The 2019 Updated AF Guidelines

In July 2019, the American Heart Association, American College of Cardiology, and Heart Rhythm Society published a focused update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation (AF).¹ The authors write that “The scope of this focused update of the 2014 AF Guideline includes revisions to the section on anticoagulation (because of the approval of new medications and thromboembolism protection devices), revisions to the section on catheter ablation of atrial fibrillation (AF), revisions to the section on the management of AF complicating acute coronary syndrome (ACS), and new sections on device detection of AF and weight loss.”¹ Ten highlights of the focused update are listed below.

1. Prescribing an oral anticoagulant to reduce thromboembolic stroke risk is recommended for patients with AF and an elevated CHA₂DS₂-VASc score of 2 or greater in men or 3 or greater in women;

2. Prescribing an oral anticoagulant to reduce thromboembolic stroke risk may be considered for patients with AF and a CHA₂DS₂-VASc score of 1 in men and 2 in women;

3. With regard to anticoagulation guidelines, the term non-valvular AF is defined as AF in a patient who does not have moderate-to-severe mitral stenosis or a mechanical heart valve;

4. Idarucizumab is recommended for the reversal of dabigatran in cases of life-threatening bleeding or urgent procedures;

5. Andexanet alfa can be useful for the reversal of rivaroxaban and apixaban in the event of life-threatening or uncontrolled bleeding;

6. Catheter ablation may be reasonable in selected patients with symptomatic AF and heart failure with reduced left ventricular ejection fraction to potentially reduce mortality rate and heart failure hospitalization;

7. In patients with AF at increased risk of stroke (based on CHA₂DS₂-VASc risk score of 2 or greater) who have undergone PCI with stenting for ACS, double therapy with a P2Y₁₂ inhibitor (clopidogrel or ticagrelor) and either dose-adjusted vitamin K antagonist, low-dose rivaroxaban 15 mg daily, or dabigatran 150 mg twice daily is reasonable to reduce the risk of bleeding as compared with triple therapy;

8. In patients with a cardiac implantable electronic device (CIED), the presence of recorded atrial high-rate episodes should prompt further evaluation to document clinically relevant AF to guide treatment decisions;

9. In patients with cryptogenic stroke in whom external ambulatory monitoring is inconclusive, implantation of a cardiac monitor is reasonable to optimize detection of silent AF;

10. Weight loss combined with risk factor modification is recommended for overweight and obese patients with AF.¹

On one hand, much of this updated AF guideline will not create much controversy. For example, no one is going to argue that the word “anticoagulant” is better than “antithrombotic”, or that weight loss is important for patients with AF and obesity. On the other hand, the wording of some of the recommendations will be challenged. There are recommendations that are too general to be helpful; for instance, how exactly does one define “clinically relevant AF” when it comes to device-detected AF? There are also some that come with an unnecessarily conservative level of recommendation. For example, the recommendations related to catheter ablation and left atrial appendage occlusion, procedures considered by most electrophysiologists as reasonable in specific patients, were only given a IIb status. Regardless, it is important that the AF guidelines be updated frequently to remain current and relevant. The authors should be congratulated for all of the volunteered time and effort put into this update.

Disclosure: Dr. Knight reports that he is a consultant, speaker, investigator, and offers fellowship support for Abbott, Baylis Medical, Biosense Webster, Inc., BIOTRONIK, Boston Scientific, Medtronic, and SentreHEART.

1. January CT, Wann LS, Calkins H, et al. 2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation. J Am Coll Cardiol. 2019;74(1):104-132. DOI: 10.1016/j.jacc.2019.01.011.