Society GuidelinesThe 2020 Canadian Cardiovascular Society/Canadian Heart Rhythm Society Comprehensive Guidelines for the Management of Atrial Fibrillation
Section snippets
Preamble and Guideline Development Methodology
This document was developed in accordance with CCS best practices and the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach.9 The primary panelists developed the scope of the document, identified topics for review, performed the literature review, evaluated the quality of the evidence, and drafted the recommendations. A systematic search was performed to identify relevant studies within each topic, including systematic reviews and meta-analyses. Draft
Classification on the basis of clinical pattern of AF
AF pattern is defined on the basis of clinical assessment of episode persistence. These patterns have been used to characterize the severity of disease, define patient populations in clinical trials, and are used to form the basis of therapeutic recommendations regarding pharmacological and invasive arrhythmia management.10
Four main clinical patterns of AF have been described. Paroxysmal AF is defined as a continuous AF episode lasting longer than 30 seconds but terminating within 7 days of
Incidence and prevalence
AF is the most common sustained arrhythmia encountered in clinical practice.29 Current evidence suggests that the prevalence of AF is 1%-2% in the general population, and increases significantly with age (< 1.0% up to 50 years of age, to 4% at 65 years, and 12% of those 80 years of age or older).29,30 Although the incidence has been relatively stable over time (approximately 28 per 1000 person-years), the overall prevalence of AF is increasing because of changing population demographics (eg,
Pathophysiology and Risk Factors
AF is a complex and multifaceted condition ranging from an isolated electrophysiological disorder or, more commonly, a manifestation or consequence of other cardiac and noncardiac pathologies (Table 1, Fig. 2).19 AF generally results from a combination of focal ectopic activity and reentry.29,60 Ectopic atrial foci arise from perturbations that cause cells to spontaneously depolarize, either secondary to enhanced automaticity or, more frequently, to triggered activity from afterdepolarizations.
Clinical Evaluation
The purpose of the initial evaluation of a patient with AF is to establish the magnitude and severity of symptoms attributable to AF, identify the underlying etiology and precipitants of AF, establish prognosis, and develop a therapeutic strategy for symptom relief and morbidity mitigation (Fig. 4).
Opportunistic AF detection in the general population
AF screening initiatives have emerged with the availability of safe and effective stroke prevention therapy, well defined stroke risk schemes, and new technologies that have simplified AF monitoring. Because a large number of patients with AF might be asymptomatic, screening might provide an opportunity for AF detection with early initiation of stroke prevention therapy to reduce the risk of AF-related complications.
The effects of screening (eg, opportunistic case finding or systematic
Detection and Management of Modifiable Risk Factors
Modifiable cardiovascular risk factors are well recognized contributors to the development and progression of AF.29,65,66 These established, emerging, and potential risk factors for AF have been summarized in section 3, and Table 1, Table 2. The risk of developing AF increases with the severity and number of modifiable cardiovascular risk factors (such as hypertension, diabetes mellitus, and obesity). In many cases this risk increase is linear within and between risk factors and might be
Integrated Approach to AF Management
As with many other chronic cardiovascular conditions, the complex and multifaceted nature of AF necessitates a systematic approach to the management of the AF patient. Much of the initial management of AF can be provided by primary care providers with the support of specialist cardiology input to guide management decisions in selected AF patients who develop problems or complications during therapy. Dedicated multidisciplinary clinics specifically focused on integrated AF care have been
Stroke risk assessment
Observations from the Framingham cohort and subsequent clinical trials revealed that NVAF is an independent risk factor for stroke (annual incidence of approximately 4.1%-4.5%) and combined stroke/systemic embolism (annual incidence of 50%).70,169 The risk was further refined by the delineation of various baseline characteristics that might affect the risk of the stroke.169, 170, 171, 172, 173 The first widely adopted tool for stroke risk assessment was the Congestive Heart Failure, H
Acute management of AF
The acute management of AF is centred on the following domains:
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Determination if AF is the primary concern (“primary AF”) or secondary to another acute medical illness (“secondary AF”). AF in the setting of critical illness has been associated with an increased risk of death (see section 11.5).505,506 Unfortunately, there is a paucity of high-quality evidence on whether or how to treat AF patients in the setting of critical illness,507,508 and there is a wide variety of reported approaches to AF
Sex Differences in Patients With AF
Recognition of sex differences offers an opportunity to improve outcomes in women with AF.659
Device-detected AF
By convention, and on the basis of somewhat arbitrary definitions, the diagnosis of AF requires ECG documentation of an irregular rhythm with no discernible, distinct P waves, lasting at least 30 seconds. Contrary to this widely accepted threshold for AF diagnosis, the minimal duration of incessant AF that a patient should manifest before warranting OAC for stroke prevention remains a matter of debate, even in the presence of other stroke risk factors. The uncertainty relates to the few studies
Acknowledgements
The authors thank Ms Christianna Brooks (CCS) for her assistance and outstanding contribution throughout the guideline writing process. We are indebted to Marc Bains (patient partner, HeartLife Foundation), Andrew Campbell (Emergency Medicine), James Douketis (Thrombosis Canada), Jasmine Grewal (Adult Congenital Cardiology), Saurabh Gupta (Cardiac Surgery), Thalia Field (Stroke Neurology), Jenny MacGillivray (Pharmacist), Arianne Marelli (Adult Congenital Cardiology), Michael McDonald (Canadian
References (885)
- et al.
The Canadian Cardiovascular Society Atrial Fibrillation Guidelines Program: a look back over the last 10 years and a look forward
Can J Cardiol
(2020) - et al.
Canadian Cardiovascular Society atrial fibrillation guidelines 2010: prevention of stroke and systemic thromboembolism in atrial fibrillation and flutter
Can J Cardiol
(2011) - et al.
Focused 2012 update of the Canadian Cardiovascular Society atrial fibrillation guidelines: recommendations for stroke prevention and rate/rhythm control
Can J Cardiol
(2012) - et al.
2014 focused update of the Canadian Cardiovascular Society Guidelines for the management of atrial fibrillation
Can J Cardiol
(2014) - et al.
2016 Focused update of the Canadian Cardiovascular Society guidelines for the management of atrial fibrillation
Can J Cardiol
(2016) - et al.
2018 Focused update of the Canadian Cardiovascular Society guidelines for the management of atrial fibrillation
Can J Cardiol
(2018) - et al.
Contemporary atrial fibrillation management: a comparison of the current AHA/ACC/HRS, CCS, and ESC guidelines
Can J Cardiol
(2017) - et al.
Clinical classifications of atrial fibrillation poorly reflect its temporal persistence: insights from 1,195 patients continuously monitored with implantable devices
J Am Coll Cardiol
(2014) - et al.
Clinical assessment of AF pattern is poorly correlated with AF burden and post ablation outcomes: a CIRCA-DOSE sub-study
J Electrocardiol
(2020) - et al.
Pattern of atrial fibrillation and risk of outcomes: the Loire Valley Atrial Fibrillation Project
Int J Cardiol
(2013)
Lone atrial fibrillation: does it exist?
J Am Coll Cardiol
Reversible or provoked atrial fibrillation?: The devil in the details
JACC Clin Electrophysiol
The 2014 atrial fibrillation guidelines companion: a practical approach to the use of the Canadian Cardiovascular Society guidelines
Can J Cardiol
Comparative effectiveness and safety of non-vitamin K antagonist oral anticoagulants versus warfarin in patients with atrial fibrillation and valvular heart disease
Int J Cardiol
Prevalence, incidence, prognosis, and predisposing conditions for atrial fibrillation: population-based estimates
Am J Cardiol
Prevalence of atrial fibrillation in elderly subjects (the Cardiovascular Health Study)
Am J Cardiol
Chronic atrial fibrillation: incidence, prevalence, and prediction of stroke using the Congestive heart failure, Hypertension, Age >75, Diabetes mellitus, and prior Stroke or transient ischemic attack (CHADS2) risk stratification scheme
Am Heart J
The impairment of health-related quality of life in patients with intermittent atrial fibrillation: implications for the assessment of investigational therapy
J Am Coll Cardiol
Quality of life and exercise performance in patients in sinus rhythm versus persistent atrial fibrillation: a Veterans Affairs Cooperative Studies Program substudy
J Am Coll Cardiol
Relation of atrial arrhythmia-related symptoms to health-related quality of life in patients with newly diagnosed atrial fibrillation: a community hospital-based cohort
Heart Lung
The impact of atrial fibrillation on the cost of stroke: the Berlin Acute Stroke study
Value Health
Comparison of the efficacy and safety of new oral anticoagulants with warfarin in patients with atrial fibrillation: a meta-analysis of randomised trials
Lancet
The burden of atrial fibrillation on the hospital sector in Canada
Can J Cardiol
Risk of hospital admissions in patients with atrial fibrillation: a systematic review and meta-analysis
Can J Cardiol
Atrial fibrillation ablation: translating basic mechanistic insights to the patient
J Am Coll Cardiol
Aggressive risk factor reduction study for atrial fibrillation and implications for the outcome of ablation: the ARREST-AF cohort study
J Am Coll Cardiol
Frequency of recurrent atrial fibrillation after catheter ablation of overt accessory pathways
Am J Cardiol
Prediction of atrial fibrillation in patients with supraventricular tachyarrhythmias treated with catheter ablation or not. Classical scores are not useful
Int J Cardiol
A novel, simple scale for assessing the symptom severity of atrial fibrillation at the bedside: the CCS-SAF scale
Can J Cardiol
Treatment strategies and subsequent changes in the patient-reported quality-of-life among elderly patients with atrial fibrillation
Am Heart J
Is screening for atrial fibrillation in Canadian family practices cost-effective in patients 65 years and older?
Can J Cardiol
Temporal relationship of atrial tachyarrhythmias, cerebrovascular events, and systemic emboli on the basis of stored device data: a subgroup analysis of TRENDS
Heart Rhythm
Canadian Cardiovascular Society Consensus Conference on Atrial Fibrillation
Can J Cardiol
2004 Canadian Cardiovascular Society Consensus Conference: Atrial Fibrillation
Can J Cardiol
GRADE: an emerging consensus on rating quality of evidence and strength of recommendations
BMJ
Atrial fibrillation burden estimates derived from intermittent rhythm monitoring are unreliable estimates of the true atrial fibrillation burden
Pacing Clin Electrophysiol
Risk of ischaemic stroke according to pattern of atrial fibrillation: analysis of 6563 aspirin-treated patients in ACTIVE-A and AVERROES
Eur Heart J
The association between patterns of atrial fibrillation, anticoagulation, and cardiovascular events
Europace
Association of atrial fibrillation episode duration with arrhythmia recurrence following ablation: a secondary analysis of a randomized clinical trial
JAMA Netw Open
Is secondary atrial fibrillation different? Or Is atrial fibrillation just atrial fibrillation?
Canadian Journal of General Internal Medicine
Dabigatran versus warfarin in patients with atrial fibrillation
N Engl J Med
Rivaroxaban versus warfarin in nonvalvular atrial fibrillation
N Engl J Med
Apixaban versus warfarin in patients with atrial fibrillation
N Engl J Med
Apixaban in patients with atrial fibrillation
N Engl J Med
Edoxaban versus warfarin in patients with atrial fibrillation
N Engl J Med
Direct oral anticoagulants in patients with atrial fibrillation and valvular heart disease other than significant mitral stenosis and mechanical valves: a meta-analysis
Circulation
The clinical profile and pathophysiology of atrial fibrillation: relationships among clinical features, epidemiology, and mechanisms
Circ Res
Incidence and prevalence of atrial fibrillation and associated mortality among Medicare beneficiaries, 1993-2007
Circ Cardiovasc Qual Outcomes
Epidemiologic features of chronic atrial fibrillation: the Framingham study
N Engl J Med
Distribution and risk profile of paroxysmal, persistent, and permanent atrial fibrillation in routine clinical practice: insight from the real-life global survey evaluating patients with atrial fibrillation international registry
Circ Arrhythm Electrophysiol
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The disclosure information of the authors and reviewers is available from the CCS on their guidelines library at www.ccs.ca.
This statement was developed following a thorough consideration of medical literature and the best available evidence and clinical experience. It represents the consensus of a Canadian panel comprised of multidisciplinary experts on this topic with a mandate to formulate disease-specific recommendations. These recommendations are aimed to provide a reasonable and practical approach to care for specialists and allied health professionals obliged with the duty of bestowing optimal care to patients and families, and can be subject to change as scientific knowledge and technology advance and as practice patterns evolve. The statement is not intended to be a substitute for physicians using their individual judgement in managing clinical care in consultation with the patient, with appropriate regard to all the individual circumstances of the patient, diagnostic and treatment options available and available resources. Adherence to these recommendations will not necessarily produce successful outcomes in every case.
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For a full listing of primary and secondary panel members, see Supplemental Appendix S1.