2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines and the Heart Rhythm Society

Craig T January, L Samuel Wann, Joseph S Alpert, Hugh Calkins, Joaquin E Cigarroa, Joseph C Cleveland Jr, Jamie B Conti, Patrick T Ellinor, Michael D Ezekowitz, Michael E Field, Katherine T Murray, Ralph L Sacco, William G Stevenson, Patrick J Tchou, Cynthia M Tracy, Clyde W Yancy, ACC/AHA Task Force Members, Jeffrey L Anderson, Jonathan L Halperin, Nancy M Albert, Biykem Bozkurt, Ralph G Brindis, Mark A Creager, Lesley H Curtis, David DeMets, Robert A Guyton, Judith S Hochman, Richard J Kovacs, E Magnus Ohman, Susan J Pressler, Frank W Sellke, Win-Kuang Shen, William G Stevenson, Clyde W Yancy, John Gordon Harold, Shalom Jacobovitz, William J Oetgen, Charlene May, Amelia Scholtz, Lisa Bradfield, Ezaldeen Ramadhan 3rd, Emily Cottrell, Mariell Jessup, Nancy Brown, Rose Marie Robertson, Gayle R Whitman, Marco Di Buono, Jody Hundley, Craig T January, L Samuel Wann, Joseph S Alpert, Hugh Calkins, Joaquin E Cigarroa, Joseph C Cleveland Jr, Jamie B Conti, Patrick T Ellinor, Michael D Ezekowitz, Michael E Field, Katherine T Murray, Ralph L Sacco, William G Stevenson, Patrick J Tchou, Cynthia M Tracy, Clyde W Yancy, ACC/AHA Task Force Members, Jeffrey L Anderson, Jonathan L Halperin, Nancy M Albert, Biykem Bozkurt, Ralph G Brindis, Mark A Creager, Lesley H Curtis, David DeMets, Robert A Guyton, Judith S Hochman, Richard J Kovacs, E Magnus Ohman, Susan J Pressler, Frank W Sellke, Win-Kuang Shen, William G Stevenson, Clyde W Yancy, John Gordon Harold, Shalom Jacobovitz, William J Oetgen, Charlene May, Amelia Scholtz, Lisa Bradfield, Ezaldeen Ramadhan 3rd, Emily Cottrell, Mariell Jessup, Nancy Brown, Rose Marie Robertson, Gayle R Whitman, Marco Di Buono, Jody Hundley

No abstract available

Keywords: AHA Scientific Statements; atrial fibrillation; cardio-renal physiology/pathophysiology; cardiovascular surgery: transplantation, ventricular assistance, cardiomyopathy; epidemiology; full revision; health policy and outcome research; other atrial fibrillation.

Figures

Figure 1. Atrial Tachycardias

Diagram summarizing types of atrial tachycardias often encountered in patients with a history of AF, including those seen after catheter or surgical ablation procedures. P-wave morphologies are shown for common types of atrial flutter; however, the P-wave morphology is not always a reliable guide to the re-entry circuit location or to the distinction between common atrial flutter and other macro–re-entrant atrial tachycardias. *Exceptions to P-wave morphology and rate are common in scarred atria. AF indicates atrial fibrillation and ECG, electrocardiogram (72, 80).

Figure 2. Mechanisms of AF

AF indicates atrial fibrillation; Ca++ ionized calcium; and RAAS, renin-angiotensin-aldosterone system.

Figure 3. Antithrombotic Therapy to Prevent Stroke in Patients who Have Nonvalvular AF (Meta-Analysis)

ACTIVE-W indicates Atrial Fibrillation Clopidogrel Trial With Irbesartan for Prevention of Vascular Events-W; AF, Atrial Fibrillation; AFASAK, Atrial Fibrillation, Aspirin and Anticoagulant Therapy Study; BAATAF, Boston Area Anticoagulation Trial for Atrial Fibrillation; CAFA, Canadian Atrial Fibrillation Anticoagulation; CI, confidence interval; EAFT, European Atrial Fibrillation Trial; ESPS, European Stroke Prevention Study; JAST, Japan AF Stroke Prevention Trial; LASAF, Low-Dose Aspirin, Stroke, Atrial Fibrillation; NASPEAF, National Study for Prevention of Embolism in Atrial Fibrillation; PATAF, Primary Prevention of Arterial Thromboembolism in Nonrheumatic Atrial Fibrillation; SAFT, Swedish Atrial Fibrillation Trial; SIFA, Studio Italiano Fibrillazione Atriale; SPAF I, Stroke Prevention in Atrial Fibrillation Study; SPINAF, Stroke Prevention in Atrial Fibrillation; and UK-TIA, United Kingdom-Transient Ischemic Attack. Adapted with permission from Hart et al. (184).

Figure 4. Coagulation Cascade

AT indicates antithrombin and VKAs, vitamin K antagonists. Adapted with permission from Nutescu et al. (213).

Figure 5. Pooled Estimates of Stroke or Systemic Embolism in Patients With AF Treated With Warfarin

ACTIVE W indicates Atrial Fibrillation Clopidogrel Trial With Irbesartan for Prevention of Vascular Events-W; Amadeus, Evaluating the Use of SR34006 Compared to Warfarin or Acenocoumarol in Patients With Atrial Fibrillation; ARISTOTLE, Apixaban Versus Warfarin in Patients With AF; BAFTA, Birmingham Atrial Fibrillation Treatment of the Aged Study; CI, confidence interval; RE-LY, Randomized Evaluation of Long-Term Anticoagulation Therapy; ROCKET AF, Rivaroxaban Versus Warfarin in Nonvalvular Atrial Fibrillation; and SPORTIF, Stroke Prevention Using Oral Thrombin Inhibitor in Atrial Fibrillation. Adapted with permission from Agarwal et al. (224).

Figure 6. Approach to Selecting Drug Therapy for Ventricular Rate Control*

*Drugs are listed alphabetically. †Beta blockers should be instituted following stabilization of patients with decompensated HF. The choice of beta blocker (cardio-selective, etc.) depends on the patient's clinical condition. ‡Digoxin is not usually first-line therapy. It may be combined with a beta blocker and/or a nondihydropyridine calcium channel blocker when ventricular rate control is insufficient and may be useful in patients with HF. §In part because of concern over its side-effect profile, use of amiodarone for chronic control of ventricular rate should be reserved for patients who do not respond to or are intolerant of beta blockers or nondihydropyridine calcium antagonists. COPD indicates chronic obstructive pulmonary disorder; CV, cardiovascular; HF, heart failure; HFpEF, heart failure with preserved ejection fraction; and LV, left ventricular.

Figure 7. Strategies for Rhythm Control in Patients with Paroxysmal* and Persistent AF†

*Catheter ablation is only recommended as first-line therapy for patients with paroxysmal AF (Class IIa recommendation). †Drugs are listed alphabetically. ‡Depending on patient preference when performed in experienced centers. §Not recommended with severe LVH (wall thickness >1.5 cm). |Should be used with caution in patients at risk for torsades de pointes ventricular tachycardia. ¶Should be combined with AV nodal blocking agents. AF indicates atrial fibrillation; CAD, coronary artery disease; HF, heart failure; and LVH, left ventricular hypertrophy.