Society Guidelines
The 2020 Canadian Cardiovascular Society/Canadian Heart Rhythm Society Comprehensive Guidelines for the Management of Atrial Fibrillation

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Abstract

The Canadian Cardiovascular Society (CCS) atrial fibrillation (AF) guidelines program was developed to aid clinicians in the management of these complex patients, as well as to provide direction to policy makers and health care systems regarding related issues. The most recent comprehensive CCS AF guidelines update was published in 2010. Since then, periodic updates were published dealing with rapidly changing areas. However, since 2010 a large number of developments had accumulated in a wide range of areas, motivating the committee to complete a thorough guideline review. The 2020 iteration of the CCS AF guidelines represents a comprehensive renewal that integrates, updates, and replaces the past decade of guidelines, recommendations, and practical tips. It is intended to be used by practicing clinicians across all disciplines who care for patients with AF. The Grading of Recommendations, Assessment, Development and Evaluations (GRADE) system was used to evaluate recommendation strength and the quality of evidence. Areas of focus include: AF classification and definitions, epidemiology, pathophysiology, clinical evaluation, screening and opportunistic AF detection, detection and management of modifiable risk factors, integrated approach to AF management, stroke prevention, arrhythmia management, sex differences, and AF in special populations. Extensive use is made of tables and figures to synthesize important material and present key concepts. This document should be an important aid for knowledge translation and a tool to help improve clinical management of this important and challenging arrhythmia.

Résumé

Le programme de lignes directrices de la Société canadienne de cardiologie (SCC) en matière de fibrillation auriculaire (FA) a été élaboré pour aider les cliniciens à prendre en charge ces patients complexes, ainsi que pour orienter les décideurs politiques et les systèmes de soins de santé sur des questions connexes. La dernière édition complète des lignes directrices de la SCC en matière de FA a été publiée en 2010. Depuis lors, des mises à jour périodiques ont été publiées, traitant de domaines en évolution rapide. Cependant, en 2020, un grand nombre de développements s'y étaient ajoutés, couvrant un large éventail de domaines, ce qui a motivé le comité à créer une refonte complète des lignes directrices. L'édition 2020 des lignes directrices de la SCC en matière de FA représente un renouvellement complet qui intègre, met à jour et remplace les lignes directrices, les recommandations et les conseils pratiques des dix dernières années. Elle est destinée à être utilisée par les cliniciens praticiens de toutes les disciplines qui s'occupent de patients souffrant de FA. L'approche GRADE (Gradation des Recommandations, de l’Appréciation, du Développement et des Évaluations) a été utilisée pour évaluer la pertinence des recommandations et la qualité des résultats. Les domaines d'intérêt incluent : la classification et les définitions de la FA, son épidémiologie, sa physiopathologie, l’évaluation clinique, le dépistage de la FA, la détection et la gestion des facteurs de risque modifiables, l’approche intégrée de la gestion de la FA, la prévention des accidents vasculaires cérébraux, la gestion de l'arythmie, les différences entre les sexes et la FA dans des populations particulières. Des tableaux et figures ont été largement utilisés pour synthétiser les éléments importants et présenter les concepts clés. Ce document devrait représenter une aide importante pour l’intégration des connaissances et un outil pour aider à améliorer la gestion clinique de cette arythmie importante et difficile à traiter.

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:

  • 1.

    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)

  • D.G. Wyse et al.

    Lone atrial fibrillation: does it exist?

    J Am Coll Cardiol

    (2014)
  • C.C. Cheung et al.

    Reversible or provoked atrial fibrillation?: The devil in the details

    JACC Clin Electrophysiol

    (2018)
  • L. Macle et al.

    The 2014 atrial fibrillation guidelines companion: a practical approach to the use of the Canadian Cardiovascular Society guidelines

    Can J Cardiol

    (2015)
  • P.A. Noseworthy et al.

    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

    (2016)
  • W.B. Kannel et al.

    Prevalence, incidence, prognosis, and predisposing conditions for atrial fibrillation: population-based estimates

    Am J Cardiol

    (1998)
  • C.D. Furberg et al.

    Prevalence of atrial fibrillation in elderly subjects (the Cardiovascular Health Study)

    Am J Cardiol

    (1994)
  • S. Rietbrock et al.

    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

    (2008)
  • P. Dorian et al.

    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

    (2000)
  • S.N. Singh et al.

    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

    (2006)
  • Y. Kang

    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

    (2006)
  • B. Bruggenjurgen et al.

    The impact of atrial fibrillation on the cost of stroke: the Berlin Acute Stroke study

    Value Health

    (2007)
  • C.T. Ruff et al.

    Comparison of the efficacy and safety of new oral anticoagulants with warfarin in patients with atrial fibrillation: a meta-analysis of randomised trials

    Lancet

    (2014)
  • D.J. O’Reilly et al.

    The burden of atrial fibrillation on the hospital sector in Canada

    Can J Cardiol

    (2013)
  • P. Meyre et al.

    Risk of hospital admissions in patients with atrial fibrillation: a systematic review and meta-analysis

    Can J Cardiol

    (2019)
  • K. Nishida et al.

    Atrial fibrillation ablation: translating basic mechanistic insights to the patient

    J Am Coll Cardiol

    (2014)
  • R.K. Pathak et al.

    Aggressive risk factor reduction study for atrial fibrillation and implications for the outcome of ablation: the ARREST-AF cohort study

    J Am Coll Cardiol

    (2014)
  • M. Haissaguerre et al.

    Frequency of recurrent atrial fibrillation after catheter ablation of overt accessory pathways

    Am J Cardiol

    (1992)
  • B. Brembilla-Perrot et al.

    Prediction of atrial fibrillation in patients with supraventricular tachyarrhythmias treated with catheter ablation or not. Classical scores are not useful

    Int J Cardiol

    (2016)
  • P. Dorian et al.

    A novel, simple scale for assessing the symptom severity of atrial fibrillation at the bedside: the CCS-SAF scale

    Can J Cardiol

    (2006)
  • K. Miura et al.

    Treatment strategies and subsequent changes in the patient-reported quality-of-life among elderly patients with atrial fibrillation

    Am Heart J

    (2020)
  • J.E. Tarride et al.

    Is screening for atrial fibrillation in Canadian family practices cost-effective in patients 65 years and older?

    Can J Cardiol

    (2018)
  • E.G. Daoud et al.

    Temporal relationship of atrial tachyarrhythmias, cerebrovascular events, and systemic emboli on the basis of stored device data: a subgroup analysis of TRENDS

    Heart Rhythm

    (2011)
  • Canadian Cardiovascular Society Consensus Conference on Atrial Fibrillation

    Can J Cardiol

    (1996)
  • 2004 Canadian Cardiovascular Society Consensus Conference: Atrial Fibrillation

    Can J Cardiol

    (2005)
  • G.H. Guyatt et al.

    GRADE: an emerging consensus on rating quality of evidence and strength of recommendations

    BMJ

    (2008)
  • E.I. Charitos et al.

    Atrial fibrillation burden estimates derived from intermittent rhythm monitoring are unreliable estimates of the true atrial fibrillation burden

    Pacing Clin Electrophysiol

    (2014)
  • T. Vanassche et al.

    Risk of ischaemic stroke according to pattern of atrial fibrillation: analysis of 6563 aspirin-treated patients in ACTIVE-A and AVERROES

    Eur Heart J

    (2015)
  • D. Atar et al.

    The association between patterns of atrial fibrillation, anticoagulation, and cardiovascular events

    Europace

    (2020)
  • J.G. Andrade et al.

    Association of atrial fibrillation episode duration with arrhythmia recurrence following ablation: a secondary analysis of a randomized clinical trial

    JAMA Netw Open

    (2020)
  • M.J. Quon et al.

    Is secondary atrial fibrillation different? Or Is atrial fibrillation just atrial fibrillation?

    Canadian Journal of General Internal Medicine

    (2018)
  • S.J. Connolly et al.

    Dabigatran versus warfarin in patients with atrial fibrillation

    N Engl J Med

    (2009)
  • M.R. Patel et al.

    Rivaroxaban versus warfarin in nonvalvular atrial fibrillation

    N Engl J Med

    (2011)
  • C.B. Granger et al.

    Apixaban versus warfarin in patients with atrial fibrillation

    N Engl J Med

    (2011)
  • S.J. Connolly et al.

    Apixaban in patients with atrial fibrillation

    N Engl J Med

    (2011)
  • R.P. Giugliano et al.

    Edoxaban versus warfarin in patients with atrial fibrillation

    N Engl J Med

    (2013)
  • K.C. Siontis et al.

    Direct oral anticoagulants in patients with atrial fibrillation and valvular heart disease other than significant mitral stenosis and mechanical valves: a meta-analysis

    Circulation

    (2017)
  • J. Andrade et al.

    The clinical profile and pathophysiology of atrial fibrillation: relationships among clinical features, epidemiology, and mechanisms

    Circ Res

    (2014)
  • J.P. Piccini et al.

    Incidence and prevalence of atrial fibrillation and associated mortality among Medicare beneficiaries, 1993-2007

    Circ Cardiovasc Qual Outcomes

    (2012)
  • W.B. Kannel et al.

    Epidemiologic features of chronic atrial fibrillation: the Framingham study

    N Engl J Med

    (1982)
  • C.E. Chiang et al.

    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

    (2012)
  • Cited by (323)

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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.

    For a full listing of primary and secondary panel members, see Supplemental Appendix S1.

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