Ablation/Cardioversion
European Heart Rhythm Association (EHRA): 2021 European Heart Rhythm Association Practical Guide on the Use of Non-Vitamin K Antagonist Oral Anticoagulants in Patients With Atrial Fibrillation (Steffel et al, EP Europace 2021)
This updated guidance, published by the EHRA in 2021, provides evidence-based recommendations for the use of direct oral anticoagulants (DOACs) in patients with nonvalvular atrial fibrillation (NVAF), including eligibility assessment; monitoring; transitioning between other anticoagulants and DOACs; possible drug-drug interactions (DDIs); dosing adjustments in the elderly, in patients with hepatic or renal impairment, or based on body weight; management of DOAC-associated bleeding (including use of reversal agents); and periprocedural management considerations for elective or emergency procedures (including ablation and cardioversion). Special considerations for DOAC use during the COVID-19 pandemic are also included. Sample pathways to help guide decision-making are included for various clinical scenarios.
Canadian Cardiovascular Society (CSC): The 2020 Canadian Cardiovascular Society/Canadian Heart Rhythm Society Comprehensive Guidelines for the Management of Atrial Fibrillation (Andrade et al, Can J Cardiol [CJC] 2020 and SUPPL)
The Canadian Cardiovascular Society, in collaboration with the Canadian Heart Rhythm Society, provides comprehensive evidence-based recommendations for the use of vitamin K antagonists and direct oral anticoagulants (DOACs) in patients with nonvalvular atrial fibrillation (NVAF), including those with chronic kidney disease (CKD), end-stage renal disease (ESRD), coronary artery disease, liver disease, advanced age, frailty, or increased body mass index (BMI), and in those undergoing cardioversion, catheter ablation, or other invasive procedures. The guidelines also provide recommendations on the prevention and management of DOAC-associated bleeding events. Several clinical pathways to help guide anticoagulation therapy decision-making in various clinical scenarios are provided.
Stroke Prevention in Atrial Fibrillation: Comparison of Recent International Guidelines (Chao et al, Eur Heart J Suppl 2020)
This review compares recently published guidelines from the European Society of Cardiology, the American College of Cardiology/American Heart Association/Heart Rhythm Society, the American College of Chest Physicians, and the Asia Pacific Heart Rhythm Society on bleeding and stroke risk assessment and recommendations on OAC use, including in patients with atrial fibrillation (AF) and chronic kidney disease or advanced liver disease, or in those undergoing cardioversion or catheter ablation. Although recommendations regarding OAC use are generally similar across the 4 guidelines, unique attributes of these guidelines are described.
Antithrombotic Treatment After Atrial Fibrillation Ablation (Antoniou et al, Curr Pharm Des 2020)
This narrative review describes the current understanding of how atrial fibrillation is related to thromboembolism and how ablation and anticoagulation affect disease course. Recommendations and factors to consider when continuing anticoagulation therapy after AF ablation are also presented.
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Interrupted or Uninterrupted Oral Anticoagulants in Patients Undergoing Atrial Fibrillation Ablation (Yang et al, Cardiovasc Drugs Ther 2020 and SUPPL)
This network meta-analysis of randomized, controlled trials evaluated the efficacy and safety of continuous or interrupted direct oral anticoagulant (DOAC) therapy versus continuous or interrupted vitamin K antagonist (VKA) therapy in patients with atrial fibrillation undergoing catheter ablation.
Stroke and Thromboembolism Prevention in Atrial Fibrillation (Jame and Barnes, Heart 2020)
This narrative review describes the association between atrial fibrillation and risk of stroke and thromboembolism. A summary of the models for assessing the risk of stroke or systemic thromboembolism in patients with atrial fibrillation is provided. The article presents algorithms for anticoagulation in patients with AF who are undergoing elective cardioversion and management of patients with AF before, during, and after AF ablation.
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European Society of Cardiology (ESC): 2020 ESC Guidelines for the Diagnosis and Management of Atrial Fibrillation Developed in Collaboration with the European Association of Cardio-Thoracic Surgery (EACTS): The Task Force for the Diagnosis and Management of Atrial Fibrillation of the European Society of Cardiology (ESC) Developed with the Special Contribution of the European Heart Rhythm Association (EHRA) of the ESC (Hindricks et al, Eur Heart J 2020 and SUPPL)
The ESC, in collaboration with the EACTS and developed with the EHRA, updated its 2016 guidelines for the screening, diagnosis, assessment, and management of atrial fibrillation (AF) in patients with or without comorbid cardiovascular disease (CVD), including valvular heart disease (direct oral anticoagulants [DOACs] are not indicated for use in patients with mechanical heart valves). Options for rate and rhythm control are described. Strategies for minimizing bleeding risk and managing bleeding episodes (including reversal options) are included, as are recommendations for periprocedural management of anticoagulation, including in patients undergoing ablation or cardioversion. Risks and benefits of DOACs and vitamin K antagonists (VKAs) are highlighted. Sample pathways to help guide decision-making are included for various clinical scenarios. These guidelines also include quality and performance indicators that may be used to evaluate the level of implementation of the guidelines and identify opportunities for improvement.
Cardioversion Safety - Are We Doing Enough? (Khatami et al, Cardiology 2020)
This article reviews periprocedural risk of thromboembolic events in patients with atrial fibrillation (AF) undergoing cardioversion and treatment with oral anticoagulants. Suggestions for simpler and more practical approaches for cardioversion than outlined in nationally recognized treatment guidelines are proposed.
Periprocedural Anticoagulation for Cardioversion of Acute Onset Atrial Fibrillation and Flutter: Evidence Base for Current Guidelines: (Andrade and Mitchell, Can J Cardiol 2019)
This article reviews the evidence informing the Canadian Cardiovascular Society’s (CCS) 2018 guidelines regarding periprocedural anticoagulation for cardioversion of atrial fibrillation, including in those at low risk for thromboembolism, and compares the CCS guidelines with other current international guidelines.
American Heart Association/American College of Cardiology/Heart Rhythm Society (AHA/ACC/HRS): 2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation (January et al, Circulation 2019)
These updated guidelines for the management of AF, published by the AHA/ACC/HRS in 2019 and developed in collaboration with the Society of Thoracic Surgeons (STS), outline risk-based initiation of anticoagulation therapy using the CHADS2, CHA2DS2-VASc, and HAS-BLED risk assessment tools and describe options for rate and rhythm control, including ablation and cardioversion. Management of anticoagulation in specific patient populations, including those with renal impairment and those undergoing ablation, cardioversion, or other invasive procedures, is also addressed. An overview of the risks and benefits of vitamin K antagonists and direct oral anticoagulants (DOACs) is provided.
Canadian Cardiovascular Society (CCS): Society Guidelines: 2018 Focused Update of the Canadian Cardiovascular Society Guidelines for the Management of Atrial Fibrillation (Andrade et al, Can J Cardiol [CJC] 2018 and SUPPL)
This updated guidance, published by the EHRA in 2018, provides evidence-based recommendations for the use of direct oral anticoagulants (DOACs) in patients with nonvalvular atrial fibrillation (NVAF), including eligibility assessment; monitoring; transitioning between vitamin K antagonists and DOACs; possible drug-drug interactions (DDIs); dosing adjustments in the elderly, in patients with hepatic or renal impairment, or based on body weight; management of DOAC-associated bleeding (including use of reversal agents); and periprocedural management considerations for elective or emergency procedures (including ablation and cardioversion). Sample pathways to help guide decision making are included for various clinical scenarios.
Acute Management of Atrial Fibrillation: From Emergency Department to Cardiac Care Unit (Atzema and Singh, Cardiol Clin 2018)
In this narrative review, the authors outline initial management strategies for patients presenting to the ED with AF, including options for rate and rhythm control and anticoagulation.
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American College of Chest Physicians (ACCP): Antithrombotic Therapy for Atrial Fibrillation: CHEST Guideline and Expert Panel Report (Lip et al, Chest 2018)
The ACCP guidelines describe risk-based antithrombotic therapy for prevention of thrombosis in patients with AF using the CHA2DS2-VASc score to help guide choice of therapy. Considerations for management of anticoagulation in patients undergoing urgent or elective cardioversion, catheter ablation, or other invasive procedure or in patients with AF and concomitant chronic kidney disease (CKD) are provided. Strategies for bleeding management, including use of reversal agents, are described. Sample pathways for determining eligibility for anticoagulation therapy in various clinical scenarios and links to patient education resources are included.
HRS/EHRA/ECAS/APHRS/SOLAECE (2017): 2017 HRS/EHRA/ECAS/APHRS/SOLAECE Expert Consensus Statement on Catheter and Surgical Ablation of Atrial Fibrillation (Calkins et al, Europace 2018)
This consensus statement, published by an international panel of experts in 2018, provides an overview of catheter and surgical ablation in patients with AF, including strategies to help minimize the risk of thromboembolism during and after the procedure. This statement was developed in partnership with and endorsed by the Heart Rhythm Society (HRS), European Heart Rhythm Association (EHRA), European Cardiac Arrhythmia Society (ECAS), Asia Pacific Heart Rhythm Society (APHRS), and the Latin American Society of Cardiac Stimulation and Electrophysiology (SOLAECE).
Periprocedural Anticoagulation in Atrial Fibrillation: Update on Electrical Cardioversion and Ablation (van Vugt and Brouwer, Neth Heart J 2018)
This article provides guidance on periprocedural and postprocedural anticoagulation in patients undergoing ablation or cardioversion for AF.
Society of Thoracic Surgeons (STS): The Society of Thoracic Surgeons 2017 Clinical Practice Guidelines for the Surgical Treatment of Atrial Fibrillation (Badhwar et al, Ann Thorac Surg [ATS] 2017)
STS information and guidelines for the treatment of AF through surgical ablation.
Periprocedural Management of Direct Oral Anticoagulants Surrounding Cardioversion and Invasive Electrophysiological Procedures (Finks et al, Cardiol Rev 2017)
This narrative review outlines available data demonstrating the risks and benefits of DOACs during ablation and cardioversion procedures and offers considerations for optimizing periprocedural anticoagulation.
American Heart Association (AHA): Management of Patients on Non-Vitamin K Antagonist Oral Anticoagulants in the Acute Care and Periprocedural Setting: A Scientific Statement From the American Heart Association (Raval et al, Circulation 2017)
This scientific statement from the AHA describes the management of direct oral anticoagulants (DOACs) in patients needing interruption or reversal of anticoagulation because of an acute bleed or procedural intervention, including in patients undergoing cardioversion or ablation. Sample pathways for these scenarios are provided. The pharmacology, potential drug-drug interactions (DDIs), and reversal of individual DOACs are compared, and guidance on transitioning between oral anticoagulants, based on the prescribing information of individual DOACs, is included.
Periprocedural Anticoagulation for Catheter Ablation of Atrial Fibrillation: Practical Implications for Perioperative Management (Briceno et al, J Cardiothorac Vasc Anesth [JCVA] 2017)
This review describes the safety and efficacy of vitamin K antagonists and direct oral anticoagulants (DOACs) for periprocedural anticoagulation in patients undergoing catheter ablation for AF.
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North American Thrombosis Forum (NATF): North American Thrombosis Forum, AF Action Initiative Consensus Document (Ruff et al, Am J Med [AJM] 2016)
The NATF consensus document describes considerations for stroke and bleeding risk assessment using the CHA2DS2-VASc and HAS-BLED, respectively, and gives recommendations for anticoagulation therapy in patients with atrial fibrillation. The risks, benefits, and cost-effectiveness of direct oral anticoagulants (DOACs) are outlined. Strategies for management of anticoagulation-related bleeding and use of reversal agents are described, as are approaches to periprocedural management of DOACs in patients undergoing ablation, cardioversion, or other surgeries. Considerations are also provided for treating AF in elderly patients, patients with impaired renal function, patients with concomitant coronary artery disease (CAD), patients who are naïve to or experienced with vitamin K antagonists (VKAs), and patients with subclinical AF, along with strategies for optimizing patient safety and adherence to therapy.
European Society of Cardiology (ESC): 2016 ESC Guidelines for the Management of Atrial Fibrillation Developed in Collaboration With EACTS (Kirchhof et al, Eur Heart J [EHJ] 2016)
The 2016 ESC guidelines outline management strategies for patients with AF (with or without comorbid cardiovascular disease [CVD], including valvular heart disease [direct oral anticoagulants (DOACs) are not indicated for use in patients with mechanical heart valves]). Options for rate and rhythm control are described. Anticoagulant dosing adjustments in patients with renal impairment are provided. Strategies for minimizing bleeding risk and managing bleeding episodes (including reversal options) are included, as are recommendations for periprocedural management of anticoagulation, including in patients undergoing ablation or cardioversion. Risks and benefits of vitamin K antagonists and DOACs are highlighted. Sample pathways to help guide decision making are included for various clinical scenarios.
Use of Non-Vitamin K Antagonist Oral Anticoagulants in Special Patient Populations with Nonvalvular Atrial Fibrillation: A Review of the Literature and Application to Clinical Practice (Kalabalik et al, Drugs 2015)
This narrative review provides an overview of direct oral anticoagulants (DOACs), including in the elderly, in patients with renal impairment, and in patients undergoing ablation or cardioversion.
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University of North Texas Health Science Center: Pharmacology, Benefits, Unaddressed Questions, and Pragmatic Issues of the Newer Oral Anticoagulants for Stroke Prophylaxis in Non-valvular Atrial Fibrillation and Proposal of a Management Algorithm (Rosanio et al, Int J Cardiol 2014)
This narrative review provides an overview of the pharmacology, efficacy, and safety of direct oral anticoagulants (DOACs) in patients with NVAF. The evidence-based anticoagulation management pathway used at the University of North Texas Health Science Center is provided, along with recommendations for anticoagulation in patients with renal impairment, the elderly, patients with AF and comorbid acute coronary syndromes (ACS) and/or undergoing coronary stenting, and patients planning to undergo ablation.
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American Heart Association/American College of Cardiology/Heart Rhythm Society (AHA/ACC/HRS): 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society (January et al, Circulation 2014)
These guidelines for the management of AF, published by the AHA/ACC/HRS in 2014 and developed in collaboration with the Society of Thoracic Surgeons (STS), outline risk-based initiation of anticoagulation therapy using the CHADS2, CHA2DS2-VASc, and HAS-BLED risk assessment tools and describe options for rate and rhythm control, including ablation and cardioversion. Management of anticoagulation in specific patient populations, including those with renal impairment and those undergoing ablation, cardioversion, or other invasive procedures, is also addressed. An overview of the risks and benefits of vitamin K antagonists and direct oral anticoagulants (DOACs) is provided.