Afib Slides 2011 Unrestricted

7/28/2019 Afib Slides 2011 Unrestricted

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Canadian Cardiovascular Society

2010 Atrial Fibrillation Guidelines


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Atrial Fibrillation Guidelines

Anne Gillis (co chair)

Allan Skanes (co chair)

John Cairns

Stuart Connolly

Jafna Cox

Paul Dorian

Jeff Healey

Laurent Macle

Sean McMurtry

Brent Mitchell

Stanley Nattel

Pierre Pag

Ratika Parkash

P. Timothy Pollak

Michael Stephenson

Ian Stiell

Mario Talajic

Teresa Tsang

Atul Verma

CCS AF Guidelines 2010

Primary Panel


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Malcolm Arnold

David Bewick

Vidal Essebag

Milan Gupta Brett Heilbron

Charles Kerr

Bob Kiaii

Jan Surkes

George Wyse

CCS AF Guidelines 2010

Secondary Panel


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Canadian Cardiovascular Society Atrial

Fibrillation Guidelines 2010:

Implementing GRADE and AchievingConsensus

Anne M Gillis MD

Allan C Skanes MD

With special acknowledgement of

Jan Brozek MD, PhD


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A New Approach to GuidelineDevelopment & Evaluation

Grading of Recommendations, Assessment,

Development and Evaluation

GRADE


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GRADE ApproachClear 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


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Quality Comments

HighFuture research unlikely to change confidence in estimate of effect; e.g.

multiple well designed, well conducted clinical trails.

Moderate

Further research likely to have an important impact on confidence in

estimate of effect and may change the estimate e.g. limited clinical trials,

inconsistency of results or study limitations.

Low

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

studies or cohort observations.

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

opinion.

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

GRADE: Rating Quality of Evidence


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Factor Comment

Quality of Evidence The higher the quality of evidence the greater the probability

that a strong recommendation is indicated.

e.g. strongrecommendation that patients with AF at moderate to high risk

of stroke be treated with oral anticoagulants.

Difference between

desirable and

undesirable effects

The greater the difference between desirable and undesirable

effects the greater the probability that a strong recommendation

is indicated e.g. strong recommendation that patients with AF

48 hr duration receive oral anticoagulation therapy for at least 3weeks prior to planned cardioversion and 4 weeks following.

Values and

Preferences

The greater the variation or uncertainty in values and

preferences, the higher the probability that a conditional

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.

Factors Determining the Strength of the Recommendation

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


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Jeff S Healey MD

Ratika Parkash MD

P Timothy Pollak MD

Teresa SM Tsang MD

Paul Dorian MD


Atrial Fibrillation Guidelines 2010:

Etiology and Investigation


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Establish Pattern of Atrial Fibrillation

Paroxysmal Persistent

Permanent

Newly Diagnosed AF

Modified with permission from Fuster et al Circulation 2006;114:e257-354.


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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


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12-Lead Electrocardiogram

Document presence of AFAssess 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


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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


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All patients with AF should have a complete

history and physical examination,

electrocardiogram, echocardiogram, basic

laboratory investigations. Details are

highlighted in Table 1.

Strong

Recommendation

Low Quality

Evidence

Other ancillary tests should be considered

under specific circumstances. Details

included in Table 2.

Strong

Recommendation

Low QualityEvidence

Recommendations

Etiology and Investigations


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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+ channelblockers vs inhibitors of renin angiotensin system.

Identify and treat obstructive sleep apnea


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CCS

SAF ScoreImpact on QOL

0 Asymptomatic

1 Minimal effect on QOL

2 Minor effect of QOL

3 Moderate effect on QOL4 Severe effect on QOL

Establish AF SeverityUse to Guide Therapeutic Approach

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


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We recommend that the assessment ofpatient well being, symptoms, and quality

of life (QOL) be part of the evaluation of

every patient with AF.

Strong

Recommendation

Low Quality of

Evidence

We suggest that QOL of the AF patient can

be assessed in routine care using theCCSSAF scale.

ConditionalRecommendation

Low Quality of

Evidence

Recommendations

Quality of Life

Values and Preferences: These recommendationsrecognize that improvement in QOL is a high priority for

therapeutic decision making.


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CCS SAF Score Impact EHRA Class Impact

CCS SAF 0 Asymptomatic EHRA I No symptoms

CCS SAF 1Minimal effect

on QOLEHRA II Mild symptoms

CCS SAF 2

Modest effect

on QOL EHRA III

Severe

symptoms;

daily activityaffected

CCS SAF 3Moderate effect

on QOL

EHRA IV

Disabling

symptoms;

Normal daily

activitydiscontinued

CCS SAF 4Severe effect

on QOL


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Atrial Fibrillation Guidelines 2010:

AF/AFL Rhythm Management

Anne M Gillis MD

Atul Verma MD

Mario Talajic MDStanley Nattel MD

Paul Dorian MD

O i f AF M t


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Management of

Arrhythmia

Rate

Control

Rhythm

Control

Overview of AF Management

AF DetectedDetection and

Treatment of

Precipitating Causes

No antithrombotic therapy may be appropriate in

selected young patients with no stroke risk factors

ASA

OAC

Assessment of

ThromboembolicRisk (CHADS2)


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We recommend that the goals of ventricular ratecontrol should be to improve symptoms and

clinical outcomes which are attributable to

excessive ventricular rates

StrongRecommendation

Low Quality

Evidence

We recommend that the goals of rhythm control

therapy should be to improve patient symptomsand clinical outcomes, and that these do not

necessarily imply the elimination of all AF

Strong

RecommendationModerate Quality

Evidence

Recommendations Rx Goals

Values and Preferenc esThese 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.


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Referral for Specialty Care

Most patients with AF/AFL should be considered for referral toa 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 radiofrequencyablation.

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 managementalternatives.


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Rate or Rhythm Control?

How do you decide if you are going topursue 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


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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

Heart Failure

Congestive Heart Failure clearly

exacerbated by AF

Previous Antiarrhythmic

Drug Failure

No Previous Antiarrhythmic

Drug Failure

Factors Influencing Decision

of Rate vs Rhythm Control


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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


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We recommend that ventricular rate be

assessed at rest in all patients with persistentand permanent AF/AFL.

Strong

Recommendation

Moderate QualityEvidence

We recommend that heart rate during exercise

be assessed in patients with persistent or

permanent AF/AFL and associated exertional

symptoms.

Strong

Recommendation

Moderate Quality

Evidence

We recommend that treatment for rate control

of persistent/permanent AF/AFL should aim for

a resting heart rate of less than 100 beats per

minute.

Strong

Recommendation

High Quality

Evidence

Values and Preferenc es

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.

Ventricular Rate Control


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Rate Control Drug Choices

No Heart

Disease

Hypertension

CAD Heart Failure

-blocker

Diltiazem

Verapamil

Combination Rx

Digitalis

-blocker*

Diltiazem

Verapamil

-blocker

digitalis

*-blockers preferred in CADDigitalis may be considered as

monotherapy in sedentary individualsDronedarone


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We recommend -blockers or non-

dihydropyridine calcium channel blockers as

initial therapy for rate control of AF/AFL in most

patients without a past history of MI or LV

dysfunction.

Strong

Recommendation

Moderate Quality

Evidence

We suggest that digoxin not be used as initial

therapy for active patients and be reserved for

rate control in patients who are sedentary or

who have LV systolic dysfunction.

Conditional

Recommendation

Moderate Quality

Evidence

We suggest that digoxin be added to therapy

with beta-blockers or calcium channel blockers

in patients whose heart rate remains

uncontrolled.

Conditional

Recommendation

Moderate Quality

Evidence



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We suggest that dronedarone may be added for

additional rate control in patients withuncontrolled ventricular rates despite therapy

with -blockers, calcium channel blockers

and/or digoxin.

Conditional


Evidence

We suggest that amiodarone for rate control

should be reserved for exceptional cases inwhich other means are not feasible or are

insufficient.

Conditional

RecommendationLow Quality

Evidence

Values and Preferences

These recommendations recognize that selection of rate control therapy needsto be individualized based on the presence or absence of underlying structural

heart disease, the activity level of the patient and other individual

considerations.



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RecommendationStrength /Class of

Recommendation

Level or

Quality of

Evidence

2010 CCS

Guidelines

We recommend that treatment for rate

control of persistent/permanent AF or

AFL should aim for a resting heart rate

< 100 bpm

Strong High

2010 ESC

Guidelines

Reasonable to initiate treatment with a

lenient rate control protocol aimed at

resting HR


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We recommend beta-blockers as initial therapy

for rate control of AF/AFL in patients with

myocardial infarction or left ventricular systolic

dysfunction

Strong

Recommendation

High Quality

Evidence


Previous MI or LV Systolic Dysfunction

Values and Preferenc es

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.


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We recommend AV junction ablation and

implantation of a permanent pacemaker in

symptomatic patients with uncontrolled

ventricular rates during AF despite maximallytolerated combination pharmacologic therapy

Strong

Recommendation

Moderate Quality

Evidence


AV Junction Ablation


This recommendation places a high value on the results of many small

randomized trials and one systematic review reporting significant improvementsin quality of life and functional capacity as well as a decrease in hospitalizations

for AF following AV junction ablation in highly symptomatic patients.


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Drug Dose Adverse Effects

verapamil *120 mg p.o. daily -

240 mg p.o. bid

bradycardia,

hypotension,

constipation

diltiazem *120-280 mg p.o.

daily - bid

bradycardia,

hypotension,

ankle swelling

digoxin

0.125 0.25 mg p.o.

daily

bradycardia,

nausea, vomiting,

visualdisturbances

Ca2+ Channel Blockers or Digoxin

for Rate Control

* Sustained release preparations are available


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We recommend use of maintenance oral

antiarrhythmic therapy as first-line therapy for patients

with recurrent AF in whom long-term rhythm control isdesired (see flow charts).

Strong

Recommendation

Moderate QualityEvidence

We recommend that oral antiarrhythmic drug therapy

should be avoided in patients with AF/AFL and

advanced sinus or AV nodal disease unless the patient

has a pacemaker/implantable defibrillator

Strong

Recommendation

Low Quality

Evidence

We recommend that an AV blocking agent should be

used in patients with AF/AFL being treated with a class

I antiarrhythmic drug (e.g. propafenone or flecainide)

in the absence of advanced AV node disease.

Strong

Recommendation

Low Quality

Evidence

Rhythm Control Recommendations

Values and p referencesThese recommendations place a high value on the decision of individual patients


outcomes with the potential greater adverse effects of Class I/III antiarrhythmic

drugs compared to rate control therapy.


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We recommend the optimal treatment of precipitating

or reversible predisposing conditions of AF prior to

attempts to restore/maintain sinus rhythm.

Strong

Recommendation

Low QualityEvidence

We recommend a rhythm control strategy for patients

with AF/AFL who remain symptomatic with rate

control therapy or in whom rate control therapy is

unlikely to control symptoms.

Strong

Recommendation

Moderate Quality

Evidence

We recommend that the goal of rhythm control

therapy should be improvement in patient symptoms

and clinical outcomes, and not necessarily the

elimination of all AF.

Strong

Recommendation

Moderate Quality

Evidence

Rhythm Control Strategy

Values and PreferencesThese recommendations place a high value on the decision of individual patients


outcomes with the potential greater adverse effects of the addition of Class I/III

antiarrhythmic drugs to rate control therapy.


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Antiarrhythmic Drug Choices

Normal Ventricular Function

Dronedarone

Flecainide*

Propafenone*

Sotalol

Amiodarone

Catheter Ablation

* Class I agents should be AVOIDED in CADThey should be combined with AV-nodal blocking agents

Sotalol contraindicated in women >65 yrs taking diuretics

Drugs listed in alphabetical order


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Antiarrhythmic Drug Choices

Abnormal Left Ventricular Function

EF > 35%

Amiodarone

Dronedarone

Sotalol*

Amiodarone

Catheter Ablation

* Sotalol should be used with caution with EF 35-40%

Contraindicated in women >65 yrs taking diuretics

EF 35%


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We recommend intermittent antiarrhythmicdrug therapy ("pill in pocket") in symptomatic

patients with infrequent, longer-lasting

episodes of AF/AFL as an alternative to daily

antiarrhythmic therapy.


Moderate Quality

Evidence

Values and p references

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.

Pill in the Pocket For Rhythm Control

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)


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Drug Efficacy Toxicity CommentsFlecainide

50-150 mg

BID

30-50% Ventricular tachycardia

Bradycardia

Rapid ventricular response

to AF or atrial flutter (1:1

conduction)

Contraindicated in patients

with CAD or LV dysfunction

Should be combined with an

AV nodal blocking agent

Propafenone

150-300 mg

TID

30-50% Ventricular tachycardia

Bradycardia

Rapid ventricular response

to AF or atrial flutter (1:1

conduction)

Abnormal taste

Contraindicated in patients

with CAD or LV dysfunction

Should be combined with an

AV nodal blocking agent

Class IC Drugs

Class III Efficacy Toxicity Comments


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Class III

Drug

Efficacy Toxicity Comments

Amiodarone

100- 200 mg OD

(after 10gmloading)

60-70% Photosensitivity

Bradycardia

GI upset

Thyroid dysfunction

Hepatic toxicityNeuropathy, tremor

Pulmonary toxicity

Torsades de pointes (rare)

Low risk of proarrhythmia

Limited by systemic side effects

Most side effects are dose & durationrelated

Dronedarone

400 mg BID

40% GI upset

BradycardiaOnly antiarrhythmic shown to reduce

hospitalizations and cardiovascularmortality

May increase mortality in patientswith recently decompensated heartfailure, EF 65 years takingdiuretics or those with renalinsufficiency

QT interval should be monitored 1week after starting

Use cautiously when EF


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Rhythm Control Does Not

Replace Anticoagulation Noevidence that AF reduction via antiarrhythmic

therapy reduces the risk of stroke/thromboembolism

Patients mustcontinue on appropriateanticoagulation according to their individual embolic

risk (CHADS2 score)


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We recommend electrical or pharmacologic

cardioversion for restoration of sinus rhythmin patients with AF/AFL selected for rhythm

control therapy who are unlikely to convert

spontaneously.

Strong


Evidence

We recommend pre-treatment with

antiarrhythmic drugs prior to electricalcardioversion in patients who have had AF

recurrence post-cardioversion without

antiarrhythmic drug pre-treatment.

Strong


Evidence

Values and p referencesThese 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.

Cardioversion for Rhythm Control


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We suggest that, in patients requiring pacing

for the treatment of symptomatic bradycardiasecondary to sinus node dysfunction, atrial

or dual chamber pacing be generally used for

the prevention of AF

Conditional

RecommendationHigh Quality

Evidence

We suggest that, in patients with intact AV

conduction, pacemakers be programmed tominimize ventricular pacing for prevention of

AF

Conditional


Evidence

Pacing for Rhythm Control

Values and p referencesThese 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.


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Danish

AAI vs VVI CTOPP

Extended

CTOPP MOST

Danish

AAI vs DDD

Number 225 2568 2568 2050 177

Age (yr) 71 17 73 10 73 10 74 (67-80) 74 9Pacing Indication SND All pacemaker

patients

All pacemaker

patients

SND SND

Follow-up (yr) 5.5 3.1 6.4 2.7 2.9

Pacing Modes AAI vs VVI AAI/R or DDD/R

vs VVI/R

AAI/R or DDD/R

vs VVI/R

DDDR vs VVIR AAI vs DDDR-s

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

Pacing Mode and AF


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Canadian Cardiovascular SocietyAtrial Fibrillation Guidelines 2010:Catheter Ablation of AtrialFibrillation and Flutter

Atul Verma MD

Jafna L Cox MD

Laurent Macle MD

Allan C Skanes MD


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Cappato R et al. Circ Arrhythm Electrophysiol. 2010;3:32-8

Type of Complication (n=14,218) No of Pts Rate%

Femoral pseudoaneurysm 152 0.93AV 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%

Worldwide AF Ablation (03-06)

R d ti Abl ti


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We recommend catheter ablation of AF in

patients who remain symptomatic

following adequate trials of anti-arrhythmic

drug therapy and in whom a rhythmcontrol strategy remains desired.

Strong Recommendation

Moderate Quality

Evidence

We suggest catheter ablation to maintain

sinus rhythm in select patients with

symptomatic AF and mild-moderate

structural heart disease who arerefractory or intolerant to at least one anti-

arrhythmic medication.

Conditional

Recommendation

Moderate Quality

Evidence

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

Low Quality Evidence

Values and Preferences:

These recommendat ions recogn ize that the balance of r isk with ablat ion and benef i t in sym ptom

rel ief and im prov ement in qu al i ty of l i fe mus t be ind ividual ized. They also recog nize that pat ients

may h ave relat ive or absolu te cardiac or n on-cardiac contra- indications to specif ic m edicat ions.

Recommendations Ablation


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We recommend curative catheter ablation for

symptomatic patients with typical atrial flutter asfirst line therapy or as a reasonable alternative to

pharmacologic rhythm or rate control therapy.

Strong


Evidence

In patients with evidence of ventricular pre-

excitation during AF, we recommend catheter

ablation of the accessory pathway, especially if AF

is associated with rapid ventricular rates, syncope,

or a pathway with a short refractory period.

Strong

Recommendation

Low Quality

Evidence

In young patients with lone, paroxysmal AF, we

suggest an electrophysiological study to exclude a

reentrant tachycardia as a cause of AF; if present,we suggest curative ablation of the tachycardia.

Conditional

Recommendation

Very LowQuality Evidence

Recommendations Ablation


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CCS Guidelines ESC Guidelines ACCF/AHA/HRS

StrengthLevel of

Evidence

ClassLevel of

Evidence

ClassLevel of

Evidence

Paroxysmal* Conditional ModerateIIa

(Conditional)A (High) I (Strong) A (High)

Persistent* Conditional ModerateIIa

(Conditional)

B

(Moderate)

IIa

(Conditional)A (High)

Failed 1 drug Conditional Moderate -- -- I (Strong) A (High)

Failed 2

drugsStrong Moderate -- -- -- --

1st Line Conditional LowIIb

(Conditional)

B

(Moderate)-- --

PAF / sign.

structural

heartdisease

-- -- -- --IIb

(Conditional)A (High)

* 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

Comparison of North American and European Guidelines


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Canadian Cardiovascular SocietyAtrial Fibrillation Guidelines 2010:Management of recent onset atrialfibrillation and atrial flutter in theemergency department

Ian G. Stiell, MD, MScLaurent Macle, MD


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We recommend for patients with acute

hemodynamic instability secondary to rapid

recent-onset AF/AFL, immediate electrical

conversion to sinus rhythm

Strong

Recommendation

Low Quality

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.

Hemodynamically Unstable Patients

with AF/AFL


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We recommend that electrical cardioversionmay be conducted in the ED with 150-200

joules biphasic waveform as the initial

energy setting.


Low Quality

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.

Electrical Cardioversion

In hemodynamically stable patients with AF/AFL of known duration


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We recommend that rate-slowing agents alone are

acceptable while awaiting spontaneous conversion

Strong

Recommendation

Moderate Quality

Evidence

We recommend that synchronized electrical

cardioversion or pharmacological cardioversion may be

used when a decision is made to cardiovert patients in

the emergency department. See Tables for drugrecommendations.

Strong

Recommendation

Moderate Quality

Evidence

We suggest that antiarrhythmic drugs may be used to

pre-treat patients before electrical cardioversion in ED in

order to decrease early recurrence of AF and to enhance

cardioversion efficacy

Conditional

Recommendation

Low Quality

Evidence

In hemodynamically stable patients with AF/AFL of known duration

< 48 h in whom a strategy of rhythm control has been selected:


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


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Duration > 48 h or unknown

or high-risk patients1

Therapeutic OAC

for 3 weeksbefore

cardioversion

Rate-

control

TEE-guided

cardioversion(OAC initiated with

heparin bridging)3

Antithrombotic therapy

-OAC continued for 4 consecutive weeks.-If AF/AFL persists or recurs or if AF/AFL has been

recurrent, antithrombotic therapy as appropriate (per

CHADS2 score) should be continued indefinitely.

-Early follow-up should be arrange to review ongoing

antithrombotic strategy.

1Patients at particularly high risk of stroke (e.g. mechanical valve, rheumatic heart disease, recent stroke/TIA)2

150-200J biphasic waveform preferred3Heparin must be initiated and continued until a therapeutic level of oral anticoagulation has been established.

Known duration < 48 h

(and not high-risk patients1)

Hemodynamically

stable

Pharmacologicalor electrical

cardioversion2

Hemodynamically

unstable

Urgent electricalcardioversion2

Failed CV

Successful CV

Antithrombotic therapy

-In general, no prior or subsequent anticoagulationis required.

-If AF/AFL persists or recurs or if AF/AFL has been

recurrent, antithrombotic therapy as appropriate

(CHADS2 score) should be initiated and continued

indefinitely.

-Early follow-up to review antithrombotic strategy.

R t C t l IV Th


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Drug Dose Risks

Diltiazem* 0.25 mg/kg IV bolus

over 10 min; repeat at

0.35 mg/kg IV

Hypertension,

bradycardia

Metoprolol 2.5-5mg IV bolus over

2 min; up to 3 doses

Hypotension,

bradycardia

Verapamil* 0.075-0.15mg/kg over 2

min

Hypotension,

bradycardia

Digoxin 0.25 mg IV each 2 h;

up to 1.5mg

Bradycardia,

Digitalis toxicity

Rate Control: IV Therapy

*Calcium-channel blockers should not be used in patients with heart failure or left

ventricular dysfunction


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We recommend urgent electrical cardioversion

if the patient is hemodynamically unstable

Strong


Evidence

We recommend Intravenous antiarrhythmic

agents procainamide or ibutilide in stable

patients

Strong

Recommendation

Low Quality

Evidence

We recommend that AV nodal blocking agents

(digoxin, calcium channel blockers, beta-

blockers, adenosine) are contra-indicated.

Strong

Recommendation

Low Quality

Evidence

Wolff Parkinson White Syndrome


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.


63/108

CCS Atrial Fibrillation Guidelines 2010:

Prevention of Stroke and Systemic

Thromboembolism inAtrial 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


64/108


We recommend that all patients with AF or

AFL (paroxysmal, persistent or permanent),

should be stratified using a predictive indexfor stroke (e.g. CHADS2) and for the risk of

bleeding (e.g. HAS-BLED), and that most

patients should receive antithrombotic

therapy.

Strong

Recommendation

High QualityEvidence

Risk Stratification

Stroke PreventionBleeding Risk


65/108


Patients

(n = 1733)

Adjusted Stroke

Rate (%/yr) 95% CI

CHADS2

Score

120 1.9 (1.2 to 3.0) 0

463 2.8 (2.0 to 3.8) 1

523 4.0 (3.1 to 5.1) 2

337 5.9 (4.6 to 7.3) 3

220 8.5 (6.3 to 11.1) 4

65 12.5 (8.2 to 17.5) 5

5 18.2 (10.5 to 27.4) 6

CHADS2

Risk Factor Score

Congestive Heart

Failure

1

Hypertension 1

Age 75 1

Diabetes Mellitus 1

Stroke/TIA/

Thromboembolism

2

Maximum Score 6

Predictive Index for Stroke


66/108


CHA2DS2-VASc

Risk Factor Score

Congestive Heart Failure 1

Hypertension 1

Age 75 2

Diabetes Mellitus 1

Stroke/TIA/Thrombo-

embolism

2

Vascular Disease 1

Age 65-74 1

Female 1

Maximum Score 9

Risk Factor Score

Congestive Heart Failure 1

Hypertension 1

Age 75 1

Diabetes Mellitus 1

Stroke/TIA/Thrombo-

embolism

2

Maximum Score 6

CHADS2


67/108


Patients (n =

7329)

Adjusted

Stroke

Rate (%/yr)

95% CI

TE Rate

assuming no

warfarin

CHA2DS

2VASc

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) 9.6 782 2.41 (0.53 to 6.88) 6.7 8

14 5.47 (0.91 to 27.0) 15.2 9

Bl di Ri k HAS BLED S


68/108


Letter Clinical Characteristic Points

H Hypertension 1

A Abnormal Liver or Renal Function

1 point each

1 or 2

S Stroke 1

B Bleeding 1

L Labile INRs 1

E Elderly (age > 65 yr) 1

D Drugs or Alcohol

1 point each

1 or 2

Maximum 9 points

Bleeding Risk HAS-BLED Score

Pisters R et al. Chest. 2010 Nov;138:1093-100

Overview of Thromboembolic Management


69/108


Overview of Thromboembolic Management

CHADS2 = 0

No antithrombotic may be

appropriate in selected young

patients with no stroke risk

factors

aspirin

*Aspirin is a reasonable

alternative in some as

indicated by risk/benefit

Dabigatran is preferred OAC over warfarin in most patients.

CHADS2 = 1 CHADS2 2

OAC* OAC

Assess Thromboembolic

Risk (CHADS2) and

Bleeding Risk (HAS-BLED)


70/108


Hart Ann Int Med 1999;131:492

RRR = 64%


71/108


Hart Ann Int Med 1999;131:492

RRR = 19%

RCTs Warfarin vs ASA


72/108


Hart. Ann Int Med 2007;147:590

50% 0 -50%

Warfarin Better Warfarin WorseRRR=39%

4040


73/108


0

5

10

15

20

25

30

35

40

CHADS 0 CHADS 1 CHADS 2

NoRx

Warfarin

Aspirin

Risk of Stroke + Non-cerebral Major Bleed among AF Patients

Events/1000

patients/ye

ar

10 12

13 18

17 24

19

28

7 11 10 17 14 23


74/108


We recommend that patients at very low riskof stroke (CHADS2 = 0) should receive aspirin

(75-325 mg/day).


High Quality

Evidence

We suggest that some young persons with

no standard risk factors for stroke may notrequire any antithrombotic therapy.

Conditional


Evidence

ASA for Stroke Prevention

Anticoagulant Therapy for Stroke Prevention


75/108


We recommend that patients at low risk of

stroke (CHADS2 = 1) should receive OAC

therapy (either warfarin [INR 2 3] ordabigatran).

Strong

Recommendation


We suggest, based on individual risk/benefit

considerations, that aspirin is a reasonable

alternative for some.

Conditional

Recommendation

Moderate Quality

Evidence

We recommend that patients at moderate

risk of stroke (CHADS2 2) should receive

OAC therapy (either warfarin [INR 2 3] or

dabigatran).

Strong

Recommendation

High Quality

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.

Anticoagulant Therapy for Stroke Prevention


76/108


We suggest, that when OAC therapy isindicated, most patients should receive

dabigatran in preference to warfarin. In

general, the dose of dabigatran 150 mg po

bid is preferable to a dose of 110 mg po bid.


High Quality

Evidence

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.

Dabigatran vs Warfarin

Antithrombotic Management of AF/AFL in CAD


77/108


Choose

antithrombotic

based on stroke risk

PCIRecent ACSStable CAD

Antithrombotic Management of AF/AFL in CAD

* Warfarin is preferred over dabigatran for patients at high risk of coronary events

Choose antithrombotic

based on balance of risks

and benefits

Choose antithrombotic

based on balance of risks

and benefits

CHADS2= 0

CHADS2 1

CHADS2 2

CHADS21

CHADS2 2

CHADS21

AspirinOAC*

monotherapy

aspirin +

clopidogrel

aspirin +

clopidogrel

Triple anti-thrombotic

Rx

Triple anti-thrombotic

Rx

We suggest that patients with AF/AFL who Conditional


78/108


We suggest that patients with AF/AFL who

have stable CAD should receive

antithrombotic therapy selected based upon

their risk of stroke (aspirin for CHADS2 = 0 and

OAC for CHADS2 1). Warfarin is preferredover dabigatran for those at high risk of

coronary events.

Conditional

Recommendation

Moderate Quality

Evidence

We suggest that patients with AF/AFL who

have experienced ACS or who have undergone

PCI, should receive antithrombotic therapyselected based on a balanced assessment of

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 ofstroke may include aspirin plus clopidogrel

plus OAC.

Conditional

Recommendation

Low QualityEvidence


79/108


We recommend that hemodynamically stable

patients with AF/AFL of 48 hours oruncertain duration for whom electrical or

pharmacological cardioversion is planned

should receive therapeutic OAC therapy

(warfarin [INR 2-3] or dabigatran) for 3 weeks

before and at least 4 weeks postcardioversion

Strong


Evidence

CardioversionAF 48 hr

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.


80/108


We recommend that hemodynamically stable

patients with AF/AFL of known duration < 48hours may undergo cardioversion without

prior or subsequent anticoagulation. However,

if the patient is at particularly high risk of

stroke (e.g. mechanical valve, rheumatic heart

disease, recent stroke or TIA), cardioversionshould be delayed and the patient should

receive OAC for 3 weeks before and at least 4

weeks post cardioversion.

Strong


Evidence

Cardioversion AF < 48 hr

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.



81/108


We suggest if the AF/AFL is of known duration < 48hr, the patient may undergo cardioversion without

prior anticoagulation. If the patient is at high risk of

stroke (e.g. mechanical valve, rheumatic heart

disease, recent stroke or TIA), the patient should

receive IV UFH or LMWH before cardioversion if

possible, or immediately thereafter and then beconverted 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 abrief delay is unacceptable. Such a patient should

then be converted to OAC for at least 4 weeks post

cardioversion.


Moderate Quality

Evidence


Emergency Cardioversion

C di iC di i


82/108


We suggest that hemodynamically stable

patients with AF/AFL of duration 48 hr or

unknown, may undergo cardioversion guided

by TEE (following the protocol from theACUTE trial as detailed in the text).

Conditional

Recommendation

High Quality

Evidence

CardioversionCardioversion

(TEE-Guided)

Patient with AF undergoing Surgical or

Diagnostic Procedure with Major Bleeding Risk


83/108


High Stroke Risk**Very low to Moderate StrokeRisk*

High Bleeding

Risk

Stop antithrombotic

pre-procedure

Re-institure when

risk of bleeding

reduced

Low Bleeding

Risk

Continue

antithrombotic

(INR < 3 if

warfarin)

High Bleeding

Risk

Stop OAC and

bridge

with UFH or LMWH

perioperatively

Low Bleeding

Risk

Continue OAC or

stop OAC and

bridge with UFH or

LMWH

perioperatively

* CHADS2 2

** mechanical valve, recent stroke or TIA, rheumatic valve disease, CHADS23 stop 12-24hr pre-procedure, restart when hemostasis secure and bridge to therapeutic OAC

Diagnostic Procedure with Major Bleeding Risk

Antithrombotic Therapy Peri-Procedure


84/108


If there is a very low to moderate risk of stroke (CHADS2 2), the

patient should have their antithrombotic agent discontinued before

the procedure (aspirin or clopidogrel for 7-10 days, warfarin for 5

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.

Conditional

Recommendation


If there is a particularly high risk of stroke (e.g. mechanical valve,

recent stroke or TIA, rheumatic valve disease, CHADS2 3) or of

other thromboembolism (e.g. Fontan procedure):

a) if there is an acceptable perioperative bleeding risk (i.e. risk ofstroke 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.

Conditional

Recommendation


py


85/108

Canadian Cardiovascular SocietyAtrial Fibrillation Guidelines 2010:Prevention and treatment of atrialfibrillation following cardiacsurgeryL. Brent Mitchell MD

Post Operative AF (POAF)


86/108


COMPLICATIONS RATES no POAF versus POAF

Post Operative AF (POAF)

Steinberg ed. Atrial Fibrillation after Cardiac Surgery pp37-50, 2000

0

2

4

6

8

10

CVA CHF MI PPM VT/VF MORT

%5.5

4.14.7

1.9

6.4

3.4

5.3

3.03.6

1.7

9.3

4.0

POAF Pre ention


87/108


TREATMENTS WITH GOOD EVIDENCE OF EFFICACY

THERAPY N n RR (95% CI)

beta-blockers 31 4452 0.36 (0.28 0.47)

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)

0.40.2 0.6 0.8 1.0 1.41.2 1.6

Relative Risk

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


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)

POAF Prevention

POAF Prevention


88/108


COMPARISONS OF TREATMENT EFFICACIES


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)

0.40.2 0.6 0.8 1.0 1.41.2 1.6

Relative Risk

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

POAF Prevention

POAF Prevention


89/108


We recommend that patients who have been

receiving a beta-blocker before cardiac surgeryhave that therapy continued through the

operative procedure in the absence of the

development of a new contraindication.

Strong

RecommendationHigh Quality

Evidence

We suggest that patients who have not been

receiving a beta-blocker before cardiac surgeryhave beta-blocker therapy initiated just before

or immediately after the operative procedure in

the absence of a contraindication.

Conditional


Evidence

POAF Prevention

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.


90/108


We recommend that patients who have acontra-indication to beta-blocker therapy

before or after cardiac surgery be considered

for prophylactic therapy with amiodarone to

prevent postoperative AF.


High Quality

Evidence

POAF Prevention

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.


91/108


We suggest that patients who have a contra-

indication to beta-blocker therapy and to

amiodarone therapy before or after cardiac

surgery be considered for prophylactic

therapy to prevent postoperative AF with IV

magnesium or with biatrial pacing.

Conditional

Recommendation

Low to Moderate

Quality Evidence

POAF Prevention

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 beindividualized by patient and institution, as the potential for adverse effects

may outweigh potential benefit based on local expertise.

POAF P i


92/108


We suggest that patients at high risk of

postoperative AF be considered for

prophylactic therapy to prevent

postoperative AF with sotalol or combination

therapy including two or more of a beta-

blocker, amiodarone, IV magnesium, or

biatrial pacing.

Conditional

Recommendation

Low to Moderate

Quality Evidence

POAF Prevention

Values and Preferences: This recommendation recognizes that data

confirming the superiority of combinations of prophylactic therapies is

sparse.


93/108


Comparison - Prevention

CCS Guidelines ESC Guidelines

Strength LOE Class LOE

BB continued if on Strong High I A

BB started if not on Cond Low I A

Amio if BB contraindicated Strong High IIa A

Sotalol may be considered Cond Mod IIb A

Bi-A Pace may be considered Cond Low IIb A

IV Mag may be considered Cond Low -- --

Corticosteriods considered -- -- IIb B


94/108


95/108


POAF - Treatment

We suggest that consideration be given toanticoagulation therapy if post-operative

continuous atrial fibrillation persists for more

than 72 hours. This consideration will include

individualized assessment of the risks of a

thromboembolic event and the risk of post-operative bleeding.


Low Quality

Evidence

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 bleedingdecreases 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


96/108


We recommend that temporary epicardial

pacing electrode wires be placed at the timeof cardiac surgery to allow backup

ventricular pacing as necessary.

Strong


Evidence

We recommend that post operative AF with a

rapid ventricular response be treated with a

beta-blocker, a non-dihydropyridine calciumantagonist, or amiodarone to establish

ventricular rate control. The specific agent

chosen will be individualized for each patient

but a beta-blocker is usually preferred.

Strong

Recommendation


POAF Treatment

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.


97/108


We suggest that post operative AF may beappropriately treated with either a ventricular

response rate-control strategy or a rhythm-

control strategy.


Low Quality

Evidence

POAF - Treatment

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.


98/108


We recommend that, when anticoagulation

therapy, rate-control therapy and/or rhythm-

control therapy has been prescribed for post-

operative AF, formal reconsideration of the

ongoing need for such therapy should be

undertaken six to twelve weeks later.

Strong

Recommendation

Moderate Quality

Evidence

POAF - Treatment

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.

C i T t t


99/108


Comparison - Treatment

CCS Guidelines ESC GuidelinesStrength LOE Class LOE

epicardial V-Pace wires at OR Strong Low -- --

Rate control with BB, CA, dig Strong High I B

Rate control in that order Strong High

AF control AAD considered Cond Low IIa C

anticoag considered at 72hr Cond Low IIa (48hr) A (48 hr)

consider DC Rx at 6-12 weeks Strong Mod -- --

agree in text

Patient for CV Surgery Assess AF Risk Factors?

Low Risk High Risk


100/108


g

On Beta-Blocker?

No

Beta-Blocker

Contraindicated?Continue BB

Beta-Blocker Amiodarone

Contraindicated?

Amiodarone IV Magnesium or

Biatrial Pacing

On Beta-Blocker?

Sotalol or

Amiodarone or

BB and another

Beta-Blocker

Contraindicated?

Sotalol or

Amiodarone or

BB and another

Amiodarone

Contraindicated?

Amiodarone IV Magnesium and

Biatrial Pacing

Yes

No

No

No

No

No

Yes

Yes

Yes

Yes

Yes


101/108

Canadian Cardiovascular SocietyAtrial Fibrillation Guidelines 2010:Surgical Therapy

Pierre Pag MD


102/108


Values and Preferences: This recommendation recognizes

that individual institutional experience and patient considerations best

determine for whom the surgical procedure is performed.

Surgical Treatment of AF

We recommend that a surgical AF ablation

procedure be undertaken in association with

mitral valve surgery in patients with AF when

there is a strong desire to maintain sinus

rhythm, the likelihood of success of the

procedure is deemed to be high, and the

additional risk is low.

Strong

Recommendation

Moderate Quality

Evidence


103/108


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 inquality of life.

We recommend that patients with

asymptomatic lone AF, in whom AF is not

expected to affect cardiac outcome, should

not be considered for surgical therapy for AF.

Strong

Recommendation

Low Quality

Evidence


S i l T t t f AF


104/108


Values and Preferences: This recommendation recognizes that left

atrial endocardial access is not routinely required for aortic or coronarysurgery. This limits ablation to newer epicardial approaches.

In patients with AF who are undergoing aortic

valve surgery or coronary artery bypass

surgery, we suggest that a surgical AF

ablation procedure be undertaken when there

is a strong desire to maintain sinus rhythm,

the success of the procedure is deemed to behigh, and the additional risk low .

Conditional

Recommendation

Low Quality

Evidence




105/108


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 closure (excision orobliteration) of the left atrial appendage be

undertaken as part of the surgical ablation of

AF associated with mitral valve surgery.


Low Quality

Evidence

We suggest that closure of the left atrial

appendage be undertaken as part of thesurgical ablation of persistent AF in patients

undergoing aortic valve surgery or coronary

artery bypass surgery if this does not

increase the risk of the surgery.

Conditional


Evidence


S i l T t t f AF


106/108


Values and Preferences: These recommendations place a highvalue on minimizing the risk of stroke and a lower value in the utility

of long-term monitoring to document the absence of AF.

We recommend that oral anticoagulant

therapy be continued following surgical AF

ablation in patients with a CHADS2score 2.

Strong

Recommendation

Moderate Quality

Evidence

We suggest that oral anticoagulant therapy be

continued following surgical AF ablation in

patients who have undergone mechanical or

bioprosthetic mitral valve replacement.

Conditional

Recommendation

Low Quality

Evidence


Cox MAZE III Ablation Pattern


107/108


Recommended Type specific


108/108

Recommended Type-specific

Surgical Strategies*

Cardiac status or

type of AF Paroxysmal

Persistent, mixed or

continuous

Lone AF PVI PVI +

Mitral Valve surgery PVI +Bi-atrial full Cox MAZE

or PVI +

Aortic valve / CABG

surgeryPVI PVI +

PVI + is PVI plus connecting lesions to LAA and mitral valve

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

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