Elsevier

Canadian Journal of Cardiology

Volume 28, Issue 2, March–April 2012, Pages 125-136
Canadian Journal of Cardiology

Society guidelines
Focused 2012 Update of the Canadian Cardiovascular Society Atrial Fibrillation Guidelines: Recommendations for Stroke Prevention and Rate/Rhythm Control

https://doi.org/10.1016/j.cjca.2012.01.021Get rights and content

Abstract

The Canadian Cardiovascular Society (CCS) published the complete set of 2010 Atrial Fibrillation (AF) Guidelines in the January, 2011 issue of the Canadian Journal of Cardiology. During its deliberations, the CCS Guidelines Committee engaged to a timely review of future evidence, with periodic composition of focused updates to address clinically important advances. In 2011, results were published from 3 pivotal AF trials: the Rivaroxaban Once Daily Oral Direct Factor Xa Inhibition Compared with Vitamin K Antagonist for Prevention of Stroke and Embolism Trial in Atrial Fibrillation (ROCKET-AF), the Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation (ARISTOTLE) study, and the Permanent Atrial Fibrillation Outcome Study Using Dronedarone on Top of Standard Therapy (PALLAS), comparing dronedarone with placebo in patients with permanent AF and additional cardiovascular disease risk-factor burden. Each of these large randomized trials provided clear results with major implications for AF management. Other important evidence that has emerged since the 2010 Guidelines includes findings about prediction instruments for AF-associated stroke and bleeding risk, stroke risk in paroxysmal-AF patients, risk-benefit considerations related to oral anticoagulation in patients with chronic kidney disease, and risk/benefit considerations in the use of antiplatelet agents, alone and in combination with each other or with oral anticoagulants, in AF patients. The Guidelines Committee judged that this extensive and important new evidence required focused updating of the 2010 Guidelines with respect to stroke prevention and rate/rhythm control. This report presents the details of the new recommendations, along with the background and rationale.

Résumé

La Société canadienne de cardiologie (SCC) a publié l'ensemble des lignes directrices de 2010 en matière de fibrillation auriculaire (FA) dans le numéro de janvier 2011 du Journal canadien de cardiologie. Au cours de ses discussions, le comité des lignes directrices de la SCC s'est engagé à revoir régulièrement les nouvelles données par la rédaction périodique de mises à jour ciblées portant sur les avancées cliniques importantes. En 2011, les résultats de 3 essais pivots sur la FA ont été publiés : le ROCKET-AF (Rivaroxaban Once Daily Oral Direct Factor Xa Inhibition Compared with Vitamin K Antagonist for Prevention of Stroke and Embolism Trial in Atrial Fibrillation), l'étude ARISTOTLE (Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation) et le PALLAS (Permanent Atrial Fibrillation Outcome Study Using Dronedarone on Top of Standard Therapy), qui compare le dronédarone au placébo chez les patients ayant une FA permanente et des facteurs de risque cardiovasculaire additionnels. Chacun de ces essais hasardisés de grande envergure a fourni des résultats clairs sur les importantes conséquences de la prise en charge de la FA. Les autres données probantes importantes qui sont ressorties depuis la publication des lignes directrices 2010 incluaient les conclusions sur les outils de prédiction du risque d'accident vasculaire cérébral et d'hémorragie associé à la FA, du risque d'accident vasculaire cérébral chez les patients ayant une FA paroxystique, les considérations risques-avantages liés à l'anticoagulation orale chez les patients ayant une maladie rénale chronique (MRC) et les considérations risques-avantages de l'utilisation d'agents antiplaquettaires, seuls ou en combinaison avec d'autres agents antiplaquettaires ou agents anticoagulants oraux, chez les patients ayant une FA. Le comité des lignes directrices a estimé que ces nouvelles données probantes, importantes et exhaustives exigeaient une mise à jour ciblée des lignes directrices 2010 en ce qui a trait à la prévention des accidents vasculaires cérébraux, le maintien du rythme et la maîtrise de la fréquence. Ce rapport présente de manière détaillée les nouvelles recommandations, ainsi que leur fondement et leurs justifications.

Section snippets

Predicting stroke risk

The Congestive Heart Failure, Hypertension, Age > 75, Diabetes Mellitus, and Prior Stroke or Transient Ischemic Attack (CHADS2) index2 assigns 1 point each for congestive heart failure, hypertension, age > 75, and diabetes, and 2 points for history of stroke or transient ischemic attack (TIA). It has been well validated, with the annual stroke rate increasing by about 2.0% for each 1-point increase in CHADS2 score (from 1.9% with a score of 0 to 18.2% with a score of 6).2, 3 A recent systematic

Updated risk/benefit assessment for dronedarone

The “A Placebo-Controlled, Double-Blind, Parallel Arm Trial to Assess the Efficacy of Dronedarone 400 mg bid for the Prevention of Cardiovascular Hospitalization or Death From Any Cause in Patients With Atrial Fibrillation/Atrial Flutter” (ATHENA) trial evaluated the safety and efficacy of dronedarone therapy in 4628 higher risk patients with AF or AFL (paroxysmal or persistent with sinus rhythm restoration planned).49 After a mean follow-up of 21 ± 5 months, there was a reduction in the

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    The disclosure information of the authors and reviewers is available from the CCS on the following websites: www.ccs.ca and www.ccsguidelineprograms.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.

    A complete list of the Canadian Cardiovascular Society Atrial Fibrillation Guidelines Committee primary and secondary panels is available in Supplemental Appendix S1.

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