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Apr 05

New AF guideline includes four key changes

New AF guideline includes four key changes: A new AF guideline by the American Heart Association, American College of Cardiology and Heart Rhythm Society in collaboration with the Society of Thoracic Surgery, describes a more precise stroke–risk calculator and when to use aspirin, novel oral anticoagulants, and catheter ablation. Simultaneously published online March 28, 2014 in the Journal of the American College of Cardiology, Circulation, and Heart Rhythm, the guideline supersedes the AF guideline published in 2006 and two updates published in 20113,4) and reflects some but not all changes to a 2012 European update. The guideline contains four significant changes.

CHA2DS2–VASc replaces CHADS2: To estimate the risk of stroke in patients with nonvalvular AF, the guideline recommends replacing the CHADS2 score with the more comprehensive CHA2DS2-VASc score, whereby one point is given each for CHF, hypertension, diabetes, vascular disease (prior MI, PAD, aortic plaque), age 65 to 74, and sex category (female), and two points each for aged 75 or older and prior stroke/transient ischemic attack (TIA)/thromboembolism. “Compared with the CHADS2 score, the CHA2DS2–VASc score for nonvalvular AF has a broader score range (0 to 9) and includes a larger number of risk factors (female sex, 65 to 74 years of age, and vascular disease). In this scheme, women cannot achieve a CHA2DS 2–VASc score of zero. CHA2DS2–VASc is better helped to define the risk, particularly in people at low risk.
Aspirin’s role diminished: Aspirin carries with it a small but definable bleeding risk and many trials (showed) either no benefit or weak benefit in terms of stroke reduction, so there’s a diminished role, if any role, for aspirin.
New anticoagulants join treatment options: Whereas the only anticoagulant previously recommended was warfarin, the guideline now includes recommendations for the three new anticoagulants for nonvalvular AF that entered the marketplace in the past two years. For patients with nonvalvular AF with prior stroke, TIA, or a CHA2DS2–VASc score of 2 or greater, oral anticoagulants are recommended. Options include warfarin, dabigatran etexilate, rivaroxaban, or apixaban. Dabigatran and rivaroxaban are contraindicated in patients with end-stage renal disease or on hemodialysis. Apixaban has recently been approved for patients on hemodialysis.
More prominent role for catheter ablation: In patients with recurrent symptomatic paroxysmal AF, catheter ablation is a reasonable initial rhythm–control strategy prior to therapeutic trials of antiarrhythmic drug therapy, after weighing risks and outcomes of drug and ablation therapy.

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