This focused update for the management of patients with atrial fibrillation (AFib) includes revised recommendations on catheter ablation and the management of AFib complicating acute coronary syndrome. A new section on device detection of AF and weight loss has also been added.

This focused update for the management of patients with atrial fibrillation (AFib) by the AHA/ACC/HRS (American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society) includes revisions to catheter ablation of AF and the management of AF complicating acute coronary syndrome. A new section on device detection of AF and weight loss has also been added.

Recommendations on rhythm control

Electrical and pharmacological cardioversion of AF and atrial flutter

Prevention of thromboembolism

1. For patients with AF or atrial flutter of 48 hours’ duration or longer, or when the duration of AF is unknown, anticoagulation with any of the following is recommended:

• Warfarin (INR 2.0 to 3.0)
• Factor Xa inhibitor
• Direct thrombin inhibitor

Anticoagulation is recommended for at least 3 weeks before and at least 4 weeks after cardioversion, irrespective of the CHA2DS2-VASc score or the method used to restore sinus rhythm.

2. Anticoagulation should be initiated as soon as possible in patients with AFib or atrial flutter (of more than 48 hours’ duration or unknown duration) who require immediate cardioversion for haemodynamic instability. Anticoagulation should be continued for at least 4 weeks after cardioversion unless contraindicated.
3. After cardioversion for AFib of any duration, the decision about long-term anticoagulation therapy should be based on the thromboembolic risk profile and bleeding risk profile.
4. For patients with AFib or atrial flutter of less than 48 hours’ duration with a CHA2DS2-VASc score of ≥2 in men and ≥3 or in women, administration of heparin, a factor Xa inhibitor, or a direct thrombin inhibitor is reasonable as soon as possible before cardioversion, followed by long-term anticoagulation therapy.
5. For patients with AFib or atrial flutter (of 48 hours’ duration or longer or of unknown duration) who have not been anticoagulated for the preceding 3 weeks, it is reasonable to perform transesophageal echocardiography before cardioversion and proceed with cardioversion if no left atrial thrombus is identified, including in the LAA, provided that anticoagulation is achieved before transesophageal echocardiography and maintained after cardioversion for at least 4 weeks.
6. For patients with AFib or atrial flutter of less than 48 hours’ duration with a CHA2DS2-VASc score of 0 in men or 1 in women, administration of heparin, a factor Xa inhibitor, or a direct thrombin inhibitor, versus no anticoagulant therapy, may be considered before cardioversion, without the need for postcardioversion oral anticoagulation.

AFib catheter ablation to maintain sinus rhythm in heart failure

In selected patients with symptomatic AFib and heart failure with reduced left ventricular (LV) ejection fraction (HFrEF), AFib catheter ablation may be reasonable to potentially lower mortality rate and reduce hospitalisation.

Specific patient groups and atrial fibrillation

AFib complicating acute coronary syndrome

1. Anticoagulation is recommended for patients with acute coronary syndrome (ACS) and AFib at increased risk of systemic thromboembolism (CHA2DS2-VASc risk score of ≥ 2).
2. Urgent direct-current cardioversion of new-onset AFib in the setting of ACS is recommended in patients with

• Haemodynamic compromise
• Ongoing ischaemia
• Inadequate rate control

3. Intravenous beta blockers are recommended to slow a rapid ventricular response to AFib in patients with ACS who do not display heart failure (HF), haemodynamic instability, or bronchospasm.
4. Clopidogrel is recommended in patients with AFib at increased risk of stroke (CHA2DS2-VASc risk score ≥ 2) who are prescribed triple therapy (oral anticoagulant, aspirin, and P2Y12 inhibitor) and have undergone percutaneous coronary intervention (PCI) with stenting for ACS.
5. Compared to triple therapy, the following is recommended in patients with AFib at increased risk of stroke (CHA2DS2-VASc risk score ≥ 2) and who have undergone PCI with stenting for ACS,

• Double therapy with a P2Y12 inhibitor (clopidogrel or ticagrelor) and dose-adjusted vitamin K antagonist
• Double therapy with P2Y12 inhibitors (clopidogrel) and low-dose rivaroxaban 15 mg daily
• Double therapy with a P2Y12 inhibitor (clopidogrel) and dabigatran 150 mg twice daily

6. If triple therapy (oral anticoagulant, aspirin, and P2Y12 inhibitor) is prescribed for patients with AFib who are at increased risk of stroke (based on CHA2DS2-VASc risk score ≥ 2) and who have undergone PCI with stenting (drug eluting or bare metal) for ACS, a transition to double therapy (oral anticoagulant and P2Y12 inhibitor) at 4 to 6 weeks may be considered.
7. Administration of amiodarone or digoxin may be considered to slow a rapid ventricular response in patients with ACS and AFib associated with severe LV dysfunction and HF or haemodynamic instability.
8. Only in the absence of significant HF or haemodynamic instability, the use of nondihydropyridine calcium antagonists may be considered to slow a rapid ventricular response in patients with ACS and AFib.

Device detection of AFib and atrial flutter

In patients with cardiac implantable electronic devices (pacemakers or implanted cardioverter-defibrillators), the presence of recorded atrial high-rate episodes (AHREs) may help evaluate clinically relevant AF.

Implantation of a cardiac monitor (loop recorder) is a reasonable option in patients with cryptogenic stroke, in whom external ambulatory monitoring is inconclusive. This helps to optimise detection of silent AF.

Weight loss

Weight loss, combined with risk factor modification, is recommended for overweight and obese patients with AF.