor Xa inhibitors rivaroxaban OR edoxaban are not recommended.
Section 6.1.1 - Prevention of Thromboembolism
For patients with AF or atrial flutter of 48 hours’
duration or longer, or when the duration of AF is
unknown, anticoagulation with warfarin (INR 2.0 Upgraded to Class I
to 3.0), a factor Xa inhibitor, or direct thrombin Recommendation
inhibitor is recommended for at least 3 weeks
before and at least 4 weeks after cardioversion.

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

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

Table will continue in the next page.

I IIa IIb III

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

2014-2019 Comparison Tool (2 of 2)

New Recommendations
Section 4.1.1 - Selection of Antithrombotic Regimen
NOACs are recommended over warfarin where eligible except in those patients with moderate - severe
mitral stenosis or a mechanical heart valve.
Section 4.3 - Interruption and Bridging Anticoagulation
Idarucizumab is the reversal agent for dabigatran in the event of life-threatening bleeding or an urgent procedure.
Andexanet Alfa is the reversal agent for apixaban and rivaroxaban.
Section 4.4.1 - Percutaneous Approaches to Occlude the Left Atrial Appendage
Percutaneous LAAO should be considered for those AF patients at an increased risk of stroke who have
contraindications to long-term anticoagulation and who are at high risk of thromboembolic events.
Section 6.3.4 - Catheter Ablation in HF
Catheter ablation of AF is reasonable in symptomatic AF patients with HF and reduced LVEF.
Section 7.4 - Complicating Acute Coronary Syndrome
If triple therapy is prescribed post-stent placement, clopidogrel is preferred over prasugrel.
Double therapy with a P2Y12 inhibitor and dose adjusted vitamin K antagonist is reasonable post-stenting.
Double therapy with clopidogrel and low-dose rivaroxaban (15 mg daily) may be reasonable post-stenting.
Double therapy with a P2Y12 inhibitor and dabigatran 150 mg twice daily is reasonable post-stenting.
If triple therapy is prescribed for patients with AF who are at increased risk of stroke and who have
undergone PCI with stenting for ACS, a transition to double therapy at 4-6 weeks may be considered.
Section 7.12 - Device Detection of AF and Atrial Flutter
In patients with cardiac implantable electronic devices, atrial high rate episodes (AHREs) should prompt
further evaluation.
In patients with cryptogenic stroke in whom long-term external ambulatory monitoring is
inconclusive implantation of a cardiac monitor is reasonable to detect silent AF.
Section 7.13 - Weight Loss
Weight loss and risk factor modification is recommended for overweight/obese patients with AF.

I IIa IIb III

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

Recommendations for Selecting an Anticoagulant Regimen—

Balancing
Recommendations for Selecting anRisks and Regimen—Balancing
Anticoagulant Benefits (1 ofRisks
3) and Benefits
COR LOE Recommendations
A 1. For patients with AF and an elevated CHA2DS2-VASc score of 2 or greater in
men or 3 or greater in women, oral anticoagulants are recommended.
B Options include:
• Warfarin (LOE: A)
• Dabigatran (LOE: B)
B
• Rivaroxaban (LOE: B)
• Apixaban (LOE: B) or
I B • Edoxaban (LOE: B-R)
MODIFIED: This recommendation has been updated in response to the approval
of edoxaban, a new factor Xa inhibitor. More precision in the use of CHA2DS2-
VASc scores is specified in subsequent recommendations. The LOEs for warfarin,
dabigatran, rivaroxaban, and apixaban have not been updated for greater
B-R granularity as per the new LOE system. (Section 4.1. in the 2014 AF Guideline)
The original text can be found in Section 4.1 of the 2014 AF guideline. Additional
information about the comparative effectiveness and bleeding risk of NOACs
can be found in Section 4.2.2.2.
2. NOACs (dabigatran, rivaroxaban, apixaban, and edoxaban) are recommended
over warfarin in NOAC-eligible patients with AF (except with moderate-to-
severe mitral stenosis or a mechanical heart valve).
NEW: Exclusion criteria are now defined as moderate-to-severe mitral stenosis
I A
or a mechanical heart valve. When the NOAC trials are considered as a group,
the direct thrombin inhibitor and factor Xa inhibitors were at least noninferior
and, in some trials, superior to warfarin for preventing stroke and systemic
embolism and were associated with lower risks of serious bleeding.
3. Among patients treated with warfarin, the international normalized ratio (INR)
should be determined at least weekly during initiation of anticoagulant
I A
therapy and at least monthly when anticoagulation (INR in range) is stable.
MODIFIED: “Antithrombotic” was changed to “anticoagulant.”
4. In patients with AF (except with moderate-to-severe mitral stenosis or a
mechanical heart valve), the CHA2DS2-VASc score is recommended for
assessment of stroke risk.
I B MODIFIED: Exclusion criteria are now defined as moderate-to-severe mitral
stenosis or a mechanical heart valve. Patients with AF with bioprosthetic heart
valves are addressed in the supportive text. (Section 4.1. in the 2014 AF
guideline)
5. For patients with AF who have mechanical heart valves, warfarin is
I B recommended.
MODIFIED: New information is included in the supportive text.
6. Selection of anticoagulant therapy should be based on the risk of
thromboembolism, irrespective of whether the AF pattern is paroxysmal,
I B
persistent, or permanent.
MODIFIED: “Antithrombotic” was changed to “anticoagulant.”
Table Iwill continue
B-NRin the 7. Renal
next page.function and hepatic function should be evaluated before initiation of a
NOAC and should be reevaluated at least annually.

6
 should be determined at least weekly during initiation of anticoagulant
I A
therapy and at least monthly when anticoagulation (INR in range) is stable.
MODIFIED: “Antithrombotic” was changed to “anticoagulant.”
Back toorTable
a of Contents
GUIDELINES MADE4.SIMPLE In patients with AF (except with moderate-to-severe mitral stenosis
AF 2019 AHA/ACC/HRS Focused mechanical
Update heart
of the valve), the CHAfor
2014 Guideline 2DS2-VASc score is recommended for
Management of Patients with Atrial Fibrillation
assessment of stroke risk.
I B MODIFIED: Exclusion criteria are now defined as moderate-to-severe mitral
stenosis or a mechanical heart valve. Patients with AF with bioprosthetic heart
valves are addressed in the supportive text. (Section 4.1. in the 2014 AF
guideline)
5. For patients with AF who have mechanical heart valves, warfarin is
I B recommended.
MODIFIED: New information is included in the supportive text.
Recommendations for Selecting an Anticoagulant Regimen—
6. Selection of anticoagulant therapy should be based on the risk of
thromboembolism, irrespective of whether the AF pattern is paroxysmal,
IBalancing Risks and Benefits
B
persistent, or permanent. (2 of 3)
MODIFIED: “Antithrombotic” was changed to “anticoagulant.”
7. Renal function and hepatic function should be evaluated before initiation of a
I B-NR
NOAC and should be reevaluated at least annually.
MODIFIED: Evaluation of hepatic function was added. LOE was updated from B
to B-NR. New evidence was added. (Section 4.1. in the 2014 AF Guideline)
8. In patients with AF, anticoagulant therapy should be individualized on the basis
of shared decision-making after discussion of the absolute risks and relative
I C
risks of stroke and bleeding, as well as the patient’s values and preferences.
MODIFIED: “Antithrombotic” was changed to “anticoagulant.”
9. For patients with atrial flutter, anticoagulant therapy is recommended
I C according to the same risk profile used for AF.
MODIFIED: “Antithrombotic” was changed to “anticoagulant.”
10. Reevaluation of the need for and choice of anticoagulant therapy at periodic
I C intervals is recommended to reassess stroke and bleeding risks.
MODIFIED: “Antithrombotic” was changed to “anticoagulant.”
11. For patients with AF (except with moderate-to-severe mitral stenosis or a
mechanical heart valve) who are unable to maintain a therapeutic INR level
with warfarin, use of a NOAC is recommended.
I C-EO MODIFIED: Exclusion criteria are now defined as moderate-to-severe mitral
stenosis or a mechanical heart valve, and this recommendation has been
changed in response to the approval of edoxaban. (Section 4.1. in the 2014 AF
Guideline)
12. For patients with AF (except with moderate-to-severe mitral stenosis or a
mechanical heart valve) and a CHA2DS2-VASc score of 0 in men or 1 in women,
IIa B it is reasonable to omit anticoagulant therapy.
MODIFIED: Exclusion criteria are now defined as moderate-to-severe mitral
stenosis or a mechanical heart valve. (Section 4.1. in the 2014 AF Guideline)
13. For patients with AF who have a CHA2DS2-VASc score of 2 or greater in men or
3 or greater in women and who have end-stage chronic kidney disease (CKD;
creatinine clearance [CrCl] <15 mL/min) or are on dialysis, it might be
IIb B-NR reasonable to prescribe warfarin (INR 2.0 to 3.0) or apixaban for oral
anticoagulation.
MODIFIED: New evidence has been added. LOE was updated from B to B-NR.
(Section 4.1. in the 2014 AF Guideline)
14. For patients with AF (except with moderate-to-severe mitral stenosis or a
Table will continue in the next page.
mechanical heart valve) and moderate-to-severe CKD (serum creatinine ≥1.5
mg/dL [apixaban], CrCl 15 to 30 mL/min [dabigatran], CrCl <50 mL/min
[rivaroxaban], or CrCl 15 to 50 mL/min [edoxaban]) with an elevated CHA2DS2-
VASc score, treatment with reduced doses of direct thrombin or factor Xa
IIb B-R inhibitors may be considered (e.g., dabigatran, rivaroxaban, apixaban, or
edoxaban).
MODIFIED: Exclusion criteria are now defined as moderate-to-severe mitral
stenosis or a mechanical heart 7 valve, and this recommendation has been changed
in response to the approval of edoxaban. LOE was updated from C to B-R. (Section
 11.with
For patients
warfarin,withuse ofAFa (except
NOAC iswith moderate-to-severe mitral stenosis or a
recommended.
I C-EO mechanical heart valve) who are
MODIFIED: Exclusion criteria are now defined unable to maintain a therapeutic INRmitral
as moderate-to-severe level
with warfarin, use of a NOAC is recommended.
stenosis or a mechanical heart valve, and this recommendation has been
I C-EO MODIFIED:
changed Exclusiontocriteria
in response are now
the approval defined as (Section
of edoxaban. moderate-to-severe
4.1. in theBack mitral
to Table
2014 AF of Contents
GUIDELINES MADE SIMPLE
AF stenosis
Guideline)
2019 AHA/ACC/HRS Focused
or
Update
a mechanical
of the 2014
heart valve, and this recommendation has been
changed in response to theGuideline
approval for Management
of edoxaban. of Patients
(Section with2014
4.1. in the AtrialAFFibrillation
12. For patients with AF (except with moderate-to-severe mitral stenosis or a
Guideline)
mechanical heart valve) and a CHA2DS2-VASc score of 0 in men or 1 in women,
IIa B 12. it
For patients with
is reasonable AF (except
to omit with moderate-to-severe
anticoagulant therapy. mitral stenosis or a
mechanical heart valve) and a CHA 2DS2-VASc score of 0 in men or 1 in women,
MODIFIED: Exclusion criteria are now defined as moderate-to-severe mitral
IIa B it is reasonable
stenosis to omit heart
or a mechanical anticoagulant therapy.
valve. (Section 4.1. in the 2014 AF Guideline)
MODIFIED: Exclusion criteria are now defined as moderate-to-severe mitral
13. For patients with AF who have a CHA2DS2-VASc score of 2 or greater in men or
stenosis or a mechanical heart valve. (Section 4.1. in the 2014 AF Guideline)
3 or greater in women and who have end-stage chronic kidney disease (CKD;
13.creatinine
For patients with AF[CrCl]
clearance who have a CHA2DSor2-VASc
<15 mL/min) are onscore of 2 itormight
dialysis, greater
bein men or
reasonable to prescribe warfarin (INR 2.0 to 3.0) or apixaban for oral (CKD;
3 or greater in women and
Recommendations for Selecting an Anticoagulant Regimen—
IIb B-NR who have end-stage chronic kidney disease
creatinine clearance
anticoagulation .
[CrCl] <15 mL/min) or are on dialysis, it might be
IIb Balancing Risks and Benefits
B-NR reasonable to prescribe
MODIFIED: New evidence
anticoagulation .
warfarin
has been (INR 2.0 to LOE
added. 3.0) was
or
(3apixaban
of 3) forfrom
updated oralB to B-NR.
(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 ≥1.5
14.mg/dL
For patients with AF
[apixaban], CrCl(except
15 to with moderate-to-severe
30 mL/min [dabigatran],mitralCrCl stenosis
<50 mL/min or a
mechanical heart valve) and moderate-to-severe CKD (serum
[rivaroxaban], or CrCl 15 to 50 mL/min [edoxaban]) with an elevated CHA2DS2- creatinine ≥1.5
mg/dLscore,
VASc [apixaban],
treatment CrClwith
15 to 30 mL/min
reduced doses of[dabigatran],
direct thrombin CrCl <50 mL/min
or factor Xa
IIb B-R [rivaroxaban],
inhibitors mayorbe CrCl 15 to 50 mL/min
considered [edoxaban]) rivaroxaban,
(e.g., dabigatran, with an elevated CHA2DSor
apixaban, 2-
VASc score,
edoxaban). treatment with reduced doses of direct thrombin or factor Xa
IIb B-R inhibitors may
MODIFIED: be considered
Exclusion criteria are (e.g.,
nowdabigatran,
defined as rivaroxaban, apixaban,
moderate-to-severe or
mitral
edoxaban).
stenosis or a mechanical heart valve, and this recommendation has been changed
MODIFIED:
in response to Exclusion criteria
the approval are now LOE
of edoxaban. defined as moderate-to-severe
was updated mitral
from C to B-R. (Section
stenosis
4.1. or2014
in the a mechanical heart valve, and this recommendation has been changed
AF Guideline)
in response to the approval of edoxaban. LOE was updated from C to B-R. (Section
15. For patients with AF (except with moderate-to-severe mitral stenosis or a
4.1. in the 2014 AF Guideline)
mechanical heart valve) and a CHA2DS2-VASc score of 1 in men and 2 in
IIb C- LD 15. For patients with AF (except with moderate-to-severe mitral stenosis or a
women, prescribing an oral anticoagulant to reduce thromboembolic stroke
mechanical
risk heart valve) and a CHA2DS2-VASc score of 1 in men and 2 in
may be considered.
IIb C- LD
MODIFIED: Exclusionancriteria
women, prescribing oral anticoagulant
are now defined to reduce thromboembolic stroke
as moderate-to-severe mitral
risk may be considered.
stenosis or a mechanical heart valve, and evidence was added to support
separate risk scores by sex. LOE was updated from C to C-LD. (Section 4.1. in the
2014 AF Guideline)
16. In patients with AF and end-stage CKD or on dialysis, the direct thrombin
inhibitor dabigatran or the factor Xa inhibitors rivaroxaban or edoxaban are
III: not recommended because of the lack of evidence from clinical trials that
No C-EO benefit exceeds risk.
Benefit MODIFIED: New data have been included. Edoxaban received FDA approval and
has been added to the recommendation. LOE was updated from C to C-EO.
(Section 4.1. in the 2014 AF Guideline)
17. The direct thrombin inhibitor dabigatran should not be used in patients with
III: AF and a mechanical heart valve.
B-R
Harm MODIFIED: Evidence was added. LOE was updated from B to B-R. Other NOACs
are addressed in the supportive text. (Section 4.1. in the 2014 AF Guideline)

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

Recommendations for
Interruption
Recommendationsand Bridging
for Interruption and Anticoagulation
Bridging Anticoagulation

COR LOE Recommendations

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

2. For patients with AF without mechanical heart valves who require

interruption of warfarin for procedures, decisions about bridging therapy
(unfractionated heparin or low-molecular-weight heparin) should balance
I B-R the risks of stroke and bleeding and the duration of time a patient will not
be anticoagulated.
MODIFIED: LOE was updated from C to B-R because of new evidence.
(Section 4.1. in the 2014 AF Guideline)
3. Idarucizumab is recommended for the reversal of dabigatran in the event of
life-threatening bleeding or an urgent procedure.
I B-NR
NEW: New evidence has been published about idarucizumab to support LOE
B-NR.
4. Andexanet alfa can be useful for the reversal of rivaroxaban and apixaban in
the event of life-threatening or uncontrolled bleeding.
IIa B-NR
NEW: New evidence has been published about andexanet alfa to support LOE
B-NR.

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

Recommendation for
Percutaneous Approaches to Occlude the LAA
Recommendation for Percutaneous Approaches to Occlude the LAA

COR LOE Recommendation

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

Recommendation forfor
Recommendation Percutaneous Approaches
Cardiac Surgery—LAA to Occlude the LAA
Occlusion/Excision

COR
COR LOE
LOE Recommendation
Recommendation
1. Surgical occlusion of the LAA maybe
1. Percutaneous LAA occlusion may beconsidered
consideredininpatients
patientswith
withAF
AFat increased
undergoing
risk of stroke who have contraindications to long-term anticoagulation.
cardiac surgery, as a component of an overall heart team approach to the
IIb
IIb B-NR
B-NR NEW: Clinical of
management trial
AF.data and FDA approval of the Watchman device necessitated
this
Recommendation for
recommendation.
MODIFIED: LOE was updated from C to B-NR because of new evidence.

Cardiac Surgery—LAA Occlusion/Excision

Recommendation for Cardiac Surgery—LAA Occlusion/Excision

COR LOE Recommendation

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

10
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GUIDELINES MADE SIMPLE
AF 2019 AHA/ACC/HRS Focused Update of the 2014 Guideline for Management of Patients with Atrial Fibrillation

Recommendations for Prevention of Thromboembolism

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

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

Recommendation for Catheter Ablation in HF

Recommendation for Catheter Ablation in HF

COR LOE Recommendation

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

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

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

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

COR LOE Recommendations

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

Recommendation for Weight

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

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