Fred Morady
Keywords: Anticoagulation Management; Arrhythmias and Clinical EP; Heart Failure and Cardiomyopathies; Invasive Cardiovascular Angiography and Intervention; Prevention; Valvular Heart Disease; Anticoagulation Management and Atrial Fibrillation; Implantable Devices; SCD/Ventricular Arrhythmias; Atrial Fibrillation/Supraventricular Arrhythmias; Novel Agents; Acute Heart Failure; Interventions and Structural Heart Disease
The following are key points to remember from this Focused Update of
the 2014 American Heart Association/American College of Cardiology/Heart
Rhythm Society (AHA/ACC/HRS) Guideline for the Management of Patients
With Atrial Fibrillation (AF):
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1. Edoxaban has been added to the list of
nonvitamin K oral anticoagulants (NOACs [apixaban, dabigatran, and
rivaroxaban]) that can be used for stroke prevention (Class of
Recommendation [COR] I, Level of Evidence [LOE] B-R).
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2. NOACs are recommended over warfarin except in patients with moderate to
severe mitral stenosis or a prosthetic heart valve (COR I, LOE A).
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3. The decision to use an anticoagulant should not be influenced by whether the AF is paroxysmal or persistent (COR I, LOE B).
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4. Renal and hepatic function should be tested before initiation of a NOAC and at least annually thereafter (COR I, LOE B-NR).
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5. In AF patients with a CHA2DS2-VASc score ≥2 in men
or ≥3 in women and a creatinine clearance <15 ml/min or who are on dialysis, it is reasonable to use warfarin or apixaban for oral anticoagulation (COR IIa, LOE B-NR).
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6. Idarucizumab is recommended for the reversal of dabigatran in the event
of a life-threatening bleed or urgent procedure (COR I, LOE B-NR).
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7. Andexanet alfa (recombinant factor Xa) can be useful for the reversal of
rivaroxaban and apixaban in the event of life-threatening bleeding (COR
IIa, LOE B-NR).
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8. Percutaneous left atrial appendage occlusion may be considered for
at-risk AF patients with AF at increased risk of stroke who have
contraindications to long-term anticoagulation (COR IIb, LOE B-NR).
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9. AF catheter ablation may be reasonable in symptomatic patients with
heart failure and a reduced ejection fraction to reduce mortality and
heart failure hospitalizations (COR IIb, B-R).
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10. In at-risk AF patients who have undergone coronary artery stenting,
double therapy with clopidogrel and low-dose rivaroxaban (15 mg daily)
or dabigatran (150 twice daily) is reasonable to reduce the risk of
bleeding as compared to triple therapy (COR IIa, B-R).
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11. Weight loss combined with risk factor modification is recommended for overweight and obese patients with AF (COR I, LOE B-R).
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12. In patients with cryptogenic stroke in whom external ambulatory
monitoring is inconclusive, implantation of a cardiac monitor is
reasonable for detection of subclinical
AF (COR IIa, B-R).