Four updates to the guidelines are important for primary care physicians to review.
In a joint effort from the American Heart Association, the American College of Cardiology and the Heart Rhythm Society, the newest iteration of the 2014 guidelines for management of atrial fibrillation (AF) were released last in March 2014.
Four significant updates were made to this document that merit consideration by primary care physicians who treat patients with AF.
1. CHA2DS2-VASc score replaces CHADS2
The CHA2DS2-VASc score has a broader score range (0 to 9) and includes a larger number of risk factors than the CHADS2 score; it incorporates gender (adds women) and vascular disease and uses a wider age range (64 to 75 years [CHADS2 is age 75 years and older]). The guidelines recommend that CHA2DS2-VASc be the preferred tool used to estimate the risk of stroke and determine whether stroke prophylaxis is indicated. An important note is that women cannot ever achieve a score of 0 as there is one point given for gender.
2. Aspirin population narrowed
Aspirin has been de-emphasized for stroke prophylaxis. It may be reasonable to use aspirin in patients with a CHA2DS2-VASc score of 1 (Class IIb recommendation). Besides this group, which can also be treated with an oral anticoagulant, there is no other group in which aspirin therapy alone is recommended. In those with a CHA2DS2-VASc score of 0, antithrombotic therapy can be omitted (Class IIa).
3. New oral anticoagulants included
The novel oral anticoagulants (dabigatran, rivaroxaban and apixaban) should be strongly considered in those patients with nonvalvular AF who have INRs that are difficult to maintain within the therapeutic range.
4. Catheter ablation highlighted
Radiofrequency catheter ablation should be considered in patients in whom rhythm control is preferred and after one advanced antiarrhythmic drug has failed. In some instances, ablation may be considered as firt-line therapy.
It’s clear why the update was issued-the approval of multiple novel oral anticoagulants has dramatically altered the landscape of stroke prophylaxis in AF management. One of the most interesting controversies to reemerge, however, is the issue of rate vs rhythm control. The long-established dogma of “rate control for everyone” is challenged in these guidelines with catheter ablation (ie, rhythm control) being suggested as first-line therapy for selected patients.
It remains to be seen where the dust will settle on the role of atrial appendage exclusion devices in AF and whether novel antifibrotic drugs will enter the armamentarium of medical therapy for AF. Stay tuned.
January CT, Wann LS, Alpert JS, et al. 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. 2014 Mar 26. doi: 10.1016/j.jacc.2014.03.022. [Epub ahead of print].