Canadian cardiovascular society sets new guidelines for atrial fibrillation management and treatment

AF is an irregular and often rapid heart rate that can increase the risk of stroke, heart failure, and other heart-related complications. It is the most common cardiac arrhythmia and the leading cause of stroke in the elderly.

"The development of guidelines has been a key activity of the CCS for over a decade," explained co-chairs Laurent Macle, MD, of the Montreal Heart Institute, Université de Montréal, Montreal, Quebec, and Atul Verma, MD, of the Southlake Regional Health Centre, Newmarket, Ontario, Canada. "Well-developed guidelines have the potential to improve the quality of cardiovascular care, lead to better patient outcomes, improve cost-effectiveness, and highlight areas for further research."

This update represents the consensus of a multidisciplinary panel of topic experts with a mandate to formulate disease-specific recommendations. The original guidelines were developed in 2010 by the Canadian Cardiovascular Society (CCS) AF Guidelines committee and are reviewed every two years. This is the third Focused Update.

This 2016 Focused Update makes important evidence-based recommendations on:

• Management of antithrombotic therapy for AF patients with various clinical presentations of coronary artery disease (CAD)
• Real-life data with non-vitamin K antagonist oral anticoagulants (NOACs)
• Use of antidotes for the reversal of NOACs
• Digoxin as a rate-control agent
• Perioperative anticoagulation management
• AF surgical therapy including the prevention and treatment of AF following cardiac surgery

An important change in this update is that for patients with AF in association with CAD who are indicated for anticoagulation therapy, a NOAC is preferred over warfarin.

For patients with AF, with an indication for primary CAD prevention or stable CAD/arterial vascular disease, the selection of antithrombotic therapy should be based on their risk of stroke.

For patients with AF and recent elective PCI, the selection of antithrombotic therapy should also be based on their risk of stroke.

For patients with AF in association with non ST-elevation acute coronary syndrome (NSTEACS) or ST-elevation myocardial infarction (STEMI), the management of antithrombotic therapy is based on the risk of stroke and whether PCI is performed.

Details of the updated recommendations are presented, along with their background and rationale. Standards, individual studies, and literature were reviewed for quality and bias. The update also includes a section on concomitant AF and coronary artery disease, which was developed in collaboration with the CCS antiplatelet (APT) guidelines committee. An updated summary of all CCS AF Guidelines recommendations, from 2010 to the present 2016 Focused Update, are provided in an Online Supplement.