Cardiovascular Society Atrial Fibrillation Guidelines Research Articles

Adherence to the Canadian Cardiovascular Society Atrial Fibrillation Guidelines by Family Medicine Groups in Quebec: the I-FACILITER project

Background: The Canadian Cardiovascular Society (CCS) Atrial Fibrillation (AF) guidelines 2014 recommends oral anticoagulation (OAC) for patients with CHADS2 ?1 or age ?65 years and non-vitamin K oral anticoagulants (NOAC)s as the preferred medications. We aimed to evaluate adherence to these guidelines by family group practices (FMG) in Quebec. Methods and results: We completed a cross-sectional evaluation at 15 FMGs. There were 431 patients with non-valvular AF: mean age of 77.3±10.4 years and 52.9% were females. CHADS2 and HAS-BLED were infrequently documented (47% and 7%, respectively). Most patients (93%) were appropriately anticoagulated (96% for both patients with CHADS2 ?1 and patients with age ?65 years). Sixty-five percent of patients were anticoagulated with warfarin, 28% with NOACs and 21% of patients received a combination of oral anticoagulant (OAC)s and aspirin. Every decade increase in age was associated with 49% increase in odds of adherence to the guidelines and 26% decrease in odds of NOACs’s use. Each point increase in HAS-BLED was associated with 51% decrease in odds of adherence to the guidelines and 36% decrease in odds of NOACS’s use. No patient with HAS-BLED of ?5 received NOAC. Heart failure was associated with a 61% decrease in odds of NOACS’s use. Conclusion: AF management by FMGs could be improved by 1) increasing NOACs uptake, 2) decreasing the combination of OAC with ASA and 3) increasing documentation of stroke and bleeding risks.

Utilization of Anticoagulation and Antiplatelet Therapies in Patients with Atrial Fibrillation and Acute Coronary Syndrome Undergoing Percutaneous Coronary Intervention

Utilization of Anticoagulation and Antiplatelet Therapies in Patients with Atrial Fibrillation and Acute Coronary Syndrome Undergoing Percutaneous Coronary Intervention

Performance of the “CCS Algorithm” in real world patients

BackgroundWith the publication of the 2014 Focused Update of the Canadian Cardiovascular Society Guidelines for the Management of Atrial Fibrillation, the Canadian Cardiovascular Society Atrial Fibrillation Guidelines Committee has introduced a new triage and management algorithm; the so-called “CCS Algorithm”. The CCS Algorithm is based upon expert opinion of the best available evidence; however, the CCS Algorithm has not yet been validated. Accordingly, the purpose of this study is to evaluate the performance of the CCS Algorithm in a cohort of real world patients. MethodsWe compared the CCS Algorithm with the European Society of Cardiology (ESC) Algorithm in 172 hospital inpatients who are at risk of stroke due to non-valvular atrial fibrillation in whom anticoagulant therapy was being considered. ResultsThe CCS Algorithm and the ESC Algorithm were concordant in 170/172 patients (99% of the time). There were two patients (1%) with vascular disease, but no other thromboembolic risk factors, which were classified as requiring oral anticoagulant therapy using the ESC Algorithm, but for whom ASA was recommended by the CCS Algorithm. ConclusionsThe CCS Algorithm appears to be unnecessarily complicated in so far as it does not appear to provide any additional discriminatory value above and beyond the use of the ESC Algorithm, and its use could result in under treatment of patients, specifically female patients with vascular disease, whose real risk of stroke has been understated by the Guidelines.

Use of an interdisciplinary, participatory design approach to develop a usable patient self-assessment tool in atrial fibrillation

After identifying that significant care gaps exist within the management of atrial fibrillation (AF), a patient-focused tool was developed to help patients better assess and manage their AF. This tool aims to provide education and awareness regarding the management of symptoms and stroke risk associated with AF, while engaging patients to identify if their condition is optimally managed and to become involved in their own care. An interdisciplinary group of health care providers and designers worked together in a participatory design approach to develop the tool with input from patients. Usability testing was completed with 22 patients of varying demographics to represent the characteristics of the patient population. The findings from usability testing interviews were used to further improve and develop the tool to improve ease of use. A physician-facing tool was also developed to help to explain the tool and provide a brief summary of the 2012 Canadian Cardiovascular Society atrial fibrillation guidelines. By incorporating patient input and human-centered design with the knowledge, experience, and medical expertise of health care providers, we have used an approach in developing the tool that tries to more effectively meet patients’ needs.

Trifecta or Triple Threat? The Challenge of Post-PCI Management in Patients Receiving Chronic Oral Anticoagulant Therapy

We are fortunate to practice in an era of medicine which has many proven therapies. However, we are increasingly faced with coadministration of therapies whose combined effects have not been fully evaluated. Perhaps the most common and difficult of these scenarios is the use of dual antiplatelet therapy in patients who require chronic oral anticoagulation. Although each of these treatments has clear benefits, there is concern about bleeding risk when they are used together. Physicians are forced to choose between risking a thromboembolic or a bleeding complication. To best serve our patients, we must consider not only our initial reaction to do no harm, but go through the slower process of calculating the risk and severity of all possible adverse effects. However, for this process to succeed, we need robust data on which to base these calculations. This issue of the Canadian Journal of Cardiology (CJC) contains 2 articles which provide much-needed data. In the first, Ho and colleagues study the most common group of patients requiring chronic anticoagulation—individuals with atrial fibrillation. Their single-centre Canadian study included 602 patients with atrial fibrillation as their only indication for anticoagulation who underwent percutaneous coronary intervention (PCI) between 2008 and 2009. All were treated with dual antiplatelet therapy using aspirin and clopidogrel. The study was not randomized; however, physicians elected to treat 382 patients with triple therapy (ie, continued warfarin along with dual antiplatelet therapy), and 220 patients received dual antiplatelet therapy alone. Physicians clearly favoured triple therapy among patients with a higher risk of stroke, as patients receiving triple therapy were older (72.9 vs 70.5 years, P 0.039), were more likely to have suffered a previous stroke (14.4% vs 6.4%, P 0.01) and had a higher Congestive Heart Failure, Hypertension, Age, Diabetes, Stroke/Transient Ischemic Attack CHADS2 score (2.6 vs 2.1; P 0.001). 6

615 Comparison of the 2010 and 2012 Canadian Cardiovascular Society Atrial Fibrillation Guidelines in a Large Urban Family Practice

615 Comparison of the 2010 and 2012 Canadian Cardiovascular Society Atrial Fibrillation Guidelines in a Large Urban Family Practice

Focused 2012 Update of the Canadian Cardiovascular Society Atrial Fibrillation Guidelines: Recommendations for Stroke Prevention and Rate/Rhythm Control

The Canadian Cardiovascular Society (CCS) published the complete set of 2010 Atrial Fibrillation (AF) Guidelines in the January, 2011 issue of the Canadian Journal of Cardiology. During its deliberations, the CCS Guidelines Committee engaged to a timely review of future evidence, with periodic composition of focused updates to address clinically important advances. In 2011, results were published from 3 pivotal AF trials: the Rivaroxaban Once Daily Oral Direct Factor Xa Inhibition Compared with Vitamin K Antagonist for Prevention of Stroke and Embolism Trial in Atrial Fibrillation (ROCKET-AF), the Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation (ARISTOTLE) study, and the Permanent Atrial Fibrillation Outcome Study Using Dronedarone on Top of Standard Therapy (PALLAS), comparing dronedarone with placebo in patients with permanent AF and additional cardiovascular disease risk-factor burden. Each of these large randomized trials provided clear results with major implications for AF management. Other important evidence that has emerged since the 2010 Guidelines includes findings about prediction instruments for AF-associated stroke and bleeding risk, stroke risk in paroxysmal-AF patients, risk-benefit considerations related to oral anticoagulation in patients with chronic kidney disease, and risk/benefit considerations in the use of antiplatelet agents, alone and in combination with each other or with oral anticoagulants, in AF patients. The Guidelines Committee judged that this extensive and important new evidence required focused updating of the 2010 Guidelines with respect to stroke prevention and rate/rhythm control. This report presents the details of the new recommendations, along with the background and rationale.

N023 Pulmonary vein isolation: A qualitative analysis of patient learning needs

Pulmonary vein isolation (PVI) is a highly specialized, minimally-invasive and increasingly accessible treatment for symptomatic Atrial Fibrillation (AF), providing significant benefits in decreasing arrhythmic burden and improving patients' functional quality of life and wellbeing. According to the recently released Canadian Cardiovascular Society Atrial Fibrillation Guidelines (2010), there is moderate level of evidence to support recommendations for the use of catheter ablation in drug refractory AF.

Canadian Cardiovascular Society Atrial Fibrillation Guidelines 2010: Catheter Ablation for Atrial Fibrillation/Atrial Flutter

Catheter ablation of atrial fibrillation (AF) offers a promising treatment for the maintenance of sinus rhythm in patients for whom a rhythm control strategy is desired. While the precise mechanisms of AF are incompletely understood, there is substantial evidence that in many cases (particularly for paroxysmal AF), ectopic activity most commonly located in and around the pulmonary veins of the left atrium plays a central role in triggering and/or maintaining arrhythmic episodes. Catheter ablation involves electrically disconnecting the pulmonary veins from the rest of the left atrium to prevent AF from being triggered. Further substrate modification may be required in patients with more persistent AF. Successful ablation of AF has never been shown to alter mortality or obviate the need for oral anticoagulation; thus, the primary indication for this procedure should be improvement of symptoms caused by AF. The success rate of catheter ablation for AF is superior to the efficacy of antiarrhythmic drugs, but success is still in the range of 75%-90% after 2 procedures. Ablation is also associated with a complication rate of 2%-3%. Thus, ablation should primarily be used as a second-line therapy after failure of antiarrhythmic drugs. In contrast to AF, catheter ablation of atrial flutter has a higher success rate with a smaller incidence of complications. Thus, catheter ablation for atrial flutter may be considered a first-line alternative to antiarrhythmic drugs.

Canadian Cardiovascular Society Atrial Fibrillation Guidelines 2010: Prevention and Treatment of Atrial Fibrillation Following Cardiac Surgery

Postoperative atrial fibrillation and atrial flutter (POAF) are the most common complications of cardiac surgery that require intervention or prolong intensive care unit and total hospital stay. For some patients, these tachyarrhythmias have important consequences including patient discomfort/anxiety, hemodynamic deterioration, cognitive impairment, thromboembolic events including stroke, exposure to the risks of antiarrhythmic treatments, longer hospital stay, and increased health care costs. We conclude that prevention of POAF is a worthwhile exercise and recommend that the dominant therapy for this purpose be β-blocker therapy, especially the continuation of β-blocker therapy that is already in place. When β-blocker therapy is contraindicated, amiodarone prophylaxis is recommended. If both of these therapies are contraindicated, therapy with either intravenous magnesium or biatrial pacing is suggested. Patients at high risk of POAF may be considered for first-line amiodarone therapy, first-line sotalol therapy, or combination prophylactic therapy. The treatment of POAF may follow either a rate-control approach (with the dominant therapy being β-blocking drugs) or a rhythm-control approach. Anticoagulation should be considered if persistent POAF lasts >72 hours and at the point of hospital discharge. The ongoing need for any POAF treatment (including anticoagulation) should be reconsidered 6-12 weeks after the surgical procedure.

Canadian Cardiovascular Society Atrial Fibrillation Guidelines 2010: Management of Recent-Onset Atrial Fibrillation and Flutter in the Emergency Department

Atrial fibrillation (AF) is the most common arrhythmia managed by emergency physicians. There is increasing evidence that most patients with recent-onset AF or atrial flutter (AFL) can be safely managed in the emergency department (ED) without the need for hospital admission. The priorities for ED management of recent-onset AF/AFL include rapid assessment of potential hemodynamic instability and identification and treatment of the underlying or precipitating cause. A careful evaluation of the patient's history should be performed to determine the time of onset of the arrhythmia. All patients should be stratified using a predictive index for the risk of stroke (eg, CHADS 2). For stable patients with recent-onset AF/AFL, a strategy of either rate control or rhythm control could be selected based on multiple factors including the duration of AF and the severity of symptoms. If a strategy of rhythm control has been selected, either electrical or pharmacologic cardioversion may be used. Before proceeding to cardioversion in the absence of systemic anticoagulation, physicians must be confident that the duration of AF/AFL is clearly <48 hours and that the patient is not at a particularly high risk of stroke. When the duration of AF/AFL is >48 hours or uncertain, rate control should be optimized first and the patients should receive therapeutic anticoagulation for 3 weeks before and 4 weeks after planned cardioversion. Adequate follow-up of patients with recent-onset AF/AFL is recommended to identify structural heart disease and evaluate the need for long-term antithrombotic or antiarrhythmic therapy.

Canadian Cardiovascular Society Atrial Fibrillation Guidelines 2010: Prevention of Stroke and Systemic Thromboembolism in Atrial Fibrillation and Flutter

The stroke rate in atrial fibrillation is 4.5% per year, with death or permanent disability in over half. The risk of stroke varies from under 1% to over 20% per year, related to the risk factors of congestive heart failure, hypertension, age, diabetes, and prior stroke or transient ischemic attack (TIA). Major bleeding with vitamin K antagonists varies from about 1% to over 12% per year and is related to a number of risk factors. The CHADS 2 index and the HAS-BLED score are useful schemata for the prediction of stroke and bleeding risks. Vitamin K antagonists reduce the risk of stroke by 64%, aspirin reduces it by 19%, and vitamin K antagonists reduce the risk of stroke by 39% when directly compared with aspirin. Dabigatran is superior to warfarin for stroke prevention and causes no increase in major bleeding. We recommend that all patients with atrial fibrillation or atrial flutter, whether paroxysmal, persistent, or permanent, should be stratified for the risk of stroke and for the risk of bleeding and that most should receive antithrombotic therapy. We make detailed recommendations as to the preferred agents in various types of patients and for the management of antithrombotic therapies in the common clinical settings of cardioversion, concomitant coronary artery disease, surgical or diagnostic procedures with a risk of major bleeding, and the occurrence of stroke or major bleeding. Alternatives to antithrombotic therapies are briefly discussed.

Canadian Cardiovascular Society Atrial Fibrillation Guidelines 2010: Etiology and Initial Investigations

The initial evaluation of patients with atrial fibrillation (AF) should include a comprehensive history, physical examination, and initial investigations. The initial evaluation of patients with AF has several important purposes, including the identification of the etiology of AF, particularly the identification of reversible causes of AF; the description of the pattern of AF; the assessment of the degree of symptomatic impairment due to AF; the assessment of the thromboembolic risk of the patient; and the identification of common comorbidities. Additional investigations may then be undertaken, with the decision guided by the initial evaluation. A comprehensive and systematic initial evaluation forms the foundation for a patient-specific plan for the management of AF.