New afib guideline covers novel anticoagulants, ablation

A new guideline for managing nonvalvular atrial fibrillation recommends using a more comprehensive risk calculator, diminishing aspirin's role, adding 3 new anticoagulants to treatment options, and increasing use of radiofrequency ablation.

The 2014 Guideline for the Management of Patients with Atrial Fibrillation was released last week by the American Heart Association, American College of Cardiology, and the Heart Rhythm Society, in collaboration with the Society of Thoracic Surgery.

The first recommendation is to use a more comprehensive thromboembolic risk calculator, the CHA₂DS₂-VASc calculator, to estimate a patient's risk of having a stroke. Compared to the CHADS₂ score, the CHA₂DS₂-VASc score for nonvalvular atrial fibrillation adds 3 additional risk variables (female sex, 65 to 74 years of age, and vascular disease) and increases the maximum point score from 6 to 9.

The second recommendation suggests diminishing the role of aspirin in patients with atrial fibrillation who have a low stroke risk, due to weak data showing that it decreases stroke risk. No studies, with the exception of the Stroke Prevention in Atrial Fibrillation-1, showed benefit for aspirin alone in preventing stroke among patients with atrial fibrillation, the experts found.

The third recommendation suggested adding 3 new anticoagulants to the treatment options for nonvalvular atrial fibrillation: dabigatran (based on the Randomized Evaluation of Long-Term Anticoagulation Therapy [RELY]), rivaroxaban (based on the Rivaroxaban Versus Warfarin in Nonvalvular Atrial Fibrillation trial [ROCKET AF]) and apixaban (based on the Apixaban Versus Warfarin in Patients with Atrial Fibrillation [ARISTOTLE] trial).

“All 3 new oral anticoagulants represent important advances over warfarin because they have more predictable pharmacological profiles, fewer drug-drug interactions, an absence of major dietary effects, and less risk of intracranial bleeding than warfarin,” the authors wrote. “They have rapid onset and offset of action such that bridging with parenteral anticoagulant therapy is not needed during initiation, and bridging may not be needed in patients on chronic therapy requiring brief interruption of anticoagulation for invasive procedures. However, strict compliance with these new oral anticoagulants is critical.”

The fourth recommendation favored increasing the role of radiofrequency ablation in treating atrial fibrillation, given increased recognition that it can be used effectively.