Atrial fibrillation secondary prevention: Difference between revisions

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{| border="1" style="border-collapse:collapse" cellpadding="3" align="right"
{| class="infobox" style="float:right;"
| colspan="3" align="center" bgcolor="#ABCDEF" | Conduction
| [[File:Siren.gif|30px|link=Atrial fibrillation resident survival guide]]|| <br> || <br>
|-
| [[Atrial fibrillation resident survival guide|'''Resident'''<br>'''Survival'''<br>'''Guide''']]
| <small>Sinus rhythm</small> [[Image:Heart conduct sinus.gif|none|75px]]
| <small>Atrial fibrillation</small> [[Image:Heart conduct atrialfib.gif|none|100px]]
|}
|}
{{Infobox_Disease |
  Name          =  |
  Image          =  |
  Caption        =  |
  DiseasesDB    = 1065 |
  ICD10          = {{ICD10|I|48||i|30}} |
  ICD9          = {{ICD9|427.31}} |
  ICDO          = |
  OMIM          = |
  MedlinePlus    = 000184 |
}}
{{Atrial fibrillation}}
{{Atrial fibrillation}}
{{CMG}}; '''Associate Editor(s)-In-Chief:''' {{CZ}}
{{CMG}}; {{AE}} {{CZ}} {{Anahita}}


'''''Synonyms and related keywords:''''' AF, Afib, fib
==Overview==
[[Prevention (medical)|Secondary prevention]] is a necessary step to lower the risk of some [[atrial fibrillation]] related [[Complication (medicine)|complications]], such as [[stroke]], [[transient ischemic attack]] ([[TIA]]), [[bleeding]] and [[hospital|hospitalization]]. For instance, [[dronedarone]] is a [[medication]] that may help to decrease the need for [[hospital|hospitalization]] in [[atrial fibrillation]] [[patients]]. In addition [[alcohol]] abstinence can [[prevention|prevent]] both recurrent [[arrhythmia]] and [[bleeding]] in [[atrial fibrillation]] [[patients]].


==Overview==
==Secondary Prevention==
{| class="wikitable"


==ACCF/AHA/HRS 2011 Guidelines - Atrial Fibrillation - Secondary Prevention with Thromboembolism Prevnetion (DO NOT EDIT) <ref name="pmid21321155">{{cite journal| author=Wann LS, Curtis AB, Ellenbogen KA, Estes NA, Ezekowitz MD, Jackman WM et al.| title=2011 ACCF/AHA/HRS focused update on the management of patients with atrial fibrillation (update on Dabigatran): a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. | journal=Circulation | year= 2011 | volume= 123 | issue= 10 | pages= 1144-50 | pmid=21321155 | doi=10.1161/CIR.0b013e31820f14c0 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21321155 }} </ref>==
|+ Summary of outcomes for drugs. Data from the [[Cochrane Collaboration]]<ref name="pmid25820938">{{cite journal| author=Lafuente-Lafuente C, Valembois L, Bergmann JF, Belmin J| title=Antiarrhythmics for maintaining sinus rhythm after cardioversion of atrial fibrillation. | journal=Cochrane Database Syst Rev | year= 2015 | volume= | issue= 3 | pages= CD005049 | pmid=25820938 | doi=10.1002/14651858.CD005049.pub4 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25820938 }} </ref>


{|class="wikitable"
! style="background-color:#9b9b9b;" | Class
! style="background-color:#9b9b9b;" | Drug
! style="background-color:#9b9b9b;" | [[Atrial fibrillation]] recurrence
! style="background-color:#9b9b9b;" | [[mortality rate|Mortality]]
|-
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
| colspan="4" style="background-color:#c0c0c0;" | I. Voltage-gated Na+ channel blockers
|-
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.'''Antithrombotic therapy to prevent [[thromboembolism]] is recommended for all patients with [[AF]], except those with lone AF or contraindications. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]]) <nowiki>"</nowiki>
| Ia
| [[Quinidine]]
| style="color:#32cb00;" | 0.51 (0.40 to 0.64)
| style="color:#cb0000;" | 2.26 (0.93 to 5.45)
|-
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' The antithrombotic agent should be chosen based upon the absolute risks of [[stroke]] and bleeding and the relative risk and benefit for a given patient. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]]) <nowiki>"</nowiki>
|
| [[Disopyramide]]
| 0.52 (0.27 to 1.01)
| style="color:#cb0000;" | 7.56 (0.47 to 122.66)
|-
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''3.''' For patients at high risk of stroke, chronic oral anticoagulant therapy with a vitamin K antagonist (INR 2.0 to 3.0) is recommended, unless contra-indicated. Factors associated with highest risk for stroke in patients with AF
| rowspan="2" | Ic
are prior stroke, TIA, or [[systemic embolism]], [[rheumatic mitral stenosis]] and a [[mechanical heart valve]]. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]]) <nowiki>"</nowiki>
| [[Flecainide]]
 
| style="color:#32cb00;" | 0.31 (0.16 to 0.60)
| style="color:#32cb00;" | Unestimable as no deaths occurred
|-
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''4.'''Anticoagulation with a vitamin K antagonist is recommended for patients with more than 1 moderate risk factor (age >75 years, [[hypertension]], [[diabetes mellitus]], [[HF]], or impaired [[LV]] systolic function [ejection fraction ≥ 35% or fractional shortening < 25%]). ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]]) <nowiki>"</nowiki>
| [[Propafenone]]
 
| style="color:#32cb00;" | 0.37 (0.28 to 0.48)
| style="color:#32cb00;" | 0.05 (0.00 to 1.02)
|-
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''5.'''INR should be determined at least weekly during initiation of therapy and monthly when stable.  ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]]) <nowiki>"</nowiki>
| colspan="4" style="background-color:#c0c0c0;" | II. Autonomic inhibitors and activators
 
|-
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''6.''' [[Aspirin]], 81–325 mg daily, is recommended in low-risk patients or in those with contraindications to oral anticoagulation. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]]) <nowiki>"</nowiki>
| IIa
 
| [[Metoprolol]]
| style="color:#32cb00;" | 0.62 (0.44 to 0.88)
| 2.75 (0.39 to 19.6)
|-
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''7.''' For patients with [[AF]] who have mechanical heart valves, the target intensity of anticoagulation should be based on the type of prosthesis, maintaining an INR of at least 2.5. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]]) <nowiki>"</nowiki>
| colspan="4" style="background-color:#c0c0c0;" | III. K+ channel blockers and openers
 
|-
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''8.''' Antithrombotic therapy is recommended for patients with [[atrial flutter]] as for AF. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]]) <nowiki>"</nowiki>
| rowspan="3" | IIIa
 
| [[Amiodarone]]
| style="color:#32cb00;" | 0.19 (0.14 to 027)
| 1.64 (0.59 to 4.56)
|-
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''9.''' [[Dabigatran]] is useful as an alternative to [[warfarin]] for the prevention of stroke and [[systemic thromboembolism]] in patients with paroxysmal to permanent [[AF]] and risk factors for [[stroke]] or systemic [[embolization]] who do not have a [[prosthetic heart valve]] or hemodynamically significant valve disease, severe [[renal failure]] (creatinine clearance <15 mL/ min) or advanced liver disease (impaired baseline clotting function). ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]]) <nowiki>"</nowiki>|}
| [[Dronedarone]]
 
| style="color:#32cb00;" | 0.59 (0.46 to 0.75)
{|class="wikitable"
| 0.85 (0.67 to 1.09)
|-
|-
|colspan="1" style="text-align:center; background:LightCoral"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]]
| [[Sotalol]]
|-
| style="color:#32cb00;" | 0.51 (0.43 to 0.60)
|bgcolor="LightCoral"|<nowiki>"</nowiki>'''1.''' Long-term anticoagulation is not recommended for primary stroke prevention in patients below age 60 years without heart disease (lone AF).([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>
| style="color:#cb0000;" | 2.23 (1.10 to 4.50)
|}
|}


{|class="wikitable"
*In [[patients]] with [[paroxysmal atrial fibrillation]], a number of [[medications]] are available after conversion of persistent [[atrial fibrillation]] ([[AF]]). [[Dronedarone]] is a [[medication]] that may be used to decrease the need for [[hospital|hospitalization]], and can be started as [[patient|outpatient]] [[therapy]]. It can not be given in [[patients]] with class IV [[heart failure]], decompensated [[heart failure]], or depressed [[ventricle|left ventricular]] function. A [[Artificial pacemaker|permanent pacemaker]] is not recommended in [[patients]] who do not have another indication for placement of a [[pacemaker]]
|-
*[[mouth|Oral]] [[anticoagulation]] use is critical to [[prevention|prevent]] the chance of [[stroke]] and [[transient ischemic attack]] ([[TIA]]) among [[patients]] with [[atrial fibrillation]]. This [[Prevention (medical)|secondary prevention]] is even more important in those who have a history of prior [[stroke]] or [[transient ischemic attack]] ([[TIA]]).<ref name="pmid27586690">{{cite journal| author=Masjuan J, DeFelipe A| title=Secondary prevention in non-valvular atrial fibrillation patients: a practical approach with edoxaban. | journal=Int J Neurosci | year= 2017 | volume= 127 | issue= 8 | pages= 716-725 | pmid=27586690 | doi=10.1080/00207454.2016.1232256 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27586690  }} </ref>
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
*Studies have been reported that [[alcohol]] abstinence is helpful to [[prevention|prevent]] the recurrent [[arrhythmia]] in [[atrial fibrillation]] [[patients]], who drink regularly.<ref name="pmid31893513">{{cite journal| author=Voskoboinik A, Kalman JM, De Silva A, Nicholls T, Costello B, Nanayakkara S | display-authors=etal| title=Alcohol Abstinence in Drinkers with Atrial Fibrillation. | journal=N Engl J Med | year= 2020 | volume= 382 | issue= 1 | pages= 20-28 | pmid=31893513 | doi=10.1056/NEJMoa1817591 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31893513  }}  [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=&cmd=prlinks&id=32422098 Review in: Ann Intern Med. 2020 May 19;172(10):JC53] </ref>
 
==="Pill-in-the-pocket" approach===


|-
*As needed [[flecainide]] or [[propafenone]] can be take [[mouth|orally]] according to [[clinical practice guideline]]s from 2014 by the [[American College of Cardiology]] and [[American Heart Association]].<ref name="pmid24685669">{{cite journal| author=January CT, Wann LS, Alpert JS, Calkins H, Cigarroa JE, Cleveland JC et al.| title=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. | journal=J Am Coll Cardiol | year= 2014 | volume= 64 | issue= 21 | pages= e1-76 | pmid=24685669 | doi=10.1016/j.jacc.2014.03.022 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24685669  }} </ref>
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' For primary prevention of [[thromboembolism]] in patients with [[nonvalvular AF]] who have just 1 of the validated risk factors (age >75 years (especially in female patients), [[hypertension]], [[diabetes mellitus]], [[HF]], or impaired [[LV]] function), antithrombotic therapy with either aspirin or a vitamin K antagonist is reasonable, based upon an assessment of the risk of bleeding complications, ability to safely sustain anticoagulation, and patient preferences. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]]) <nowiki>"</nowiki>


|-
*The guidelines, give a IIa recommendation after "observed to be safe in a monitored setting." The guidelines cite one [[randomized controlled trial]].<ref name="pmid15575054">{{cite journal| author=Alboni P, Botto GL, Baldi N, Luzi M, Russo V, Gianfranchi L et al.| title=Outpatient treatment of recent-onset atrial fibrillation with the "pill-in-the-pocket" approach. | journal=N Engl J Med | year= 2004 | volume= 351 | issue= 23 | pages= 2384-91 | pmid=15575054 | doi=10.1056/NEJMoa041233 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15575054  }} </ref>. In this trial, the dose was:
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2.''' For patients with nonvalvular AF who have 1 or more of the less well-validated risk factors (age 65-74 years, female gender, or [[CAD]]), treatment with either aspirin or a vitamin K antagonist is reasonable. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]]) <nowiki>"</nowiki>
** [[Patient]] weighed less than 70 kg:  [[flecainide]] 200 mg or [[propafenone]] was 450 mg
** [[patient]] weighed 70 kg or more: [[flecainide]] 300 mg or [[propafenone]] was 600 mg
*In the trials, the [[medication|drug]] was first tested in a monitored setting: "After administration of the [[medication|drug]], [[sinus rhythm|heart rhythm]] was monitored for at least 8 hours, [[blood pressure]] was measured every 30 minutes with the use of a cuff, and a 12-lead [[electrocardiogram]] was recorded every hour."<ref name="pmid15575054"/>


|-
==2011 ACCF/AHA/HRS Focused Updates Incorporated Into the 2006 Guidelines for the Management of Patients With Atrial Fibrillation (DO NOT EDIT) <ref name="pmid16908781">Fuster V, Rydén LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA et al. (2006) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=16908781 ACC/AHA/ESC 2006 Guidelines 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 European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation): developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society.] ''Circulation'' 114 (7):e257-354. [http://dx.doi.org/10.1161/CIRCULATIONAHA.106.177292 DOI:10.1161/CIRCULATIONAHA.106.177292] PMID: [http://pubmed.gov/16908781 16908781]</ref><ref name="pmid21382897">Fuster V, Rydén LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA et al. (2011) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=21382897 2011 ACCF/AHA/HRS focused updates incorporated into the ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines.] ''Circulation'' 123 (10):e269-367. [http://dx.doi.org/10.1161/CIR.0b013e318214876d DOI:10.1161/CIR.0b013e318214876d] PMID: [http://pubmed.gov/21382897 21382897]</ref>==
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''3.''' It is reasonable to select antithrombotic therapy using the same criteria irrespective of the pattern (paroxysmal, persistent, or permanent) of AF. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]]) <nowiki>"</nowiki>
====Preventing Hospitalization Due to Recurrent AF (DO NOT EDIT)<ref name="pmid16908781">Fuster V, Rydén LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA et al. (2006) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=16908781 ACC/AHA/ESC 2006 Guidelines 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 European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation): developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society.] ''Circulation'' 114 (7):e257-354. [http://dx.doi.org/10.1161/CIRCULATIONAHA.106.177292 DOI:10.1161/CIRCULATIONAHA.106.177292] PMID: [http://pubmed.gov/16908781 16908781]</ref><ref name="pmid21382897">Fuster V, Rydén LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA et al. (2011) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=21382897 2011 ACCF/AHA/HRS focused updates incorporated into the ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines.] ''Circulation'' 123 (10):e269-367. [http://dx.doi.org/10.1161/CIR.0b013e318214876d DOI:10.1161/CIR.0b013e318214876d] PMID: [http://pubmed.gov/21382897 21382897]</ref>====


{|class="wikitable" style="width: 80%;"
|-
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''4.''' In patients with AF without a mechanical heart valve, it is reasonable to interrupt anticoagulation for up to 1 wk for procedures that carry a risk of bleeding. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]]) <nowiki>"</nowiki>
|colspan="1" style="text-align:center; background:LightCoral"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]] (Harm)
 
|-
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''5.''' It is reasonable to re-evaluate the need for anticoagulation at regular intervals. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]]) <nowiki>"</nowiki>
|bgcolor="LightCoral"|<nowiki>"</nowiki>'''1.''' [[Dronedarone]] should not be administered to patients with [[Congestive heart failure classification|Class IV]] heart failure or patients who have had an episode of decompensated heart failure in the past 4 wks, especially if they have depressed [[LV]] function (LV ejection fraction ≤ 35%). ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|}
|}


{|class="wikitable"
{|class="wikitable" style="width: 80%;"
|-
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' In patients 75 years of age and older at risk of bleeding but without contraindications to anticoagulant therapy, and in patients who are unable to safely tolerate standard anticoagulation (INR 2.0 to 3.0), a lower INR target (2.0;
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' [[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. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
range 1.6 to 2.5) may be considered for primary prevention of stroke and systemic embolism. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]]) <nowiki>"</nowiki>
|}


|-
====Secondary Prevention with Pacing (DO NOT EDIT)<ref name="pmid16908781">Fuster V, Rydén LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA et al. (2006) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=16908781 ACC/AHA/ESC 2006 Guidelines 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 European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation): developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society.] ''Circulation'' 114 (7):e257-354. [http://dx.doi.org/10.1161/CIRCULATIONAHA.106.177292 DOI:10.1161/CIRCULATIONAHA.106.177292] PMID: [http://pubmed.gov/16908781 16908781]</ref><ref name="pmid21382897">Fuster V, Rydén LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA et al. (2011) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=21382897 2011 ACCF/AHA/HRS focused updates incorporated into the ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines.] ''Circulation'' 123 (10):e269-367. [http://dx.doi.org/10.1161/CIR.0b013e318214876d DOI:10.1161/CIR.0b013e318214876d] PMID: [http://pubmed.gov/21382897 21382897]</ref>====
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2.''' When interruption of oral anticoagulant therapy for longer than 1 wk is necessary in high-risk patients, unfractionated or low-molecular-weight heparin may be given by injection, although efficacy is uncertain. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]]) <nowiki>"</nowiki>
 
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''3.''' Following [[coronary revascularization]] in patients with AF, low-dose [[aspirin]] (<100 mg daily) and/or [[clopidogrel]] (75 mg daily) may be given concurrently with anticoagulation, but these strategies are associated with an increased risk of bleeding. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]]) <nowiki>"</nowiki>
 
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''4.''' In patients undergoing [[coronary revascularization]], anticoagulation may be interrupted to prevent bleeding, but should be resumed as soon as possible after the procedure and the dose adjusted to achieve a therapeutic [[INR]]. Aspirin may be given during the hiatus. For patients undergoing [[percutaneous intervention]], the maintenance regimen should consist of [[clopidogrel]], 75 mg daily, plus [[warfarin]] (INR 2.0 to 3.0). [[Clopidogrel]] should be given for a minimum of 1 mo after a bare metal stent, at least 3 mo for a sirolimus-eluting stent, at least 6 mo for a paclitaxeleluting [[stent]], and 12 mo or longer in selected patients, followed by warfarin alone. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]]) <nowiki>"</nowiki>
 
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''5.''' In patients with AF who sustain [[ischemic stroke]] or [[systemic embolism]] during treatment with anticoagulation (INR 2.0 to 3.0), it may be reasonable to raise the intensity of anticoagulation up to a target INR of 3.0 to 3.5. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]]) <nowiki>"</nowiki>
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''6.''' The addition of [[clopidogrel]] to [[aspirin]] 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. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]]) <nowiki>"</nowiki>
|}


==ACCF/AHA/HRS 2011 Guidelines - Atrial Fibrillation - Secondary Prevention with Pacing (DO NOT EDIT) <ref name="pmid16908781">Fuster V, Rydén LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA et al. (2006) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=16908781 ACC/AHA/ESC 2006 Guidelines 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 European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation): developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society.] ''Circulation'' 114 (7):e257-354. [http://dx.doi.org/10.1161/CIRCULATIONAHA.106.177292 DOI:10.1161/CIRCULATIONAHA.106.177292] PMID: [http://pubmed.gov/16908781 16908781]</ref><ref name="pmid21382897">Fuster V, Rydén LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA et al. (2011) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=21382897 2011 ACCF/AHA/HRS focused updates incorporated into the ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines.] ''Circulation'' 123 (10):e269-367. [http://dx.doi.org/10.1161/CIR.0b013e318214876d DOI:10.1161/CIR.0b013e318214876d] PMID: [http://pubmed.gov/21382897 21382897]</ref>==
{|class="wikitable" style="width: 80%;"
{|class="wikitable"
|-
|-
|colspan="1" style="text-align:center; background:LightCoral"|[[ACC AHA Guidelines Classification Scheme#Classification of Recommendations|Class III]]
|colspan="1" style="text-align:center; background:LightCoral"|[[ACC AHA Guidelines Classification Scheme#Classification of Recommendations|Class III]]
|-
|-
|bgcolor="LightCoral"|<nowiki>"</nowiki>'''1.''' Permanent [[pacemaker|pacing]] is not indicated for the prevention of AF in patients without any other indication for [[pacemaker]] implantation. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|bgcolor="LightCoral"|<nowiki>"</nowiki>'''1.''' Permanent [[pacemaker|pacing]] is not indicated for the prevention of AF in patients without any other indication for [[pacemaker]] implantation. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|}
|}
===Prevention of Bleeding===
*It is critical to control any [[bleeding]] [[risk factor|risk]] in [[patients]] who are receiving [[treatment]] for [[atrial fibrillation]].<ref name="pmid34020968">{{cite journal| author=Perry M, Kemmis Betty S, Downes N, Andrews N, Mackenzie S, Guideline Committee| title=Atrial fibrillation: diagnosis and management-summary of NICE guidance. | journal=BMJ | year= 2021 | volume= 373 | issue=  | pages= n1150 | pmid=34020968 | doi=10.1136/bmj.n1150 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=34020968  }} </ref><ref name="pmid31893513">{{cite journal| author=Voskoboinik A, Kalman JM, De Silva A, Nicholls T, Costello B, Nanayakkara S | display-authors=etal| title=Alcohol Abstinence in Drinkers with Atrial Fibrillation. | journal=N Engl J Med | year= 2020 | volume= 382 | issue= 1 | pages= 20-28 | pmid=31893513 | doi=10.1056/NEJMoa1817591 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31893513  }}  [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=&cmd=prlinks&id=32422098 Review in: Ann Intern Med. 2020 May 19;172(10):JC53] </ref>
*Based on NICE guideline the following interventions should be done in order to [[prevent]] [[bleeding]]:<ref name="pmid34020968">{{cite journal| author=Perry M, Kemmis Betty S, Downes N, Andrews N, Mackenzie S, Guideline Committee| title=Atrial fibrillation: diagnosis and management-summary of NICE guidance. | journal=BMJ | year= 2021 | volume= 373 | issue=  | pages= n1150 | pmid=34020968 | doi=10.1136/bmj.n1150 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=34020968  }} </ref>
**Control uncontrolled [[hypertension]]
**Check [[Prothrombin time|INR]] properly in [[patients]] who are receiving [[vitamin K antagonists]]
**Control [[medication]] history of your [[patient]] (check for [[medications]] that can increase the risk of [[bleeding]], such as [[selective serotonin reuptake inhibitor]] ([[Selective serotonin reuptake inhibitor|SSRIs]]), [[Non-steroidal anti-inflammatory drugs]] ([[Non-steroidal anti-inflammatory drug|NSAIDs]]) and [[Antiplatelet drug|antiplatelet drugs]])
**Ask [[patients]] to avoid excess [[alcohol]] drinking
**[[treatment|Treat]] [[anemia]]


==Vote on and Suggest Revisions to the Current Guidelines==
==Sources==
* [[The Living Guidelines: Diagnosis and Management of Atrial Fibrillation | The AF Living Guidelines: Vote on current recommendations and suggest revisions to the guidelines]]


==Guideline Resources==
*[http://content.onlinejacc.org/cgi/reprint/48/4/e149.pdf ACC/AHA/ESC 2006 Guidelines for the Management of Patients With Atrial Fibrillation] <ref name="pmid16908781">Fuster V, Rydén LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA et al. (2006) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=16908781 ACC/AHA/ESC 2006 Guidelines 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 European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation): developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society.] ''Circulation'' 114 (7):e257-354. [http://dx.doi.org/10.1161/CIRCULATIONAHA.106.177292 DOI:10.1161/CIRCULATIONAHA.106.177292] PMID: [http://pubmed.gov/16908781 16908781]</ref>
*[http://content.onlinejacc.org/cgi/reprint/48/4/e149.pdf ACC/AHA/ESC 2006 Guidelines for the Management of Patients With Atrial Fibrillation] <ref name="pmid16908781">Fuster V, Rydén LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA et al. (2006) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=16908781 ACC/AHA/ESC 2006 Guidelines 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 European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation): developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society.] ''Circulation'' 114 (7):e257-354. [http://dx.doi.org/10.1161/CIRCULATIONAHA.106.177292 DOI:10.1161/CIRCULATIONAHA.106.177292] PMID: [http://pubmed.gov/16908781 16908781]</ref>


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==References==
==References==
{{reflist|2}}
{{reflist|2}}
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[[CME Category::Cardiology]]


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[[Category:Emergency medicine]]
 
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[[de:Vorhofflimmern]]
[[fr:Fibrillation auriculaire]]
[[it:Fibrillazione atriale]]
[[nl:Boezemfibrilleren]]
[[ja:心房細動]]
[[no:Atrieflimmer]]
[[pl:Migotanie przedsionków]]
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Latest revision as of 03:32, 2 December 2021
Resident
Survival
Guide

Atrial Fibrillation Microchapters

Home

Patient Information

Overview

Historical Perspective

Classification

Pathophysiology

Causes

Differentiating Atrial Fibrillation from other Diseases

Epidemiology and Demographics

Risk Factors

Screening

Natural History, Complications and Prognosis

Special Groups

Postoperative AF
Acute Myocardial Infarction
Wolff-Parkinson-White Preexcitation Syndrome
Hypertrophic Cardiomyopathy
Hyperthyroidism
Pulmonary Diseases
Pregnancy
ACS and/or PCI or valve intervention
Heart failure

Diagnosis

History and Symptoms

Physical Examination

Laboratory Findings

Electrocardiogram

EKG Examples
A-Fib with LBBB

Chest X Ray

Echocardiography

Holter Monitoring and Exercise Stress Testing

Cardiac MRI

Treatment

Rate and Rhythm Control

Cardioversion

Overview
Electrical Cardioversion
Pharmacological Cardioversion

Anticoagulation

Overview
Warfarin
Converting from or to Warfarin
Converting from or to Parenteral Anticoagulants
Dabigatran

Maintenance of Sinus Rhythm

Surgery

Catheter Ablation
AV Nodal Ablation
Surgical Ablation
Cardiac Surgery

Specific Patient Groups

Primary Prevention

Secondary Prevention

Supportive Trial Data

Cost-Effectiveness of Therapy

Case Studies

Case #1

Atrial fibrillation secondary prevention On the Web

Most recent articles

Most cited articles

Review articles

CME Programs

Powerpoint slides

Images

Ongoing Trials at Clinical Trials.gov

US National Guidelines Clearinghouse

NICE Guidance

FDA on Atrial fibrillation secondary prevention

CDC on Atrial fibrillation secondary prevention

Atrial fibrillation secondary prevention in the news

Blogs on Atrial fibrillation secondary prevention

Directions to Hospitals Treating Atrial fibrillation secondary prevention

Risk calculators and risk factors for Atrial fibrillation secondary prevention

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Cafer Zorkun, M.D., Ph.D. [2] Anahita Deylamsalehi, M.D.[3]

Overview

Secondary prevention is a necessary step to lower the risk of some atrial fibrillation related complications, such as stroke, transient ischemic attack (TIA), bleeding and hospitalization. For instance, dronedarone is a medication that may help to decrease the need for hospitalization in atrial fibrillation patients. In addition alcohol abstinence can prevent both recurrent arrhythmia and bleeding in atrial fibrillation patients.

Secondary Prevention

Summary of outcomes for drugs. Data from the Cochrane Collaboration[1]
Class Drug Atrial fibrillation recurrence Mortality
I. Voltage-gated Na+ channel blockers
Ia Quinidine 0.51 (0.40 to 0.64) 2.26 (0.93 to 5.45)
Disopyramide 0.52 (0.27 to 1.01) 7.56 (0.47 to 122.66)
Ic Flecainide 0.31 (0.16 to 0.60) Unestimable as no deaths occurred
Propafenone 0.37 (0.28 to 0.48) 0.05 (0.00 to 1.02)
II. Autonomic inhibitors and activators
IIa Metoprolol 0.62 (0.44 to 0.88) 2.75 (0.39 to 19.6)
III. K+ channel blockers and openers
IIIa Amiodarone 0.19 (0.14 to 027) 1.64 (0.59 to 4.56)
Dronedarone 0.59 (0.46 to 0.75) 0.85 (0.67 to 1.09)
Sotalol 0.51 (0.43 to 0.60) 2.23 (1.10 to 4.50)

"Pill-in-the-pocket" approach

2011 ACCF/AHA/HRS Focused Updates Incorporated Into the 2006 Guidelines for the Management of Patients With Atrial Fibrillation (DO NOT EDIT) [6][7]

Preventing Hospitalization Due to Recurrent AF (DO NOT EDIT)[6][7]

Class III (Harm)
"1. 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 wks, especially if they have depressed LV function (LV ejection fraction ≤ 35%). (Level of Evidence: B)"
Class IIa
"1. 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)"

Secondary Prevention with Pacing (DO NOT EDIT)[6][7]

Class III
"1. Permanent pacing is not indicated for the prevention of AF in patients without any other indication for pacemaker implantation. (Level of Evidence: B)"

Prevention of Bleeding

Sources

References

  1. ↑ Lafuente-Lafuente C, Valembois L, Bergmann JF, Belmin J (2015). "Antiarrhythmics for maintaining sinus rhythm after cardioversion of atrial fibrillation". Cochrane Database Syst Rev (3): CD005049. doi:10.1002/14651858.CD005049.pub4. PMID 25820938.
  2. ↑ Masjuan J, DeFelipe A (2017). "Secondary prevention in non-valvular atrial fibrillation patients: a practical approach with edoxaban". Int J Neurosci. 127 (8): 716–725. doi:10.1080/00207454.2016.1232256. PMID 27586690.
  3. ↑ 3.0 3.1 Voskoboinik A, Kalman JM, De Silva A, Nicholls T, Costello B, Nanayakkara S; et al. (2020). "Alcohol Abstinence in Drinkers with Atrial Fibrillation". N Engl J Med. 382 (1): 20–28. doi:10.1056/NEJMoa1817591. PMID 31893513. Review in: Ann Intern Med. 2020 May 19;172(10):JC53
  4. ↑ January CT, Wann LS, Alpert JS, Calkins H, Cigarroa JE, Cleveland JC; et al. (2014). "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". J Am Coll Cardiol. 64 (21): e1–76. doi:10.1016/j.jacc.2014.03.022. PMID 24685669.
  5. ↑ 5.0 5.1 Alboni P, Botto GL, Baldi N, Luzi M, Russo V, Gianfranchi L; et al. (2004). "Outpatient treatment of recent-onset atrial fibrillation with the "pill-in-the-pocket" approach". N Engl J Med. 351 (23): 2384–91. doi:10.1056/NEJMoa041233. PMID 15575054.
  6. ↑ 6.0 6.1 6.2 6.3 Fuster V, Rydén LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA et al. (2006) ACC/AHA/ESC 2006 Guidelines 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 European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation): developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society. Circulation 114 (7):e257-354. DOI:10.1161/CIRCULATIONAHA.106.177292 PMID: 16908781
  7. ↑ 7.0 7.1 7.2 7.3 Fuster V, Rydén LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA et al. (2011) 2011 ACCF/AHA/HRS focused updates incorporated into the ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. Circulation 123 (10):e269-367. DOI:10.1161/CIR.0b013e318214876d PMID: 21382897
  8. ↑ 8.0 8.1 Perry M, Kemmis Betty S, Downes N, Andrews N, Mackenzie S, Guideline Committee (2021). "Atrial fibrillation: diagnosis and management-summary of NICE guidance". BMJ. 373: n1150. doi:10.1136/bmj.n1150. PMID 34020968 Check |pmid= value (help).
  9. ↑ Estes NA, Halperin JL, Calkins H, Ezekowitz MD, Gitman P, Go AS et al. (2008) ACC/AHA/Physician Consortium 2008 clinical performance measures for adults with nonvalvular atrial fibrillation or atrial flutter: a report of the American College of Cardiology/American Heart Association Task Force on Performance Measures and the Physician Consortium for Performance Improvement (Writing Committee to Develop Clinical Performance Measures for Atrial Fibrillation): developed in collaboration with the Heart Rhythm Society. Circulation 117 (8):1101-20. DOI:10.1161/CIRCULATIONAHA.107.187192 PMID: 18283199


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