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March  31,  2014

The  "2014  AHA/ACC/HRS  Guideline  for  the  Management  of  Patients  With  Atrial  Fibrillation"  is  here.  I've  read  theentire  123  pages.  Let's  do  this  report  in  10  categories  (some  with  bulleted  lists).  I'll  mix  reporting  with  editorialcomment.  I'll  try  to  keep  it  to  one  to  two  paragraphs  per  issue,  and  look  for  blatant  editorial  to  be  in  italics.  At  theend,  I'll  offer  one  criticism.

The  writers  began  strongly—with  the  obvious,  which  is  often  elusive.

1.  Guidelines  are  for  guidance.  Let's  start  with  this  quote  from  the  introduction  (emphasis  mine):  "Theguidelines  attempt  to  define  practices  that  meet  the  needs  of  most  patients  in  most  circumstances.  The  ultimatejudgment  about  care  of  a  particular  patient  must  be  made  by  the  clinician  and  patient  in  light  of  all  thecircumstances  presented  by  that  patient."  Writing  committee  chair  Dr  Craig  January  (University  of  Wisconsin,Madison)  offered  this  nugget  of  self-­awareness  in  the  press  release:  "Because  what  we  say  in  the  guideline  canaffect  how  a  drug  is  used,  we  were  careful  to  be  even-­handed  and  evidence-­based  in  presenting  new  drugs."

These  two  statements  deserve  emphasis  because  patient-­centered  care  is  threatened  when  guidelines  morphinto  scripture.  Good  on  the  writers.

2.  Nonvalvular  AF  gets  a  definition  (sort  of):  From  table  3:  Nonvalvular  AF  is  that  which  occurs  in  the  absenceof  rheumatic  mitral  stenosis,  a  mechanical  or  bioprosthetic  heart  valve,  or  mitral-­valve  repair.  Hmm?

3.  Atrial  flutter  gets  special  emphasis:  Heart-­rhythm  doctors  are  seeing  more  atrial  flutter.  The  increasedincidence  of  typical  flutter,  which  we  painfully  call  cavotricuspid-­isthmus  (CTI)  dependent,  parallels  the  rise  inobesity,  sleep  apnea,  use  of  AF  drugs,  and  advancing  age  of  the  populace.  Our  efforts  in  the  left  atrium—withablation  catheters—have  brought  us  enhanced  knowledge  of  the  atypical  forms  of  flutter.

The  writers  urge  care  with  the  flutter/fib  diagnosis,  specifically  calling  out  the  fact  that  "coarse"  AF  can  bemistaken  as  atrial  flutter—a  common  error  in  the  real  world.  Also,  efforts  to  distinguish  typical  from  atypical  flutterare  important  for  counseling  patients  on  expectations  of  ablation.  The  former  is  easy  to  ablate,  and  the  latter  isnot.

4.  Antithrombotic-­therapy  recommendations:  Check  this  out.The  very  first  class  I  recommendation:  "Inpatients  with  AF,  antithrombotic  therapy  should  be  individualized  based  on  shared  decision-­making  afterdiscussion  of  the  absolute  and  [relative  risks]  RRs  of  stroke  and  bleeding  and  the  patient's  values  andpreferences.  Read  that  again.  The  patient-­centric  nature  of  that  statement  is  a  remarkable  and  welcome  stand  forexperts  to  take.  Thank  you.

Let's  do  a  bulleted  list  of  other  notables  on  stroke-­prevention  strategies:

Use  the  CHA2DS2-­VASc  score  rather  than  the  CHADS2  score.

Bleeding  scores,  such  as  HAS-­BLED,  REITE,  and  HEMORR2HAGES  may  be  helpful  in  defining  risk,  butthe  evidence  for  using  them  for  specific  recommendations  was  not  sufficient.

The  non–vitamin  K–antagonist  anticoagulant  (NOAC)  drugs—dabigatran  etexilate  (Pradaxa,  BoehringerIngelheim),  rivaroxaban  (Xarelto,  Bayer/Janssen  Pharmaceuticals),  and  apixaban  (Eliquis,  Bristol-­MyersSquibb/Pfizer)—were  added  to  warfarin  as  preferred  therapy.

Patients  who  struggle  to  maintain  stable  INRs  may  be  considered  for  NOAC  drugs.  In  my  view,  INR  yo-­yoing  most  often  reflects  deficits  in  patient  education  and/or  adherence.  Neither  of  these  are  necessarilygood  situations  for  the  use  of  NOAC  drugs.

2014  AF  Treatment  Guidelines:  10  Things  to  Like  and  OnlyOne  to  DislikeJohn  Mandrola

Bridging  strategies  with  unfractionated  heparin  (UFH)  or  low-­molecular-­weight  heparin  (LMWH)  came

with  strong  wording  to  "balance  the  risks  of  stroke  and  bleeding."  My  take  on  bridging  is  that  it's  no  small

thing.  So  I  am  glad  for  this  language.

In  patients  with  AF  who  are  undergoing  stent  placement,  bare-­metal  stents  could  be  considered  as  well  as

dual  antiplatelet  therapy  (minus  aspirin).

5.  Little  benefit  with  aspirin:  This  quote  says  a  lot.  "No  studies,  with  the  exception  of  the  [Stroke  Prevention

in  Atrial  Fibrillation-­1]  SPAF-­1  trial,  show  benefit  for  aspirin  alone  in  preventing  stroke  among  patients  with  AF."

The  writers  then  use  data  that  I  quote  often  in  the  clinic.  The  Birmingham  Atrial  Fibrillation  Treatment  of  the

Aged  (BAFTA)  trial  compared  warfarin  and  aspirin  in  high-­risk  subjects  greater  than  75  years  old.  Those  treated

with  warfarin  had  fewer  strokes  and  similar  rates  of  bleeding.  Most  striking:  the  risk  of  extracranial  bleeding  was

1.4%  with  warfarin  and  1.6%  with  aspirin.

We  were  also  urged  to  question  the  common  practice  of  using  aspirin  in  low-­risk  patients.  Did  you  know  "aspirin

has  not  been  studied  in  a  low-­risk  AF  population?"

6.  Warfarin  vs  NOAC  drugs:  What  was  so  notable  about  the  discussion  of  how  and  why  to  choose  between

agents  was  what  the  writers  did  not  say.  They  did  not  use  the  word  superior,  nor  did  they  recommend  one  drug

over  another.  Rather,  a  reader  learned  the  pros,  cons,  and  expectations  of  each  drug.  Good.  Doctors  and  patients

should  be  able  to  evaluate  the  results  of  the  clinical  trials  that  enrolled  more  than  50  000  patients  and  counted

easy  things  to  count,  such  as  strokes,  bleeds,  and  deaths.

7.  Wait  and  see  on  LAA  occlusion:  Percutaneous  left  atrial  appendage  occlusion  devices  earned  a  couple  of

paragraphs,  but  no  formal  recommendations  were  made.  Comments  regarding  surgical  closure  at  the  time  of

concomitant  cardiac  surgery  were  interesting.  "The  current  data  regarding  LAA  occlusion  at  the  time  of

concomitant  cardiac  surgery  reveals  a  lack  of  clear  consensus  because  of  the  inconsistency  of  techniques  used

for  surgical  excision,  the  highly  variable  rates  of  successful  LAA  occlusion,  and  the  unknown  impact  LAA

occlusion  may  or  may  not  have  upon  future  thromboembolic  events."  On  the  matter  of  the  left  atrial  appendage,

put  me  down  as  skeptical  on  the  idea  that  a  focal  strategy  (LAA  occlusion)  can  treat  a  systemic  disease  (stroke).

8.  Rate  control:  There  were  not  many  surprises  in  the  recommendations  on  rate  control.  Here  are  four  topics

worth  mentioning:

Acute  rate  control:  Ca-­channel  blocker  vs  beta-­blocker?  The  clinical  trials  of  acute  rate  control  were

performed  in  the  1980s  and  1990s.  These  studies  had  variable  end  points  and  small  sample  sizes  and

were  often  from  single  sites.  It  is  with  great  pleasure  that  I  offer  this  quote:  "Unless  immediate  rate  control

is  required  or  an  enteral  route  of  administration  is  not  available,  oral  administration  is  appropriate."  Regular

readers  know  how  this  column  feels  about  using  IV  drugs  when  oral  ones  will  do.

Be  cautious  with  digoxin.  The  writers  reiterate  the  pharmacology  of  digoxin  and  give  mention  to  recent

meta-­analyses  that  suggest  a  possible  signal  of  harm.  Attention  to  digoxin's  narrow  therapeutic  window  is

laudable.

Lenient  rate-­control  strategy  (less  than  110  bpm)  may  be  reasonable:  The  caveat  is  that  patients

remain  symptom-­free  with  preserved  LV  function.  Noting  the  limitations  of  the  RACE-­II  trial,  the  writers

expressed  worry  that  its  findings  may  not  apply  well  to  a  broad  group  of  AF  patients.

AV-­node  ablation  and  pacing  earns  a  class  IIa  indication.  The  writers  make  it  clear  that  this

irreversible  procedure  has  both  benefits  and  risks.  They  also  nudge  us  to  think  about  the  benefits  of

cardiac  resynchronization  therapy  (CRT)  pacing  for  patients  who  have  undergone  AV  node  ablation  and

have  moderate  to  severe  LV  systolic  dysfunction.

9.  Rhythm  control:  The  writers  were  clear  that  rhythm-­control  therapy  of  AF  must  be  individualized.  Four  topics

struck  me  as  notable.

What's  a  reversible  cause  of  AF?  The  writers  say  this:  "Class  I:  Before  initiating  antiarrhythmic  drugtherapy,  treatment  of  precipitating  or  reversible  causes  of  AF  is  recommended."

Here  we  have  a  real  dilemma.  In  past  guidelines,  this  sort  of  wording  implied  underlying  causes  likeectopic  atrial  tachycardia,  hyperthyroidism,  acute  alcohol  ingestion,  infection,  chronic  obstructivepulmonary  disease  (COPD)  exacerbation,  or  trauma.  Okay.  I  get  that.  Fix  those  problems  and  AF  mightresolve  itself.  The  interesting  caveat  now  is  that  we  know  obesity,  sleep  apnea,  hypertension,  andmetabolic  syndrome  are  both  precipitating  and  reversible  causes  of  AF.

So,  do  the  writers  mean  we  should  treat  these  problems  before  initiating  rhythm  control?  Because  if  theydo,  there  will  be  a  lot  fewer  AF  patients  treated  with  AF  drugs  and  ablation.  It's  provocative  to  even  thinkthat  patients  help  themselves.  But  you  see  where  failing  in  this  regard  got  us  with  hypertension  therapy—eg,  drugs  (and  kidney  ablation  almost)  get  used  as  substitutes  for  lifestyle  changes.

Big  changes  in  AF  ablation  recommendations:  AF  ablation  has  been  moved  to  first-­line  status  for  bothparoxysmal  and  persistent  AF  patients.  This  welcome  change  aligns  these  guidelines  with  those  fromEurope.  My  previous  post  discusses  many  of  the  issues  surrounding  the  decision-­making  in  the  initialapproach  to  rhythm  control.

Class  III  harm  distinction  added  for  two  false  beliefs  .  AF  ablation  should  not  be  performed  in  patientswho  cannot  be  treated  with  anticoagulants,  and  AF  ablation  should  not  be  done  with  the  sole  intent  ofavoiding  anticoagulation.  This  might  seem  obvious  to  electrophysiologists  but  it  is  not  well-­known  in  thereal  world.  A  good  add.

Don't  forget  about  the  surgical  maze  option:  Both  stand-­alone  and  concomitant  procedures  arementioned  as  options.  This  is  a  worthy  addition  because  AF  surgery  offers  selected  patients  reasonableoptions.

10.  Special  patients:

Athletes:  Two  particular  strategies  were  suggested  for  athletes.  One  was  the  "pill-­in-­the-­pocket"  approach  tousing  antiarrhythmic  drugs  (AADs),  and  the  other  was  to  consider  catheter  ablation  as  first-­line  therapy.

The  elderly  patient  rightly  earned  mention.  Two  paragraphs  outlined  the  need  for  nuance  and  caution  whentreating  the  elderly  with  rhythm-­control  tools.  In  my  opinion,  it  is  impossible  to  overdo  caution  when  it  comes  totreating  the  elderly  AF  patient.

Hypertrophic  cardiomyopathy  (HCM):  The  writers  say  "success  and  complication  rates  for  AF  catheter  ablationappear  to  be  similar  for  HCM  and  other  forms  of  heart  disease."  I  have  not  found  that.  I  find  patients  with  HCMtough  to  ablate.  Recurrences  and  redo  procedures  are  the  norm.  I  would  be  interested  in  hearing  your  experiencein  the  comments.

Heart  failure  and  AF:  There  were  a  lot  of  basics  in  this  discussion.  One  notable  point  of  emphasis  was  therecommendation  to  use  nondihydropyridine  calcium-­channel  blockers  only  in  patients  with  heart  failure  and  anormal  ejection  fraction.  As  most  patients  with  new-­onset  AF  present  without  a  known  ejection  fraction  (and  oftenhave  at  least  transient  systolic  dysfunction),  the  reflexive  use  of  IV  diltiazem  in  emergency  departments  andICUs  deserves  reappraisal.

The  criticism:

There  wasn't  much  not  to  like  in  this  document.

But  I  did  find  one  glaring  problem.  It  comes  in  this  sentence  concerning  anticoagulation  with  warfarin:

Despite  strong  evidence  for  the  efficacy  of  warfarin,  several  limitations  have  led  to  its  underutilization.

Do  you  see  what  I  am  talking  about?  Focus  on  the  word  underutilization.

This  sentence  follows  a  beautiful  discussion  on  the  importance  of  making  shared  decisions—those  that  turn  on

patient-­specific  preferences.  Therefore  .  .  .  to  describe  a  therapy  (given  by  a  doctor  to  a  patient)  as  underutilized

undermines  the  notion  of  individualized  care.

What  is  the  correct  utilization  rate  of  warfarin?  The  answer  is  that  it  depends  not  on  what  doctors  say  it  should  be

but  what  informed,  involved  patients  think  it  to  be.  That's  the  thing  about  AF  care:  it's  all  preference–sensitive.

I  don't  want  to  be  too  hard  on  the  writers,  though.  Putting  shared  decision  making  as  a  class  I  recommendation

for  anticoagulation  is  a  huge  step  forward.  This  document  gets  us  closer  to  the  famous  tweet  from  Dr  Harlan

Krumholz  (Yale  University):

"T    he  highest-­quality  care  is  when  the  patient  chooses  the  path  that  best  fits  their  values,  preferences,  andgoals.  And  we  have  made  sure  the  decisions  are  not  a  result  of  ignorance  or  fear."

JMM

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Cite  this  article:  2014  AF  Treatment  Guidelines:  10  Things  to  Like  and  Only  One  to  Dislike.  Medscape.  Mar  31,  2014.