The AAFP recently released an updated clinical practice guideline on the pharmacologic management of atrial fibrillation (AF). The new document replaces a 2003 guideline developed by the AAFP and the American College of Physicians that the Academy reaffirmed in 2008.
AF is one of the most common arrhythmias in adults, affecting as many as 6.1 million people in the United States, according to the CDC.(www.cdc.gov) The number of patients affected is expected to increase as the U.S. population ages, given that AF is more common in adults older than 65.
In addition to increases in mortality, myocardial infarction, heart failure exacerbation and cardiomyopathy, patients with AF have a significantly increased risk of stroke; almost a quarter of strokes in elderly patients are related to AF.
Overall, management options for AF involve controlling heart rate and/or rhythm and preventing thromboembolic events using medications, electrical cardioversion, ablation and/or other surgical interventions.
- The AAFP has issued a new guideline, "Pharmacologic Management of Newly Detected Atrial Fibrillation," that includes five key recommendations and updates a 2003 guideline from the AAFP and the American College of Physicians.
- The guideline is based on two systematic reviews of randomized controlled trials and prospective and retrospective observational studies published from 2000 to 2012, as well as an updated literature search that identified newer studies published through Dec. 31, 2015.
- A key update in the guideline is that it includes an analysis of newer oral anticoagulant drugs that have become available since 2003, when warfarin was the only option.
Stroke prophylaxis is key for patients with AF who have additional risk factors for stroke and includes vitamin K antagonists such as warfarin, as well as newer direct oral anticoagulants.
The AAFP's new guideline, "Pharmacologic Management of Newly Detected Atrial Fibrillation,"(531 KB PDF) outlines five key treatment recommendations and provides the rationale for each.
The revised guideline is based on two comparative effectiveness reviews from the Agency for Healthcare Research and Quality (AHRQ). Those systematic reviews evaluated randomized controlled trials (RCTs) and prospective and retrospective observational studies from 2000 to 2012. An additional literature search also was performed to identify newer studies published through Dec. 31, 2015.
The target audience for the guideline includes all primary care clinicians, and the target patient population includes adults who have paroxysmal, persistent or permanent AF -- as defined by electrocardiographic evidence -- with or without symptoms. The guideline does not apply to patients with AF that is caused by valvular disease or that is due to a reversible cause (e.g., post-myocardial infarction or hyperthyroidism).
The guideline was developed using a modified version of the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system developed by the GRADE working group(www.gradeworkinggroup.org) to evaluate the quality of the evidence and make recommendations based on the balance of benefits and harms.
The guideline's five main recommendations -- along with a number of ancillary recommendations -- are as follows:
Recommendation 1: For most patients with AF, controlling heart rate is preferred to controlling heart rhythm. This is a strong recommendation based on moderate-quality evidence.
Non-dihydropyridine calcium channel blockers and beta blockers are the preferred options for rate-control therapy. Rhythm control may be considered in certain instances based on patients' symptoms, exercise tolerance and preferences and may be an option for patients who fail rate-control therapy. This is a weak recommendation based on low-quality evidence.
Recommendation 2: The AAFP recommends lenient heart rate control (less than 110 beats per minute resting) rather than strict rate control (less than 80 beats per minute resting); this is a weak recommendation based on low-quality evidence.
Recommendation 3: Clinicians should discuss the risk of stroke and bleeding with all patients considering anticoagulation therapy. Consider using the continuous CHADS2 score, which assesses patient risk in terms of
- Congestive heart failure (or left ventricular systolic dysfunction);
- Hypertension (blood pressure consistently above 140/90 mmHg or treated hypertension on medication);
- Age (75 or older);
- Diabetes status; and
- History of Stroke or transient ischemic attack or thromboembolism
or the continuous CHA2DS2-VASc score, which examines additional stroke factors, as well as
- Vascular disease (e.g., peripheral artery disease, myocardial infarction, aortic plaque);
- Age (65-74); and
- Sex category (i.e., female sex)
to predict stroke risk. This is a weak recommendation based on low-quality evidence.
HAS-BLED, which assesses
- Abnormal renal and liver function,
- Labile international normalized ratios,
- Elderly, and
- Drugs or alcohol
should be used to predict bleeding risk in patients with AF. This also is a weak recommendation based on low-quality evidence.
Recommendation 4: Patients who have AF should receive chronic anticoagulation therapy unless they are at low risk of stroke or have specific contraindications. This is a strong recommendation that is based on high-quality evidence.
Choice of anticoagulation therapy should be based on patient preferences and patient history. Options include warfarin (Coumadin, Jantoven), apixaban (Eliquis), dabigatran (Pradaxa), edoxaban (Savaysa) and rivaroxaban (Xarelto).
Recommendation 5: The AAFP strongly recommends against dual treatment with anticoagulant and antiplatelet therapy in most patients who have AF; this strong recommendation is based on moderate-quality evidence.
Notes From Guideline Co-author
Kenneth Lin, M.D., M.P.H., of Washington, D.C., represented the AAFP's Commission on Health of the Public and Science on the guideline creation team. Lin told AAFP News the group began by reviewing the recommendations from the 2003 guideline and then prioritized questions that were most relevant to primary care and that had been reviewed in the updated AHRQ evidence reports.
"For example, we decided not to cover management strategies around cardioversion because although some FPs do this, the updated evidence report did not include relevant new evidence," he said.
According to Lin, the biggest update in the newly released AF guideline is that it includes an analysis of the oral anticoagulant drugs that have become available since 2003, when warfarin was the only option.
"We found that their benefits and adverse effects were similar enough to each other and to warfarin that we decided not to express a preference for any particular drug over another," he said.
Another update is that various stroke risk and bleeding scores have been evaluated, which can help FPs determine whether their patients with AF are good candidates for anticoagulation and assist with shared decision-making.
Additionally, in contrast to the 2014 guideline for management of AF(circ.ahajournals.org) from the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society, the AAFP team found that evidence supported a lenient -- rather than strict -- approach to heart rate control for most patients because it offers similar benefits and fewer harms, said Lin. The AAFP's guideline development group also found the CHADS2 stroke risk score was not inferior to the CHA2DS2-VASc score, which has more variables but no greater predictive power.
As to future research needs in pharmacologic management of AF, Lin said there was a dearth of studies comparing the effectiveness of different rate-control medications on long-term outcomes such as symptom control, quality of life and mortality.
Furthermore, he said, it would be useful to have RCTs comparing the effectiveness and harms of direct oral anticoagulants, especially in specific subpopulations (e.g., patients with multiple comorbidities or those with kidney disease).
Finally, regarding the overall value of this guideline to family physicians, Lin stated: "This is a high-quality guideline on an important clinical topic developed by a group of nonconflicted family physicians for family physicians, using a rigorous evidence-based process."
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