Practice Guidelines

Management of Atrial Fibrillation: Updated Guidance from the AHA, ACC, and HRS


Am Fam Physician. 2020 Jan 15;101(2):123-124.

Author disclosure: No relevant financial affiliations.

Key Points for Practice

• Anticoagulation is recommended for AF at a CHA2DS2-VASc score of 2 for men and 3 for women without moderate or severe mitral stenosis or a mechanical valve. The score has not been validated for mitral stenosis or mechanical valves.

• Direct oral anticoagulants are recommended over warfarin for AF without moderate or severe mitral stenosis or a mechanical valve. Warfarin is still recommended for mitral stenosis and mechanical valves.

• Although CHA2DS2-VASc scores of 0 for men and 1 for women do not require treatment, scores of 1 for men and 2 for women are indeterminate and anticoagulation may be considered by shared decision-making.

From the AFP Editors

This guideline on atrial fibrillation (AF) management from the American Heart Association (AHA), American College of Cardiology (ACC), and Heart Rhythm Society (HRS) is an update of the 2014 version and is based on new evidence from clinical trials and the U.S. Food and Drug Administration (FDA). Treatment recommendations apply to paroxysmal, persistent, and permanent AF as well as atrial flutter. In this update, the sections on anticoagulation, catheter ablation, and management of AF complicating acute coronary syndrome were modified, and new sections were added outlining weight loss and device detection of AF; however, this summary focuses on the new and revised recommendations for choosing an anticoagulant and new recommendations for preventing stroke via nonpharmacologic options and use of catheter ablation.

Key Recommendations


Based on high-quality evidence, oral anticoagulants should be prescribed for women with AF and a CHA2DS2-VASc (congestive heart failure; hypertension; age of at least 75 years [doubled]; diabetes mellitus; previous stroke, transient ischemic attack, or thromboembolism [doubled]; vascular disease; age 65 to 74 years; sex category) score of at least 3 and for men with AF with a score of at least 2. Direct oral anticoagulants, including dabigatran (Pradaxa), rivaroxaban (Xarelto), apixaban (Eliquis), and edoxaban (Savaysa), are preferred to warfarin (Coumadin) unless the patient has concomitant moderate

Author disclosure: No relevant financial affiliations.

Coverage of guidelines from other organizations does not imply endorsement by AFP or the AAFP.

This series is coordinated by Sumi Sexton, MD, editor-in-chief.

A collection of Practice Guidelines published in AFP is available at



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