Afib Slides 2011 Unrestricted

Canadian Cardiovascular Society
2010 Atrial Fibrillation Guidelines

CCS AF Guidelines 2010
Primary Panel
Anne Gillis (co chair) Brent Mitchell
Allan Skanes (co chair) Stanley Nattel
John Cairns Pierre Pag
Stuart Connolly Ratika Parkash
Jafna Cox P. Timothy Pollak
Paul Dorian Michael Stephenson
Jeff Healey Ian Stiell
Laurent Macle Mario Talajic
Sean McMurtry Teresa Tsang
Atul Verma
Atrial Fibrillation Guidelines

CCS AF Guidelines 2010
Secondary Panel
Malcolm Arnold
David Bewick
Vidal Essebag
Milan Gupta
Brett Heilbron
Charles Kerr
Bob Kiaii
Jan Surkes
George Wyse

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
GRADE
Grading of Recommendations, Assessment,
Development and Evaluation

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

GRADE: Rating Quality of Evidence
Quality Comments
Future research unlikely to change confidence in estimate of effect; e.g.
High multiple well designed, well conducted clinical trails.
Further research likely to have an important impact on confidence in

estimate of effect and may change the estimate e.g. limited clinical trials,
Moderate
inconsistency of results or study limitations.
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
Low
studies or cohort observations.
The estimate of effect is very uncertain; e.g. case studies; consensus

Very Low opinion.
Modified with permission from: Guyatt GH, et al. BMJ 2008;336:926

Factors Determining the Strength of the Recommendation
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 The greater the difference between desirable and undesirable
effects the greater the probability that a strong recommendation
desirable and
is indicated e.g. strong recommendation that patients with AF
undesirable effects 48 hr duration receive oral anticoagulation therapy for at least 3
weeks prior to planned cardioversion and 4 weeks following.
Values and The greater the variation or uncertainty in values and

preferences, the higher the probability that a conditional
Preferences
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.
Modified with permission from: Guyatt GH, et al. BMJ 2008;336:926

Atrial Fibrillation Guidelines 2010:
Etiology and Investigation
Jeff S Healey MD
Ratika Parkash MD
P Timothy Pollak MD
Teresa SM Tsang MD
Paul Dorian MD
Establish Pattern of Atrial Fibrillation
Newly Diagnosed AF
Paroxysmal Persistent
Permanent
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. CHADS2 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

Recommendations
Etiology and Investigations
All patients with AF should have a complete Strong
history and physical examination, Recommendation
electrocardiogram, echocardiogram, basic Low Quality
laboratory investigations. Details are Evidence
highlighted in Table 1.
Other ancillary tests should be considered Strong

under specific circumstances. Details Recommendation
included in Table 2. Low Quality
Evidence

Practical Tips
Aggressive treatment of hypertension may prevent

or reduce recurrences
Choice of antihypertensive therapy should favor rate
controlling drugs e.g. -blockers and Ca2+ channel
blockers vs inhibitors of renin angiotensin system.
Identify and treat obstructive sleep apnea

Establish AF Severity
Use to Guide Therapeutic Approach
CCS
Impact on QOL
SAF Score
0 Asymptomatic
1 Minimal effect on QOL
2 Minor effect of QOL
3 Moderate effect on QOL
4 Severe effect on QOL

Dorian et al Can J Cardiol 2006;22:383-386

Recommendations
Quality of Life
We recommend that the assessment of Strong
patient well being, symptoms, and quality Recommendation
of life (QOL) be part of the evaluation of Low Quality of
every patient with AF. Evidence
Conditional
We suggest that QOL of the AF patient can Recommendation
be assessed in routine care using the CCS Low Quality of
SAF scale. Evidence
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
Minimal effect
CCS SAF 1 EHRA II Mild symptoms
on QOL
Severe
Modest effect symptoms;
CCS SAF 2 EHRA III
on QOL daily activity
affected
Disabling
symptoms;
Moderate effect
CCS SAF 3 EHRA IV Normal daily
on QOL
activity
discontinued
Severe effect
CCS SAF 4
on QOL

Atrial Fibrillation Guidelines 2010:
AF/AFL Rhythm Management
Anne M Gillis MD
Atul Verma MD
Mario Talajic MD
Stanley Nattel MD
Paul Dorian MD
Overview of AF Management
Detection and
AF Detected Treatment of
Precipitating Causes
Assessment of Management of
Thromboembolic Arrhythmia
Risk (CHADS2)
ASA Rate Rhythm

OAC Control Control
No antithrombotic therapy may be appropriate in

selected young patients with no stroke risk factors

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

Recommendations Rx Goals
We recommend that the goals of ventricular rate Strong
control should be to improve symptoms and Recommendation
clinical outcomes which are attributable to Low Quality
excessive ventricular rates Evidence
We recommend that the goals of rhythm control Strong

therapy should be to improve patient symptoms Recommendation
and clinical outcomes, and that these do not Moderate Quality
necessarily imply the elimination of all AF Evidence
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

Factors Influencing Decision
of Rate vs Rhythm Control
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 Congestive Heart Failure clearly
Heart Failure exacerbated by AF
Previous Antiarrhythmic No Previous Antiarrhythmic
Drug Failure Drug Failure

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

Ventricular Rate Control
Strong
We recommend that ventricular rate be Recommendation
assessed at rest in all patients with persistent Moderate Quality
and permanent AF/AFL. Evidence
We recommend that heart rate during exercise Strong
be assessed in patients with persistent or Recommendation
permanent AF/AFL and associated exertional Moderate Quality
symptoms. Evidence
We recommend that treatment for rate control Strong
of persistent/permanent AF/AFL should aim for Recommendation
a resting heart rate of less than 100 beats per High Quality
minute. 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.

Rate Control Drug Choices
No Heart CAD Heart Failure

Disease
Hypertension
-blocker -blocker* -blocker

Diltiazem Diltiazem digitalis
Verapamil Verapamil
Combination Rx
Digitalis
*-blockers preferred in CAD

Digitalis may be considered as
monotherapy in sedentary individuals
Dronedarone

We recommend -blockers or non- Strong
dihydropyridine calcium channel blockers as Recommendation
initial therapy for rate control of AF/AFL in most Moderate Quality
patients without a past history of MI or LV Evidence
dysfunction.
We suggest that digoxin not be used as initial Conditional
therapy for active patients and be reserved for Recommendation
rate control in patients who are sedentary or Moderate Quality
who have LV systolic dysfunction. Evidence
We suggest that digoxin be added to therapy Conditional
with beta-blockers or calcium channel blockers Recommendation
in patients whose heart rate remains Moderate Quality
uncontrolled. Evidence

We suggest that dronedarone may be added for Conditional
additional rate control in patients with Recommendation
uncontrolled ventricular rates despite therapy Moderate Quality
with -blockers, calcium channel blockers Evidence
and/or digoxin.
We suggest that amiodarone for rate control Conditional
should be reserved for exceptional cases in Recommendation
which other means are not feasible or are Low Quality
insufficient. 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.

Level or
Strength /Class of
Recommendation Quality of
Recommendation
Evidence
We recommend that treatment for rate
2010 CCS control of persistent/permanent AF or
AFL should aim for a resting heart rate Strong High
Guidelines
< 100 bpm
Reasonable to initiate treatment with a
lenient rate control protocol aimed at
resting HR <110 bpm. Reasonable to
2010 ESC adopt a stricter rate control strategy IIa B
Guidelines when symptoms persist or
tachycardiomyopathy occurs, despite
lenient rate control: HR <80
Treatment to achieve strict rate control
of heart rate is not beneficial compared
2010 to achieving a resting heart rate < 110
ACCF/AHA/HRS bpm in patients with persistent AF who
III no benefit B
Focused have stable ventricular function (LVEF
Update > 0.40) and no or acceptable symptoms
related to AF
2004 CCS HR <80 bpm at rest and <110 bpm

during 6 min hallwalk IIa C
Guidelines

Previous MI or LV Systolic Dysfunction
We recommend beta-blockers as initial therapy Strong

for rate control of AF/AFL in patients with Recommendation
myocardial infarction or left ventricular systolic High Quality
dysfunction Evidence

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.

AV Junction Ablation
We recommend AV junction ablation and Strong

implantation of a permanent pacemaker in Recommendation
symptomatic patients with uncontrolled Moderate Quality
ventricular rates during AF despite maximally Evidence
tolerated combination pharmacologic therapy

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.

-blockers for Rate Control
Drug Dose Adverse Effects

bradycardia,
atenolol 50 150 mg p.o. daily 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
* Sustained release preparations are available

Ca2+ Channel Blockers or Digoxin
for Rate Control
Drug Dose Adverse Effects
bradycardia,
120 mg p.o. daily -
verapamil * hypotension,
240 mg p.o. bid
constipation
bradycardia,
120-280 mg p.o.
diltiazem * hypotension,
daily - bid
ankle swelling
bradycardia,
0.125 0.25 mg p.o. nausea, vomiting,
digoxin
daily visual
disturbances
* Sustained release preparations are available

Rhythm Control Recommendations
We recommend use of maintenance oral Strong
antiarrhythmic therapy as first-line therapy for patients Recommendation
with recurrent AF in whom long-term rhythm control is Moderate Quality
desired (see flow charts). Evidence
We recommend that oral antiarrhythmic drug therapy Strong
should be avoided in patients with AF/AFL and Recommendation
advanced sinus or AV nodal disease unless the patient Low Quality
has a pacemaker/implantable defibrillator Evidence
We recommend that an AV blocking agent should be Strong

used in patients with AF/AFL being treated with a class Recommendation
I antiarrhythmic drug (e.g. propafenone or flecainide) Low Quality
in the absence of advanced AV node disease. Evidence
Values and preferences

outcomes with the potential greater adverse effects of Class I/III antiarrhythmic
drugs compared to rate control therapy.

Rhythm Control Strategy
We recommend the optimal treatment of precipitating Strong
or reversible predisposing conditions of AF prior to Recommendation
attempts to restore/maintain sinus rhythm. Low Quality
Evidence
We recommend a rhythm control strategy for patients Strong
with AF/AFL who remain symptomatic with rate Recommendation
control therapy or in whom rate control therapy is Moderate Quality
unlikely to control symptoms. Evidence
We recommend that the goal of rhythm control Strong

therapy should be improvement in patient symptoms Recommendation
and clinical outcomes, and not necessarily the Moderate Quality
elimination of all AF. Evidence

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
Catheter Ablation
Amiodarone
* 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% EF 35%
Amiodarone Amiodarone
Dronedarone
Sotalol*
Catheter Ablation
* Sotalol should be used with caution with EF 35-40%
Contraindicated in women >65 yrs taking diuretics

Pill in the Pocket For Rhythm Control
We recommend intermittent antiarrhythmic Strong
drug therapy ("pill in pocket") in symptomatic Recommendation
patients with infrequent, longer-lasting Moderate Quality
episodes of AF/AFL as an alternative to daily Evidence
antiarrhythmic therapy.
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)

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.

Class IC Drugs
Drug Efficacy Toxicity Comments
Flecainide 30-50% Ventricular tachycardia Contraindicated in patients
50-150 mg Bradycardia with CAD or LV dysfunction
BID Rapid ventricular response Should be combined with an
to AF or atrial flutter (1:1 AV nodal blocking agent
conduction)
Propafenone 30-50% Ventricular tachycardia Contraindicated in patients

150-300 mg Bradycardia with CAD or LV dysfunction
TID Rapid ventricular response Should be combined with an
to AF or atrial flutter (1:1 AV nodal blocking agent
conduction)
Abnormal taste

Class III Efficacy Toxicity Comments
Drug
Amiodarone 60-70% Photosensitivity Low risk of proarrhythmia
Bradycardia Limited by systemic side effects
100- 200 mg OD
GI upset Most side effects are dose & duration
(after 10gm Thyroid dysfunction related
Hepatic toxicity
loading)
Neuropathy, tremor
Pulmonary toxicity
Torsades de pointes (rare)
Dronedarone 40% GI upset Only antiarrhythmic shown to reduce
Bradycardia hospitalizations and cardiovascular
400 mg BID
mortality
May increase mortality in patients
with recently decompensated heart
failure, EF <35%
Effective rate control agent
New drug limited experience
outside trials
Sotalol 30-50% Torsades de pointes Should be avoided in patients at high
Bradycardia risk of Torsades de pointes VT
80-160 mg BID
Beta-blocker side effects 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 (CHADS2 score)

Cardioversion for Rhythm Control
We recommend electrical or pharmacologic Strong
cardioversion for restoration of sinus rhythm Recommendation
in patients with AF/AFL selected for rhythm Low Quality
control therapy who are unlikely to convert Evidence
spontaneously.
We recommend pre-treatment with Strong
antiarrhythmic drugs prior to electrical Recommendation
cardioversion in patients who have had AF Moderate Quality
recurrence post-cardioversion without Evidence
antiarrhythmic drug pre-treatment.

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.

Pacing for Rhythm Control
We suggest that, in patients requiring pacing Conditional
for the treatment of symptomatic bradycardia Recommendation
secondary to sinus node dysfunction, atrial High Quality
or dual chamber pacing be generally used for Evidence
the prevention of AF
We suggest that, in patients with intact AV Conditional

conduction, pacemakers be programmed to Recommendation
minimize ventricular pacing for prevention of Moderate Quality
AF Evidence

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.

Pacing Mode and AF
Danish Extended Danish
AAI vs VVI CTOPP CTOPP MOST 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 All pacemaker SND SND
patients patients
Follow-up (yr) 5.5 3.1 6.4 2.7 2.9

Pacing Modes AAI vs VVI AAI/R or DDD/R AAI/R or DDD/R DDDR vs VVIR AAI vs DDDR-s
vs VVI/R vs VVI/R 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

Canadian Cardiovascular
Society Atrial Fibrillation
Guidelines 2010: Catheter
Ablation of Atrial Fibrillation
andAtul
Flutter
Verma MD
Jafna L Cox MD
Laurent Macle MD
Allan C Skanes MD
Systematic Review of RCTs
Ablation vs Drug Rx
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
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
Piccini JP et al. Circ Arrhythm 2009;2:626

Worldwide AF Ablation (03-06)
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%
Cappato R et al. Circ Arrhythm Electrophysiol. 2010;3:32-8

Recommendations Ablation
We recommend catheter ablation of AF in Strong Recommendation
patients who remain symptomatic Moderate Quality
following adequate trials of anti-arrhythmic Evidence
drug therapy and in whom a rhythm
control strategy remains desired.
We suggest catheter ablation to maintain Conditional
sinus rhythm in select patients with Recommendation
symptomatic AF and mild-moderate Moderate Quality
structural heart disease who are Evidence
refractory or intolerant to at least one anti-
arrhythmic medication.
We suggest catheter ablation to maintain Conditional

sinus rhythm as first-line therapy for relief Recommendation
of symptoms in highly selected patients Low Quality Evidence
with symptomatic, paroxysmal AF.
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 Strong
symptomatic patients with typical atrial flutter as Recommendation
first line therapy or as a reasonable alternative to Moderate Quality
pharmacologic rhythm or rate control therapy. Evidence
In patients with evidence of ventricular pre- Strong

excitation during AF, we recommend catheter Recommendation
ablation of the accessory pathway, especially if AF Low Quality
is associated with rapid ventricular rates, syncope, Evidence
or a pathway with a short refractory period.
In young patients with lone, paroxysmal AF, we Conditional

suggest an electrophysiological study to exclude a Recommendation
reentrant tachycardia as a cause of AF; if present, Very Low
we suggest curative ablation of the tachycardia. Quality Evidence

Comparison of North American and European Guidelines
CCS Guidelines ESC Guidelines ACCF/AHA/HRS
Level of Level of Level of
Strength Class Class
Evidence Evidence Evidence
IIa
Paroxysmal* Conditional Moderate A (High) I (Strong) A (High)
(Conditional)
IIa B IIa
Persistent* Conditional Moderate A (High)
(Conditional) (Moderate) (Conditional)
Failed 1 drug Conditional Moderate -- -- I (Strong) A (High)
Failed 2
Strong Moderate -- -- -- --
drugs
IIb B
1st Line Conditional Low -- --
(Conditional) (Moderate)
PAF / sign.
structural IIb
-- -- -- -- A (High)
heart (Conditional)
disease
* 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

Guidelines 2010:
Management of recent onset
atrial fibrillation and atrial
flutter in the emergency
department
Ian G. Stiell, MD, MSc
Laurent Macle, MD
ED Management of Recent Onset AF/AFL
We recommend that in stable patients with Strong

recent-onset AF/AFL, a strategy of rate Recommendation
control or rhythm control could be selected 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.

Hemodynamically Unstable Patients
with AF/AFL
We recommend for patients with acute Strong
hemodynamic instability secondary to rapid Recommendation
recent-onset AF/AFL, immediate electrical Low Quality
conversion to sinus rhythm 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.

Electrical Cardioversion
We recommend that electrical cardioversion Strong
may be conducted in the ED with 150-200 Recommendation
joules biphasic waveform as the initial Low Quality
energy setting. 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.

In hemodynamically stable patients with AF/AFL of known duration
< 48 h in whom a strategy of rhythm control has been selected:
We recommend that rate-slowing agents alone are Strong

acceptable while awaiting spontaneous conversion Recommendation
Moderate Quality
Evidence
We recommend that synchronized electrical Strong
cardioversion or pharmacological cardioversion may be Recommendation
used when a decision is made to cardiovert patients in Moderate Quality
the emergency department. See Tables for drug Evidence
recommendations.
We suggest that antiarrhythmic drugs may be used to Conditional
pre-treat patients before electrical cardioversion in ED in Recommendation
order to decrease early recurrence of AF and to enhance Low Quality
cardioversion efficacy Evidence

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
Known duration < 48 h Duration > 48 h or unknown

(and not high-risk patients1) or high-risk patients1
Failed CV Rate-
Hemodynamically Hemodynamically
control
unstable stable
Therapeutic OAC TEE-guided

Pharmacological for 3 weeks cardioversion
Urgent electrical
or electrical before (OAC initiated with
cardioversion2
cardioversion2 cardioversion heparin bridging)3
Successful CV
Antithrombotic therapy Antithrombotic therapy

-In general, no prior or subsequent anticoagulation is -OAC continued for 4 consecutive weeks.
required. -If AF/AFL persists or recurs or if AF/AFL has been
-If AF/AFL persists or recurs or if AF/AFL has been recurrent, antithrombotic therapy as appropriate (per
recurrent, antithrombotic therapy as appropriate CHADS2 score) should be continued indefinitely.
(CHADS2 score) should be initiated and continued -Early follow-up should be arrange to review ongoing
indefinitely. antithrombotic strategy.
-Early follow-up to review antithrombotic strategy.
1
Patients at particularly high risk of stroke (e.g. mechanical valve, rheumatic heart disease, recent stroke/TIA)
150-200J biphasic waveform preferred
2
3
Heparin must be initiated and continued until a therapeutic level of oral anticoagulation has been established.
Rate Control: IV Therapy
Drug Dose Risks
Diltiazem* 0.25 mg/kg IV bolus Hypertension,

over 10 min; repeat at bradycardia
0.35 mg/kg IV
Metoprolol 2.5-5mg IV bolus over Hypotension,
2 min; up to 3 doses bradycardia
Verapamil* 0.075-0.15mg/kg over 2 Hypotension,

min bradycardia
Digoxin 0.25 mg IV each 2 h; Bradycardia,

up to 1.5mg Digitalis toxicity
*Calcium-channel blockers should not be used in patients with heart failure or left
ventricular dysfunction

Pharmacologic Cardioversion
Drug Dose Efficacy Risks
Class 1A 15-17 mg/kg IV ++ 5% hypotension
Procainamide over 60 min
Class IC* Hypotension, 1:1
Propafenone 450-600 mg PO +++ flutter, bradycardia
Flecainide 300-400 mg PO +++ Hypotension, 1:1
flutter, bradycardia
Class III 1-2 mg IV over 2-3% Torsades de

Ibutilide 10-20 min ++ pointes
Pre-treat with
MgSO4 1-2 mg IV
*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.

Wolff Parkinson White Syndrome
We recommend urgent electrical cardioversion Strong
if the patient is hemodynamically unstable Recommendation
Low Quality
Evidence
We recommend Intravenous antiarrhythmic Strong
agents procainamide or ibutilide in stable Recommendation
patients Low Quality
Evidence
We recommend that AV nodal blocking agents Strong

(digoxin, calcium channel blockers, beta- Recommendation
blockers, adenosine) are contra-indicated. Low Quality
Evidence

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
Risk Stratification
Stroke Prevention
Bleeding Risk
We recommend that all patients with AF or Strong
AFL (paroxysmal, persistent or permanent), Recommendation
should be stratified using a predictive index High Quality
for stroke (e.g. CHADS2) and for the risk of Evidence
bleeding (e.g. HAS-BLED), and that most
patients should receive antithrombotic
therapy.

Predictive Index for Stroke
CHADS2
Risk Factor Score Patient Adjusted
s Stroke CHAD
Congestive Heart 1 (n = Rate (%/yr) S2
Failure
1733) 95% CI Score
Hypertension 1
1.9 (1.2 to
Age 75 1 120 0
3.0)
Diabetes Mellitus 1 2.8 (2.0 to
Stroke/TIA/ 2 463 1
3.8)
Thromboembolism
4.0 (3.1 to
Maximum Score 6 523 2
5.1)
5.9 (4.6 to
337 3
7.3)
Atrial Fibrillation 8.5 (6.3 to
Guidelines
220 4
CHADS2 CHA2DS2-VASc
Risk Factor Score Risk Factor Score
Congestive Heart Failure 1 Congestive Heart Failure 1
Hypertension 1 Hypertension 1
Age 75 1 Age 75 2
Diabetes Mellitus 1 Diabetes Mellitus 1
Stroke/TIA/Thrombo- 2 Stroke/TIA/Thrombo- 2
embolism embolism
Vascular Disease 1
Age 65-74 1
Female 1
Maximum Score 6 Maximum Score 9

Adjusted
Stroke TE Rate
Patients (n = Rate (%/yr) assuming no CHA2DS2VASc
7329) 95% CI warfarin 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

Bleeding Risk HAS-BLED Score
Letter Clinical Characteristic Points
H Hypertension 1
A Abnormal Liver or Renal Function 1 or 2

1 point each
S Stroke 1
B Bleeding 1
L Labile INRs 1
E Elderly (age > 65 yr) 1
D Drugs or Alcohol 1 or 2
1 point each
Maximum 9 points
Pisters R et al. Chest. 2010 Nov;138:1093-100

Overview of Thromboembolic
Management
Assess
Thromboembolic
Risk (CHADS2) and
Bleeding Risk (HAS-
BLED)
CHADS2 = 0 CHADS2 = 1 CHADS2 2
aspirin OAC* OAC
No antithrombotic *Aspirin is a
may be appropriate in reasonable
selected young alternative in some
patients with no as indicated by
stroke risk factors Dabigatran
risk/benefit is preferred OAC over warfarin
in most patients.

RRR = 64%
Hart Ann Int Med 1999;131:492

RRR = 19%
Hart Ann Int Med 1999;131:492

RCTs Warfarin vs ASA
RRR=39% 50% 0 -50%

Warfarin Better Warfarin
Hart. Ann Int MedWorse
2007;147:590

40
17 24
Events/1000 patients/year
28
19 13 18
10 12
7 11 10 17 14 23
Risk of Stroke + Non-cerebral Major Bleed among AF Patients

ASA for Stroke Prevention
We recommend that patients at very low risk Strong
of stroke (CHADS2 = 0) should receive aspirin Recommendation
(75-325 mg/day). High Quality
Evidence
We suggest that some young persons with Conditional
no standard risk factors for stroke may not Recommendation
require any antithrombotic therapy. Moderate Quality
Evidence

Anticoagulant Therapy for Stroke Prevention
We recommend that patients at low risk of Strong
stroke (CHADS2 = 1) should receive OAC Recommendation
therapy (either warfarin [INR 2 3] or High Quality
dabigatran). Evidence
We suggest, based on individual risk/benefit Conditional
considerations, that aspirin is a reasonable Recommendation
alternative for some. Moderate Quality
Evidence
We recommend that patients at moderate Strong
risk of stroke (CHADS2 2) should receive Recommendation
OAC therapy (either warfarin [INR 2 3] or High Quality
dabigatran). 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.

Dabigatran vs Warfarin
We suggest, that when OAC therapy is Conditional
indicated, most patients should receive Recommendation
dabigatran in preference to warfarin. In High Quality
general, the dose of dabigatran 150 mg po Evidence
bid is preferable to a dose of 110 mg po bid.
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.

Antithrombotic Management of AF/AFL in
CAD
Stable CAD Recent ACS PCI
Choose Choose
Choose
antithrombotic antithrombotic
antithrombotic
based on balance based on balance
based on stroke
of risks of risks
risk
and benefits and benefits
CHADS2 CHADS2 CHADS2 CHADS2

CHADS2 1 CHADS2 1
=0 1 2 2
Triple anti- Triple anti-

OAC* aspirin + aspirin +
Aspirin thrombotic thrombotic
monotherapy clopidogrel clopidogrel
Rx Rx
* Warfarin is preferred over dabigatran for patients at high risk of coronary events

We suggest that patients with AF/AFL who Conditional
have stable CAD should receive Recommendation
antithrombotic therapy selected based upon Moderate Quality
their risk of stroke (aspirin for CHADS2 = 0 and Evidence
OAC for CHADS2 1). Warfarin is preferred
over dabigatran for those at high risk of
coronary events.
We suggest that patients with AF/AFL who Conditional

have experienced ACS or who have undergone Recommendation
PCI, should receive antithrombotic therapy Low Quality
selected based on a balanced assessment of Evidence
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.

Cardioversion AF 48 hr
We recommend that hemodynamically stable Strong
patients with AF/AFL of 48 hours or Recommendation
uncertain duration for whom electrical or Moderate Quality
pharmacological cardioversion is planned Evidence
should receive therapeutic OAC therapy
(warfarin [INR 2-3] or dabigatran) for 3 weeks
before and at least 4 weeks post
cardioversion
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.

Cardioversion AF < 48 hr
We recommend that hemodynamically stable Strong
patients with AF/AFL of known duration < 48 Recommendation
hours may undergo cardioversion without Moderate Quality
prior or subsequent anticoagulation. However, Evidence
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.
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
(CHADS2) score and in selected cases expert consultation may be required.

Hemodynamically Unstable
Patients
We suggest if Emergency Cardioversion
the AF/AFL is of known duration < 48 Conditional
hr, the patient may undergo cardioversion without Recommendation
prior anticoagulation. If the patient is at high risk of Moderate Quality
stroke (e.g. mechanical valve, rheumatic heart Evidence
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.

Cardioversion
(TEE-Guided)
We suggest that hemodynamically stable Conditional

patients with AF/AFL of duration 48 hr or Recommendation
unknown, may undergo cardioversion guided High Quality
by TEE (following the protocol from the Evidence
ACUTE trial as detailed in the text).

Patient with AF undergoing Surgical or
Diagnostic Procedure with Major Bleeding Risk
Very low to Moderate Stroke

High Stroke Risk**
Risk*
Low Bleeding High Bleeding Low Bleeding High Bleeding

Risk Risk Risk Risk
Stop antithrombotic Continue OAC or

Continue Stop OAC and
pre-procedure stop OAC and
antithrombotic bridge
Re-institure when bridge with UFH or
(INR < 3 if with UFH or LMWH
risk of bleeding LMWH
warfarin) perioperatively
reduced perioperatively
* CHADS2 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

Antithrombotic Therapy Peri-Procedure
If there is a very low to moderate risk of stroke (CHADS 2 2), the Conditional
patient should have their antithrombotic agent discontinued before Recommendation
the procedure (aspirin or clopidogrel for 7-10 days, warfarin for 5 Low Quality Evidence
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.
If there is a particularly high risk of stroke (e.g. mechanical valve, Conditional

recent stroke or TIA, rheumatic valve disease, CHADS 2 3) or of Recommendation
other thromboembolism (e.g. Fontan procedure): Low Quality Evidence
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.

Guidelines 2010:
Prevention and treatment of
atrial fibrillation following
cardiac surgery
L. Brent Mitchell MD
Post Operative AF (POAF)
COMPLICATIONS RATES no POAF versus POAF
10 9.3
8
6.4
6 5.3 5.5
% 4.7
3.6
4.0 4.1
4 3.4 3.0
1.9 1.7
2
0
CVA CHF MI PPM VT/VF MORT
Steinberg ed. Atrial Fibrillation after Cardiac Surgery pp37-50, 2000

POAF Prevention
TREATMENTS WITH GOOD EVIDENCE OF EFFICACY
THERAPY N n RR (95% CI)
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)
0.2 0.4 0.6 0.8 1.0 1.2 1.4 1.6

Relative Risk
Burgess DC et al. Eur Heart J 27:2846-57, 2006

POAF Prevention
COMPARISONS OF TREATMENT EFFICACIES
THERAPY N n RR (95% CI)
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)
0.2 0.4 0.6 0.8 1.0 1.2 1.4 1.6

Relative Risk
Mitchell LB et al. Can J Cardiol 21:45B-50B, 2005

POAF Prevention
We recommend that patients who have been Strong
receiving a beta-blocker before cardiac surgery Recommendation
have that therapy continued through the High Quality
operative procedure in the absence of the Evidence
development of a new contraindication.
We suggest that patients who have not been Conditional
receiving a beta-blocker before cardiac surgery Recommendation
have beta-blocker therapy initiated just before Low Quality
or immediately after the operative procedure in Evidence
the absence of a contraindication.
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.

POAF Prevention
We recommend that patients who have a Strong
contra-indication to beta-blocker therapy Recommendation
before or after cardiac surgery be considered High Quality
for prophylactic therapy with amiodarone to Evidence
prevent postoperative AF.
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.

POAF Prevention
We suggest that patients who have a contra- Conditional
indication to beta-blocker therapy and to Recommendation
amiodarone therapy before or after cardiac Low to Moderate
surgery be considered for prophylactic Quality Evidence
therapy to prevent postoperative AF with IV
magnesium or with biatrial pacing.
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.

POAF Prevention
We suggest that patients at high risk of Conditional
postoperative AF be considered for Recommendation
prophylactic therapy to prevent Low to Moderate
postoperative AF with sotalol or combination Quality Evidence
therapy including two or more of a beta-
blocker, amiodarone, IV magnesium, or
biatrial pacing.
Values and Preferences: This recommendation recognizes that data

confirming the superiority of combinations of prophylactic therapies is
sparse.

Comparison - Prevention
CCS ESC
Guidelines Guidelines
Stren LOE Class LOE
gth
BB continued if on Strong High I A
BB started if not on Cond Low I A
Amio if BB
Strong High IIa A
contraindicated
Sotalol may be
Cond Mod IIb A
considered
Bi-A Pace may be
Cond Low IIb A
considered
IV Mag may be
Cond Low -- --
considered
Corticosteriods
--
Atrial Fibrillation -- IIb
Guidelines B
considered
POAF - Treatment
RCT of Rate- vs Rhythm-Control Treatment of PAOF (N=50)
1.00 96%
91%
9.0 0.7 days
0.80 13.2 2.0 days
Pts in hospital
0.60 p = 0.05
0.40
rhythm rate
0.20
p = 0.27
0.00
0 5 10 15 20 25 30 35 rhythm rate
Days Post-Op NSR at 8 weeks
Lee JK et al. Am Heart J 2000;140:9:871-7.

POAF - Treatment
We suggest that consideration be given to Conditional
anticoagulation therapy if post-operative Recommendation
continuous atrial fibrillation persists for more Low Quality
than 72 hours. This consideration will include Evidence
individualized assessment of the risks of a
thromboembolic event and the risk of post-
operative bleeding.
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.

POAF - Treatment
We recommend that temporary epicardial Strong
pacing electrode wires be placed at the time Recommendation
of cardiac surgery to allow backup Low Quality
ventricular pacing as necessary. Evidence
We recommend that post operative AF with a Strong
rapid ventricular response be treated with a Recommendation
beta-blocker, a non-dihydropyridine calcium High Quality
antagonist, or amiodarone to establish Evidence
ventricular rate control. The specific agent
chosen will be individualized for each patient
but a beta-blocker is usually preferred.
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.

POAF - Treatment
We suggest that post operative AF may be Conditional
appropriately treated with either a ventricular Recommendation
response rate-control strategy or a rhythm- Low Quality
control strategy. Evidence
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.

POAF - Treatment
We recommend that, when anticoagulation Strong
therapy, rate-control therapy and/or rhythm- Recommendation
control therapy has been prescribed for post- Moderate Quality
operative AF, formal reconsideration of the Evidence
ongoing need for such therapy should be
undertaken six to twelve weeks later.
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 ESC
Guidelines Guidelines
Stren LOE Class LOE
gth
epicardial V-Pace -- --
Strong Low
wires at OR
Rate control with BB, agree
I in
B text
Strong High
CA, dig
Rate control in that
Strong High
order
AF control AAD
Cond Low IIa C
considered
anticoag considered IIa A (48
Cond Low
at 72hr (48hr) hr)
consider DC Rx at 6-
AtrialStrong
FibrillationMod
Guidelines-- --
12 weeks
Patient for CV Surgery Assess AF Risk Factors?
Low Risk High Risk
On Beta-Blocker? On Beta-Blocker?
No Yes No Yes
Beta-Blocker Continue BB Beta-Blocker Sotalol or

Contraindicated? Contraindicated? Amiodarone or
BB and another
No Yes No Yes
Beta-Blocker Amiodarone Sotalol or Amiodarone

Contraindicated? Amiodarone or Contraindicated?
BB and another
No Yes No Yes
Amiodarone IV Magnesium or Amiodarone IV Magnesium and

Biatrial Pacing Biatrial Pacing

Guidelines 2010:
Surgical Therapy
Pierre Pag MD
Surgical Treatment of AF
We recommend that a surgical AF ablation Strong
procedure be undertaken in association with Recommendation
mitral valve surgery in patients with AF when Moderate Quality
there is a strong desire to maintain sinus Evidence
rhythm, the likelihood of success of the
procedure is deemed to be high, and the
additional risk is low.
Values and Preferences: This recommendation recognizes

that individual institutional experience and patient considerations best
determine for whom the surgical procedure is performed.

We recommend that patients with Strong
asymptomatic lone AF, in whom AF is not Recommendation
expected to affect cardiac outcome, should Low Quality
not be considered for surgical therapy for AF. 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.

In patients with AF who are undergoing aortic Conditional
valve surgery or coronary artery bypass Recommendation
surgery, we suggest that a surgical AF Low Quality
ablation procedure be undertaken when there Evidence
is a strong desire to maintain sinus rhythm,
the success of the procedure is deemed to be
high, and the additional risk low .
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.

We recommend that closure (excision or Strong
obliteration) of the left atrial appendage be Recommendation
undertaken as part of the surgical ablation of Low Quality
AF associated with mitral valve surgery. Evidence
We suggest that closure of the left atrial Conditional
appendage be undertaken as part of the Recommendation
surgical ablation of persistent AF in patients Low Quality
undergoing aortic valve surgery or coronary Evidence
artery bypass surgery if this does not
increase the risk of the surgery.
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 oral anticoagulant Strong
therapy be continued following surgical AF Recommendation
ablation in patients with a CHADS2 score 2. Moderate Quality
Evidence
We suggest that oral anticoagulant therapy Conditional
be continued following surgical AF ablation in Recommendation
patients who have undergone mechanical or Low Quality
bioprosthetic mitral valve replacement. 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.

Cox MAZE III Ablation Pattern

Recommended Type-specific
Surgical Strategies*
Cardiac status or Persistent, mixed or
type of AF Paroxysmal continuous
Lone AF PVI PVI +
Bi-atrial full Cox MAZE

Mitral Valve surgery PVI +
or PVI +
Aortic valve / CABG
PVI PVI +
surgery
PVI + is PVI plus connecting lesions to LAA and mitral valve

* All procedures must include exclusion or resection of the left atrial appendage

Afib Slides 2011 Unrestricted

Hochgeladen von

Dokumentinformationen

Originaltitel

Copyright

Verfügbare Formate

Dieses Dokument teilen

Dokument teilen oder einbetten

Freigabeoptionen

Stufen Sie dieses Dokument als nützlich ein?

Sind diese Inhalte unangemessen?

Copyright:

Verfügbare Formate

Afib Slides 2011 Unrestricted

Hochgeladen von

Copyright:

Verfügbare Formate

Canadian Cardiovascular Society

2010 Atrial Fibrillation Guidelines

Atrial Fibrillation Guidelines

Atrial Fibrillation Guidelines

With special acknowledgement of

Atrial Fibrillation Guidelines

1. Four Categories of Quality of Evidence:

2. Strength of Recommendations: 2 Grades

Atrial Fibrillation Guidelines

Further research likely to have an important impact on confidence in

Further research very likely to have a significant impact in the estimate of

The estimate of effect is very uncertain; e.g. case studies; consensus

Modified with permission from: Guyatt GH, et al. BMJ 2008;336:926

Atrial Fibrillation Guidelines

Values and The greater the variation or uncertainty in values and

Modified with permission from: Guyatt GH, et al. BMJ 2008;336:926

Atrial Fibrillation Guidelines

Atrial Fibrillation Guidelines

Identify potentially heritable causes of AF (particularly in lone AF)

Atrial Fibrillation Guidelines

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

Atrial Fibrillation Guidelines

Identify risk factors for complications of therapy for AF

Atrial Fibrillation Guidelines

Assess ventricular size / LV wall thickness / function

Evaluate left atrial size (if possible, left atrial volume)

Exclude significant valvular or congenital heart

Atrial Fibrillation Guidelines

Other ancillary tests should be considered Strong

Atrial Fibrillation Guidelines

Aggressive treatment of hypertension may prevent

Atrial Fibrillation Guidelines

1 Minimal effect on QOL

2 Minor effect of QOL

3 Moderate effect on QOL

4 Severe effect on QOL

Atrial Fibrillation Guidelines

Values and Preferences: These recommendations

Atrial Fibrillation Guidelines

CCS SAF 0 Asymptomatic EHRA I No symptoms

Atrial Fibrillation Guidelines

ASA Rate Rhythm

No antithrombotic therapy may be appropriate in

Atrial Fibrillation Guidelines

Atrial Fibrillation Guidelines

We recommend that the goals of rhythm control Strong

Values and Preferences

Atrial Fibrillation Guidelines

Atrial Fibrillation Guidelines

Atrial Fibrillation Guidelines

Atrial Fibrillation Guidelines

RACE II suggested that strict rate control

Atrial Fibrillation Guidelines

Values and Preferences

Atrial Fibrillation Guidelines

No Heart CAD Heart Failure

-blocker -blocker* -blocker

Atrial Fibrillation Guidelines

Atrial Fibrillation Guidelines