Abstract
Résumé
I. Stroke Prevention Principles
January CT, Wann LS, Alpert JS, et al. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: executive summary: a report of the American College of Cardiology/American Heart Association task force on practice guidelines and the Heart Rhythm Society. Circulation 2014 Apr 10. [Epub ahead of print]

- 1.We recommend that all patients with AF or atrial flutter (AFL), whether paroxysmal or persistent, should be stratified using a predictive index for stroke risk (for example, the “CCS algorithm” based on the CHADS2 model) (Strong Recommendation, High-Quality Evidence).
- 2.We recommend that OAC therapy be prescribed for most patients aged ≥ 65 years or CHADS2 score ≥ 1 (the “CCS algorithm”; Fig. 1) (Strong Recommendation, Moderate-Quality Evidence).
- 3.We suggest that ASA (81 mg/d) be prescribed for patients with none of the risks outlined in the “CCS algorithm” (age < 65 years and no CHADS2 risk factors) who have arterial disease (coronary, aortic, or peripheral) (Conditional Recommendation, Moderate-Quality Evidence).
- 4.We suggest no antithrombotic therapy for patients with none of the risks outlined in the “CCS algorithm” (age < 65 and no CHADS2 risk factors) and free of arterial vascular disease (coronary, aortic, peripheral) (Conditional Recommendation, Low-Quality Evidence).
FDA Drug Safety Communication: FDA study of Medicare patients finds risks lower for stroke and death but higher for gastrointestinal bleeding with Pradaxa (dabigatran) compared to warfarin. Available at: http://www.fda.gov/Drugs/DrugSafety/ucm396470.htm. Accessed May 13, 2014.
FDA Drug Safety Communication: FDA study of Medicare patients finds risks lower for stroke and death but higher for gastrointestinal bleeding with Pradaxa (dabigatran) compared to warfarin. Available at: http://www.fda.gov/Drugs/DrugSafety/ucm396470.htm. Accessed May 13, 2014.
II. Patients With Chronic Kidney Disease
- Piccini J.P.
- Stevens S.R.
- Chang Y.
- et al.
III. Detection of AF in Patients With Stroke
- 8.For patients being investigated for an acute embolic ischemic stroke or TIA, we recommend at least 24 hours of ECG monitoring to identify paroxysmal AF in potential candidates for OAC therapy (Strong Recommendation, Moderate-Quality Evidence).
- 9.For selected older patients with an acute, nonlacunar, embolic stroke of undetermined source for which AF is suspected but unproven, we suggest additional ambulatory monitoring (beyond 24 hours) for AF detection, where available, if it is likely that OAC therapy would be prescribed if prolonged AF is detected (there are currently insufficient data to indicate what the minimum AF duration should be for OAC to be instituted, and expert opinion varies widely) (Conditional Recommendation, Moderate-Quality Evidence).
IV. Investigation and Management of SCAF
- 10.We suggest that it is reasonable to prescribe OAC therapy for patients with age ≥ 65 years or CHADS2 score ≥ 1 (“CCS algorithm”) who have episodes of SCAF lasting > 24 hours, or for shorter episodes in high-risk patients (such as those with a recent cryptogenic stroke) (Conditional Recommendation, Low-Quality Evidence).
V. Left Atrial Appendage Closure in Stroke Prevention
- Reddy V.Y.
- Doshi S.K.
- Sievert H.
- et al.
- 11.We suggest these nonapproved LAA closure devices not be used, except in research protocols or in systematically documented use protocols in patients at high risk of stroke (CHADS2 score ≥ 2) for whom antithrombotic therapy is precluded (Conditional Recommendation, Low-Quality Evidence).
VI. Emergency Department Management
- 12.For patients with no high-risk factors for stroke (recent stroke or TIA within 6 months; rheumatic heart disease; mechanical valve) and clear AF onset within 48 hours or therapeutic OAC therapy for ≥ 3 weeks, we recommend that they may undergo cardioversion in the ED without immediate initiation of anticoagulation. After attempted or successful cardioversion, antithrombotic therapy should be initiated as per the CCS algorithm (Strong Recommendation, Moderate-Quality Evidence).

- 13.For patients at high risk of stroke with cardioversion (not receiving therapeutic OAC therapy for ≥ 3 weeks with any of the following: AF episode duration not clearly < 48 hours, stroke or TIA within 6 months, rheumatic heart disease, mechanical valve), we recommend optimized rate control and therapeutic OAC for 3 weeks before and at least 4 weeks after cardioversion (Strong Recommendation, Moderate-Quality Evidence).
- 14.We suggest that patients at high risk of stroke (not receiving therapeutic OAC therapy for ≥ 3 weeks with any of the following: AF episode duration not clearly < 48 hours, stroke or TIA within 6 months, rheumatic heart disease, mechanical valve) may undergo cardioversion guided by transesophageal echocardiography with immediate initiation of intravenous or low molecular weight heparin (LMWH) before cardioversion followed by therapeutic OAC for at least 4 weeks after cardioversion (Conditional Recommendation, Moderate-Quality Evidence).
- 15.For patients whose recent-onset AF/AFL is the direct cause of instability with hypotension, acute coronary syndrome, or florid pulmonary edema, we recommend that immediate electrical cardioversion be considered with immediate initiation of intravenous or LMWH before cardioversion followed by therapeutic OAC for 4 weeks afterward (unless AF onset was clearly within 48 hours or the patient has received therapeutic OAC for ≥ 3 weeks) followed by therapeutic OAC for at least 4 weeks after cardioversion (Strong Recommendation, Low-Quality Evidence).
VII. Periprocedural Anticoagulation Management
Thrombosis Canada. Peri-operative management of patients who are receiving warfarin. Available at: http://www.thrombosiscanada.ca/guides/pdfs/Warfarin_perioperative_management.pdf. Accessed May 13, 2014.
High risk |
Neurosurgery (intracranial or spinal surgery) |
Cardiac surgery (coronary artery bypass or heart valve replacement) |
Major vascular surgery (abdominal aortic aneurysm repair, aortofemoral bypass) |
Major urologic surgery (prostatectomy, bladder tumour resection) |
Major lower limb orthopaedic surgery (hip/knee joint replacement surgery) |
Lung resection surgery |
Intestinal anastomosis surgery |
Selected invasive procedures (kidney biopsy, prostate biopsy, cervical cone biopsy, pericardiocentesis, colonic polypectomy or biopsies) |
Intermediate risk |
Other intra-abdominal surgery |
Other intrathoracic surgery |
Other orthopaedic surgery |
Other vascular surgery |
Low risk |
Laparoscopic cholecystectomy |
Laparoscopic inguinal hernia repair |
Dental procedures |
Dermatologic procedures |
Ophthalmologic procedures |
Coronary angiography |
Gastroscopy or colonoscopy |
Selected invasive procedures (bone marrow aspirate and biopsy, lymph node biopsy, thoracentesis, paracentesis, arthrocentesis) |
Cardiac implantable device surgery (pacemaker or implantable defibrillator) |
Very low risk |
Dental extractions (1 or 2 teeth) or teeth cleaning |
Skin biopsy or skin cancer removal |
Cataract removal |
Thrombosis Canada. Peri-operative management of patients who are receiving warfarin. Available at: http://www.thrombosiscanada.ca/guides/pdfs/Warfarin_perioperative_management.pdf. Accessed May 13, 2014.
- 16.We recommend that in a patient with AF/AFL, a decision to interrupt antithrombotic therapy for an invasive procedure must balance the risks of a thromboembolic event (as indicated by a higher CHADS2 score, mechanical heart valve, or rheumatic heart disease) with those of a bleeding event (as indicated by a higher HASBLED score and procedures with higher bleeding risks) (Strong Recommendation, Low-Quality Evidence).
- 17.We suggest that interruption of anticoagulant therapy in a patient with AF/AFL is not necessary for most procedures with a very low risk of bleeding, including cardiac device implantation (pacemaker or implantable defibrillator; Table 1) (Conditional Recommendation, Low-Quality Evidence; High-Quality Evidence for cardiac device implantation).
- 18.We recommend that interruption of anticoagulant therapy in a patient with AF or AFL will be necessary for most procedures with an intermediate or high risk of major bleeding (Table 1) (Strong Recommendation, Low-Quality Evidence).
PERIOP 2-A Safety and Effectiveness Study of LMWH Bridging Therapy Versus Placebo Bridging Therapy for Patients on Long Term Warfarin and Require Temporary Interruption of Their Warfarin. Available at: http://clinicaltrials.gov/show/NCT00432796. Accessed June 30, 2014.
Effectiveness of Bridging Anticoagulation for Surgery (The BRIDGE Study). Available at: http://clinicaltrials.gov/show/NCT00786474. Accessed June 30, 2014.
Eliquis product monograph, l3 version 1.1. Available at: http://www.pfizer.ca/en/our_products/products/monograph/313. Accessed June 30, 2014.
Pradax product monograph. Available at: http://www.boehringer-ingelheim.ca/content/dam/internet/opu/ca_EN/documents/humanhealth/product_monograph/PradaxaPMEN.pdf. Accessed June 30, 2014.
- 19.When a decision to interrupt aspirin or clopidogrel therapy for an invasive procedure has been made for a patient with AF/AFL, we suggest that interruption begin 5-7 days before the procedure, except for procedures with a very high risk of bleeding, in which case we suggest interruption 7-10 days before the procedure (Conditional Recommendation, Low-Quality Evidence).
- 20.When a decision to interrupt warfarin therapy for an invasive procedure has been made for a patient with AF/AFL, we suggest that interruption begin 5 days before the procedure. A procedure with low bleeding risk may proceed when the INR is < 1.5 and a procedure with an intermediate or high bleeding risk may proceed when the INR is < 1.2 (Conditional Recommendation, Low-Quality Evidence).
- 21.When a decision to interrupt warfarin therapy for an invasive procedure has been made for a patient with AF/AFL, we suggest that bridging therapy with LMWH or UFH be instituted when the INR is below that patient's therapeutic INR target in a patient at high risk of thromboembolic events (CHADS2 score ≥ 3, mechanical heart valve, stroke or TIA within 3 months, rheumatic heart disease) (Conditional Recommendation, Low-Quality Evidence).
- 22.When a decision to interrupt apixaban or rivaroxaban therapy for an invasive procedure has been made for a patient with AF/AFL, we suggest that interruption begin 1-2 days before a procedure with low risk of major bleeding and 2-3 days before a procedure with an intermediate or high risk of major bleeding (Conditional Recommendation, Low-Quality Evidence).
- 23.When a decision to interrupt dabigatran therapy for an invasive procedure has been made for a patient with AF/AFL, we suggest that interruption begin 1-2 days before a procedure with low risk of major bleeding and 2-3 days before a procedure with an intermediate or high risk of major bleeding when eGFR is ≥ 80 mL/min/1.73 m2 (Conditional Recommendation, Low-Quality Evidence). The upper end of these ranges should be used if eGFR is 50-80 mL/min/1.73 m2, an additional day should be added when eGFR is 30-50 mL/min/1.73 m2, and in case eGFR is < 30 mL/min/1.73 m2, yet 1 more day of dabigatran withdrawal should be added (Conditional Recommendation, Low-Quality Evidence).
- 24.We recommend that when LMWH or UFH bridging is used for an invasive procedure, the therapy should be started before the procedure when the INR is < 2.0 and be stopped 24 hours before the procedure for LMWH and 4-6 hours befolre the procedure for UFH (Strong recommendation, Low-Quality Evidence).
- 25.When LMWH or UFH bridging is used for an invasive procedure, we suggest that such therapy be restarted after the procedure when hemostasis is established (usually 24 hours for a procedure with a low risk of bleeding and 48-72 hours for a procedure with an intermediate or high risk of bleeding) in prophylactic dosages for the first 24-72 hours and then increased to therapeutic dosages. Bridging is then continued until an OAC is therapeutic (Conditional Recommendation, Low-Quality Evidence).
- 26.When warfarin, ASA, or clopidogrel therapy has been interrupted for an invasive procedure, we suggest that such therapy be restarted after the procedure when hemostasis is established (usually 24-48 hours for a procedure with a low risk of bleeding and 48-72 hours for a procedure with an intermediate or high risk of bleeding) (Conditional Recommendation, Low-Quality Evidence).
- 27.When apixaban, dabigatran, or rivaroxaban have been withdrawn for an invasive procedure we suggest that such therapy be restarted after the procedure 1 day after hemostasis is established (usually 48 hours for a procedure with low risk of bleeding and 72 hours for a procedure with an intermediate or high risk of bleeding) (Conditional Recommendation, Low-Quality Evidence).
VIII. Rate and Rhythm Control
Target for rate control
Use of digoxin for rate control
Algorithm for choice of rate vs rhythm control for AF

IX. Catheter Ablation for AF
AF ablation as first-line therapy
Long-standing | Persistent | Paroxysmal | |
---|---|---|---|
First line | — | — | + |
Failed first drug | — | + | ++ |
Failed second drug | + | ++ | +++ |
Failed multiple drugs | ++ | +++ | +++ |
Alternate energy sources for catheter ablation
- Gaita F.
- Leclercq J.F.
- Schumacher B.
- et al.
- Verma A.
- Debruyne P.
- Nardi S.
- et al.
Complications of catheter ablation
Long-term efficacy of catheter ablation
Antithrombotic therapy in relation to catheter ablation
- 28.We recommend catheter ablation of AF in patients who remain symptomatic after an adequate trial of AAD therapy and in whom a rhythm control strategy remains desired (Strong Recommendation, Moderate-Quality Evidence).
- 29.We suggest catheter ablation to maintain sinus rhythm as first-line therapy for relief of symptoms in highly selected patients with symptomatic, paroxysmal AF (Conditional Recommendation, Moderate-Quality Evidence).
- 30.We suggest that catheter ablation of AF should be performed by electrophysiologists with a high degree of expertise and high annual procedural volumes (Conditional Recommendation, Low-Quality Evidence).
Acknowledgements
Supplementary Material
- Supplemental Data
References
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The disclosure information of the authors and reviewers is available from the CCS on their guidelines library at www.ccs.ca.
This statement was developed following a thorough consideration of medical literature and the best available evidence and clinical experience. It represents the consensus of a Canadian panel comprised of multidisciplinary experts on this topic with a mandate to formulate disease-specific recommendations. These recommendations are aimed to provide a reasonable and practical approach to care for specialists and allied health professionals obliged with the duty of bestowing optimal care to patients and families, and can be subject to change as scientific knowledge and technology advance and as practice patterns evolve. The statement is not intended to be a substitute for physicians using their individual judgment in managing clinical care in consultation with the patient, with appropriate regard to all the individual circumstances of the patient, diagnostic and treatment options available and available resources. Adherence to these recommendations will not necessarily produce successful outcomes in every case.
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- ErratumCanadian Journal of CardiologyVol. 30Issue 12
- PreviewIn the article, “2014 Focused Update of the Canadian Cardiovascular Society Guidelines for the Management of Atrial Fibrillation” by Verma et al, published in the October issue (Can J Cardiol 2014;30:1114-30), there is an error in the affiliations. The affiliation for Ian G. Stiell, MD, should be listed as Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada.
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- ErratumCanadian Journal of CardiologyVol. 31Issue 10
- PreviewIn the article “2014 Focused Update of the Canadian Cardiovascular Society Guidelines for the Management of Atrial Fibrillation” by Verma et al., published in the October 2014 issue of the Canadian Journal of Cardiology (Can J Cardiol 2014;30:1114-30), the authors wish to correct unfortunate errors that crept into the text:
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