The Heart Rhythm Society and the American College of Cardiology presented a complimentary webinar, The Focused Update on the Management of Patients with Atrial Fibrillation: Who Should Get ‘What’, ‘When,’ on March 7, 2011 6:00 – 7:15 p.m. ET — learn more.

2011 ACCF/AHA/HRS Focused Update on the Management of Patients With Atrial Fibrillation
(Updating the 2006 Guideline)

A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines

Download 2011 Update on the Management of AF Patients » (PDF, 230K)

This guideline update focuses on several areas in which new data on management of patients with atrial fibrillation (AF) have become available, including:

"Due to the emergence of new atrial fibrillation clinical trial evidence in recent years, it was time to collaborate with the American Heart Association and the American College of Cardiology to update the 2006 Guidelines for the Management of Patients with Atrial Fibrillation. The information provided in the updated guidelines is timely, relevant and based on the latest evidence from important clinical trials. Sharing this information with you will ultimately lead to better safety and effectiveness of treatment for our patients." — Douglas L. Packer, MD, FHRS 2010 – 2011 President Heart Rhythm Society View Dr. Packer's video message for more information about the guidelines See also the 2011 ACCF/AHA/HRS Focused Update on the Management of Patients With Atrial Fibrillation (Update on Dabigatran), released February 14, 2011, which states that Dabigatran is an alternative to warfarin to help prevent dangerous blood clots in patients with AF.

• catheter ablation is useful to maintain normal sinus rhythm in AF patients
• recommendations for heart rate control — strict heart rate control in AFpatients is not beneficial over lenient control
• combined use of antiplatelet and anticoagulant therapy — the antiplatelet drug clopidogrel, plus aspirin, might be considered to reduce the risk of major vascular events (including stroke) in patients who are poor candidates for the anticoagulant drug warfarin
• use of dronedarone

Read the Heart Rhythm Society press release on the creation and publication of this document. This focused update is not intended to represent an update based on a full literature review from the date of the previous guideline publication. Consult the ACC/AHA/ESC 2006 Guidelines for the Management of Patients with Atrial Fibrillation full-text version (PDF, 824K) or executive summary (PDF, 438K) for policy on clinical areas not covered by the focused update. With the exception of the recommendations presented in this document, the guideline remains current. Only the recommendations from the affected section(s) of the full-text guideline are included in this focused update.

Recommendations are not made for use of dabigatran, a new antithrombotic agent which was not approved by the U.S. Food and Drug Administration (FDA) at the time of organizational approval of this document, or for the Watchman device for occlusion of the left atrial appendage, which is investigational pending FDA approval.

Figure 1. Therapy to maintain sinus rhythm in patients with recurrent paroxysmal or persistent atrial fibrillation. Drugs are listed alphabetically and not in order of suggested use. The seriousness of heart disease progresses from left to right, and selection of therapy in patients with multiple conditions depends on the most serious condition present. LVH indicates left ventricular hypertrophy.
Modified from Fuster et al2 (formerly Figure 15 from 2006 Section 8.3.3).

Recommendations for Maintenance of Sinus Rhythm

Class I

1. Catheter ablation performed in experienced centers* is useful in maintaining sinus rhythm in selected patients with significantly symptomatic, paroxysmal AF who have failed treatment with an antiarrhythmic drug and have normal or mildly dilated left atria, normal or mildly reduced LV function, and no severe pulmonary disease. (Level of Evidence: A)
   * An experienced center is defined as one performing more than 50 AF catheter ablation cases per year

Class IIa

1. In patients with AF without structural or coronary heart disease, initiation of propafenone or flecainide can be beneficial on an outpatient basis in patients with paroxysmal AF who are in sinus rhythm at the time of drug initiation. (Level of Evidence: B)
2. Catheter ablation is reasonable to treat symptomatic persistent AF. (Level of Evidence: A)

Class IIb

1. Catheter ablation may be reasonable to treat symptomatic paroxysmal AF in patients with significant left atrial dilatation or with significant LV dysfunction. (Level of Evidence: A)

Guide to Class and Level of Evidence Categorization Class I: The procedure/treatment SHOULD be performed/ administered Class IIa: It is reasonable to perform procedure/administer treatment (additional studies with focused objectives are needed to make this a Class I) Class IIB: The Procedure/Treatment MAY BE CONSIDERED (additional studies with broad objectives and additional registry data would be helpful to bring this to a Class I indication) Level Evidence A: Multiple populations evaluated (data derived from multiple randomized clinical trials or meta-analyses) Level Evidence B: Limited population evaluated (data derived from a single randomized trial or nonrandomized studies) Level Evidence C: Very limited populations evaluated (only consensus opinion of experts, case studies, or standard of care) Class III: There is Harm/ No Benefit, the procedure/treatment is not useful, nor is there indication for it to be administered.

Recommendation for Rate Control During Atrial Fibrillation

Class III
Treatment to achieve strict rate control of heart rate (<80 bpm at rest or <110 bpm during a 6-minute walk) is not beneficial compared to achieving a resting heart rate <110 bpm in patients with persistent AF who have stable ventricular function (left ventricular ejection fraction >0.40) and no or acceptable symptoms related to the arrhythmia, though uncontrolled tachycardia may over time be associated with a reversible decline in ventricular performance. (Level of Evidence: B)

Recommendation for Combining Anticoagulant with Antiplatelet Therapy

Class IIb
The addition of clopidogrel to aspirin (ASA) to reduce the risk of major vascular events, including stroke, might be considered in patients with AF in whom oral anticoagulation with warfarin is considered unsuitable due to patient preference or the physician’s assessment of the patient’s ability to safely sustain anticoagulation.  (Level of Evidence: B) 

Recommendations for Use of Dronedarone in Atrial Fibrillation

Class IIa
Dronedarone is reasonable to decrease the need for hospitalization for cardiovascular events in patients with paroxysmal AF or after conversion of persistent AF. Dronedarone can be initiated during outpatient therapy. (Level of Evidence: B)

Class III
Dronedarone should not be administered to patients with class IV heart failure or patients who have had an episode of decompensated heart failure in the past 4 weeks, especially if they have depressed left ventricular function (left ventricular ejection fraction < 35%).  (Level of Evidence: B)

 

2011 Writing Group Members

L. Samuel Wann, MD, Chair
Anne B. Curtis, MD, FHRS
Craig T. January, MD, Ph.D.
Kenneth A. Ellenbogen, MD, FHRS*
James E. Lowe, MD
N.A. Mark Estes III, MD, FHRS
Richard L. Page, MD, FHRS*
Michael D. Ezekowitz, MB, ChB,
David J. Slotwiner, MD*
Warren M. Jackman, MD, FHRS
William G. Stevenson, MD
Cynthia M. Tracy, MD

* = represented the Heart Rhythm Society