Atrial Fibrillation (AF)

Background Information Etiology

 Estimated prevalence of 1-2% in adults  Any disturbance in atrial structure such as fibrosis,
 Associated with up to a 5-fold-increase in the risk dilation, ischemia, and hypertrophy
of stroke  Extracardiac factors include hypertension, obesity, sleep
 Prevalence is expected to increase by up to 5 apnea, hyperthyroidism, and alcohol/drug use
times by 2050  Many other factors
Presentation Diagnosis
 Asymptomatic
 Palpitations
 Dizziness, fatigue, SOB
 Stroke, TIA, systemic embolism
 Hemodynamic instability
 Sequelae/complications: stroke, death,  No discernable P - wave
hospitalizations, reduced exercise capacity and  Atrial rates 300 600 bpm resulting in ventricular rates of
quality of life, and tachycardia-mediated 120 150 bpm (rapid ventricular response)
cardiomyopathy

Patterns/types Goals
 Paroxysmal: self-terminating within 7 days 1. Treat underlying causes
 Persistent: > 7 days 2. Prevent stroke/TIA and systemic embolism
 Long-standing: > 12 months 3. Reduce morbidity
 Permanent: decision has been decided to not 4. Alleviate symptoms
pursue rhythm control 5. HR < 80-110 bpm for symptom relief
 Non-valvular: excludes rheumatic mitral stenosis,
mitral valve repair, a mechanical or bioprosthetic
heart valve
Treatment
1. If hemodynamically unstable – DCCV 3. If symptomatic despite rate control – consider using
2. If hemodynamically stable, give IV agents to control an antiarrhythmic medication to cardiovert them
their heart rate and then convert to PO agent a. If they have been in A.fib > 48 hours, you
 must do a TEE to rule out an atrial thrombus
B or have them on therapeutic anticoagulants
for at least 3 weeks before and 4 weeks after
cardioversion
b. NO difference in outcomes between rate and
rhythm control (higher ADR in rhythm-control
group)

eta blocker is main stay – but digoxin amiodarone has

less effect on BP and HR if that is a concern
 Atrial Fibrillation (AF)
Anticoagulation
CHADS2 -VASc – calculates stroke risk HAS-BLED – calculates hemorrhaging risk
+1 - C: Heart Failure +1 H: hypertension (SBP > 160 mmHg)
+1 - H: HTN (>140/90 or HTN treatment) +1 or 2 A: abnormal renal/liver function
+2 - A: Age > 75 yo +1 S: stroke
+1 - D: DM (BG > 125 fasting or treatment for DM) +1 B: bleeding tendency
+2 - S: Stroke/TIA +1 L: labile INR
+1 - V: MI, PAD, aortic plaque +1 E: elderly age (>65)
+1 - A: Age 65-74 yo +1 or 2 D: drugs (concomitant ASA, NSAIDS) or
+1 - Sc: Female (alone doesn’t warrant OAC) alcohol
0 = None, 1 = ASA or OAC, > 2 = OAC 0-2: low bleeding risk, >3 high risk of bleeding

 Dabigatran antidote: Idarucizumab

 Xa-inhibitor antidote: Andexanet Alfa

Edoxaban: time to peak: 1-2 hours, T-1/2: 10-14 hours, renal clearance ~ 50% of total clearance excreted primarily
unchanged in the urine, minimal metabolism via hepatic CHAD2VAS2 CHEST 2018 AHA/ACC/HRS
enzymes 2 2019 UPDATE
Heparin: inhibits Xa and thrombin, monitor anti-Xa with a goal 0 (men) or <= No AC No AC
of 0.2-0.5 units/mL, 70 u/kg bolus then 15 u/kg/hr infusion 1 (women)
adjusted to anti-Xa 1 (men) or <=2 AC AC may be
LMWH: 1U/kg BID (women) recommended considered
Warfarin: inhibits II, VII, IX, X and protein C and S, monitor INR >=2 (men) or AC AC recommended
with a goal of 2-3 (2.5-3.5 if they have a mechanical heart valve >=3 (women) recommended
 Atrial Fibrillation (AF)

Relevant trials
Name of Trial Synopsis

ACTIVE W (2006) Among patients with nonvalvular AF, combination aspirin/clopidogrel is inferior to warfarin for the prevention of stroke,
systemic embolism, MI, and CV death, and appears to cause at least as much bleeding.

RELY (2009) Pradaxa (dabigatran) 110 mg and 150 mg twice daily is non-inferior to warfarin. The 150mg dose was superior to
warfarin with respect to stroke or systemic embolism.

ARISTOTLE In patients with nonvalvular atrial fibrillation and at ≥1 risk factor, apixaban is associated with a greater reduction in
(2011) rates of stroke or systemic embolism while having a lower rate of lower bleeding than warfarin.

ORBIT-AF (2013) In patients with atrial fibrillation (AF) treated with oral anticoagulation (OAC), this retrospective review demonstrated
increased bleeding and hospitalization rates with the concomitant use of aspirin versus OAC alone

ENGAGE AF-TIMI Among patients with nonvalvular atrial fibrillation edoxaban is superior to warfarin in preventing stroke or systemic
(2013) embolism and is associated with lower rates of bleeding and death from CV events.

ROCKET-AF In patients with NVAF, rivaroxaban is noninferior to warfarin in preventing stroke and systemic thromboembolism and
(2011) noninferior major bleeding + clinically relevant non-major bleeding compared to warfarin.

Anticoagulation Clinical Pearls

 2019 AHA/ACC/HRS Focused Update:
o DOACs are recommended as the preferred alternative to warfarin for reducing the risk of stroke associated with
A.Fib (less risk of bleeding and may be more effective at preventing blood clots), except moderate-severe mitral
stenosis or mechanical heart valve.
o A.fib with Moderate to severe mitral stenosis or mechanical heart valve are warrant AC without CHAD2DS2-
VASc assessment (Warfarin)
o Edoxaban added to approved oral AC for A.fib (already approved: warfarin, dabigatran, rivaroxaban, apixaban)
o Oral anticoagulants are recommended for patients with AF and elevated CHA2DS2-VASc scores — ≥2 in men
and ≥3 in women.
 If only point in CHA2DS2-VASc is coming from being a woman, it doesn’t count
o In end-stage renal disease, apixaban is a reasonable alternative to warfarin.
o AF with ACS:
 Triple therapy:
 Post stenting triple therapy (Plavix+Asp+OAC) might be considered for 4-6 wks (in practice, do
triple for 4-6 wks, then Plavix + OAC to complete 12 mos, then OAC+ Asp.
 Plavix is preferred over Prasugrel in triple therapy
 Double therapy: P2Y12 + Xarelto 15QD/Dabigatran 150BID/Dosed adjusted warfarin is reasonable post
stenting.
 CHEST 2018 guidelines recommend use of apixaban over other DOACs in patients with hx of unprovoked bleed
o Trials showed dabigatran and rivaroxaban increased GI bleed compared to warfarin
 2014 AHA/ACC/HRS guideline:  
o Bridging with UFH or LMWH with AC Interruption
 Mechanical Heart Valve → Decision to bridge; balance risks of stroke and bleeding. Only use warfarin.
(DOACs were not studied in this ppl, Dabigatran worse outcome compared to warfarin with more
thrombosis/bleeding)
 Non-Mechanical Heart Valve → Balance stroke and bleeding risks
 BRIDGE TRIAL (2015): Among patients with low- and intermediate-risk (avg. CHAD2DS2-VASc =2.3)
atrial fibrillation receiving anticoagulation and undergoing an invasive procedure, periprocedural
bridging anticoagulation with LMWH did not reduce the incidence of arterial thromboembolism when
compared to no bridging, but did increase the risk of major bleeding. 
o A.fib patient with mitral valve disease (stenosis/regurgitation) are indicated for anticoagulant, regardless of
CHAD2DS2-VASc
o If AC contraindicated, combination of Plavix+ Asp(75-325mg) can be used.
 Atrial Fibrillation (AF)
o Anticoagulation & Cardioversion
 Patients undergoing elective cardioversion for AF lasting at least 48h or for unknown duration → must
be therapeutically anticoagulated for 3 weeks before cardioversion performed. If not feasible, patient
can undergo TEE (check for thrombus) prior to cardioversion.
 Patients with AF <48 hours → anticoagulation prior to CV is unnecessary because there has not been
sufficient time to form atrial thrombus
 ALL Patients undergoing cardioversion → must be therapeutically anticoagulated for at least 4 weeks
regardless of baseline risk of stroke.
o Post Coronary Revascularization + CHA2DS2-VASc <=2 → reasonable to use clopidogrel + oral anticoagulant,
without aspirin. 
 International Society of Thrombosis and Haemostasis (ISTH): Does not support the use of DOACs in patients with a BMI of
>40 kg/m or weight of >120 kg due to significant disparities in PK/PD responses among extremes of body weight
2

(particularly under-treating).

References:

1. Conti JB. 2014 AHA / ACC / HRS Guideline for the Management of Patients With Atrial Fibrillation : Executive Summary. J Am Coll Cardiol.
2014;(212). doi:10.1016/j.jacc.2014.03.021
2. Cove CL, Hylek EM. An Updated Review of Target-Specific Oral Anticoagulants Used in Stroke Prevention in Atrial Fibrillation, Venous
Thromboembolic Disease, and Acute Coronary Syndromes. J Am Heart Assoc. 2013;2(5). doi:10.1161/JAHA.113.000136
3. Lexicomp - edoxaban, dabigatran, rivaroxaban, apixaban, heparin, and warfarin
4. https://www.acc.org/~/media/Non-Clinical/Files-PDFs-Excel-MS-Word-etc/Guidelines/2019/2019-Afib-Guidelines-Made-Simple-Tool.pdf