moderate-quality evidence

Access the activity, “Making the Connection: A Call to Action Against Undiagnosed Atrial Fibrillation,” at PeerView.com/NTH40

AAFP Updated Guideline on Pharmacologic Management of Newly Detected Atrial Fibrillation1

PRACTICE AID

AAFP: American Academy of Family Physicians; AF: atrial fibrillation; CHA2DS2-VASc: congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, stroke/transient ischemic attack/thromboemolic event, vascular disease, age 65 to 74 years, sex category; CHADS2: congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, stroke/transient ischemic attack/thromboembolic event; HAS-BLED: hypertension, abnormal renal and liver function, stroke history, bleeding (prior major bleeding or predisposition to bleeding), labile INR, elderly (age >65 years), medication usage predisposing to bleeding and prior alcohol or drug usage history.

1. https://www.aafp.org/dam/AAFP/documents/patient_care/clinical_recommendations/a-fib-guideline.pdf. Accessed March 3, 2020.

Recommendation 1 The AAFP strongly recommends rate control in preference to rhythm control for themajority of patients with AF

Preferred options for rate-control therapy include non-dihydropyridine calcium channelblockers and β-blockers

Rhythm control may be considered for certain patients based on symptoms, exercisetolerance, and patient preferences

Recommendation 2 The AAFP recommends lenient rate control (<110 bpm at rest) over strict rate control (<80 bpm at rest) for patients with atrial fibrillation

Recommendation 3 The AAFP recommends that clinicians discuss the risk of stroke and bleeding with allpatients considering anticoagulation

Clinicians should consider using the continuous CHADS2 or continuous CHA2DS2-VAScfor prediction for risk of stroke and HAS-BLED for prediction of risk for bleeding in patientswith AF

Recommendation 4 The AAFP strongly recommends that patients with atrial fibrillation receive chronicanticoagulation unless they are at low risk of stroke (CHADS2 <2) or have specificcontraindications

Choice of anticoagulation therapy should be based on patient preferences and patienthistory. Options for anticoagulant therapy may include warfarin, apixaban, dabigatran,edoxaban, or rivaroxaban

Recommendation 5 The AAFP strongly recommends against dual treatment with anticoagulant andantiplatelet therapy in most patients who have atrial fibrillation

Strong recommendation,high-quality evidence

Strong recommendation,moderate-quality evidence Weak recommendation,

low-quality evidence Good practice point

https://www.peerview.com/NTH40


EHRA Atrial Fibrillation Screening Method and AF-SCREEN Recommended Populations

AF: atrial fibrillation; BP: blood pressure; EHRA: European Heart Rhythm Association; ESUS: embolic stroke of undetermined source; PPG: photoplethysmography.

1. Mairesse GH et al. Eurospace. 2017;19:1589-1623.2. Freedman B et al. Circulation. 2017;135:1851-1867.

PRACTICE AID

Automated BPmeasurement

Pulse palpation

Multi-lead patch recording

Handheld ECG devices

Implanted devices

Smartphone application

ECG confirmation

• Clinical evaluation• 12-lead ECG • Refer for

echocardiogram

• Treat underlying heart disease• Assess risk of stroke • Anticoagulation if needed • Rate-control therapy • Rhythm control if needed

European Heart Rhythm Association Atrial Fibrillation Screening Method1

AF-SCREEN Screening Recommendations2

Primary care or specialistclinics

Non-medical healthcarepractitioners: Pharmacy

General populations:Various venues

Where?

People aged ≥65 years

Patients aged <65 years +enrichmenta

Whom?

• Opportunistic pulsethen ECG

• Single time point:Single-lead ECG

• Patient activated ECG(2-week): >75 years oldor younger if high risk

• Post-stroke ESUS:Long-term continuous

Patient-activated devices:Blood pressure/PPG

How?

AF-SCREEN preferred

Possible with further data

Clinical screening

ECG screening

a Use of additional risk factors or biomarkers to increase the proportion with unknown AF in the screened population.


North American Thrombosis Forum (NATF) Anticoagulant Comparison Chart1,a

PRACTICE AID


Warfarin(Coumadin)

Dabigatran(Pradaxa)

Rivaroxaban(Xarelto)

Apixaban(Eliquis)

Edoxaban(Savaysa)

Generic? Yes No No No No

FDA approval Pre-1982

Warfarin was first used inhumans in 1954, beforethe FDA regulated drugs

October 2010 July 2011 December 2012 January 2015

FDA approvedfor

• Stroke preventionin AF and valvereplacements

• Treatment andprevention of DVTand PE

• Stroke preventionin nonvalvular AF

• Treatment andsecondaryprevention of DVTand PE

• VTE preventionafter hipreplacementsurgery



• VTE preventionafter hip and kneereplacementsurgery



• VTE preventionafter hip and kneereplacementsurgery



Drug image

Availablestrengths Variable 75-mg, 110-mg, or

150-mg capsule10-mg, 15-mg, or

20-mg tablet 5-mg or 2.5-mg tablet 15-mg, 30-mg, or60-mg tablet


North American Thrombosis Forum (NATF) Anticoagulant Comparison Chart1,a

a Betrixaban is not approved for treatment of atrial fibrillation.

AF: atrial fibrillation; NATF: North American Thrombosis Forum; PE: pulmonary embolism; VTE: venous thromboembolism.

1. https://natfonline.org/wp-content/uploads/2018/01/Anticoagulant-Comparison-Chart-Jan2018.pdf. Accessed April 11, 2018.

PRACTICE AID


Warfarin(Coumadin)

Dabigatran(Pradaxa)

Rivaroxaban(Xarelto)

Apixaban(Eliquis)

Edoxaban(Savaysa)

Dosingfrequency Once daily Twice daily

Once daily Following a 3-week

loading period of twicedaily for PE and DVT

Twice daily Following a 1-week

loading period of 10 mgtwice daily for PE and DVT

Once daily

Onset Slow Several days

Fast A few hours

Fast A few hours

Fast A few hours

Fast A few hours

Kidneyfunction No

Yes Kidney function affects

the dosage


the dosage


the dosage


the dosage

Food effect Yes

Speak with your providerabout vitamin K intake

and warfarin

No Yes

Rivaroxaban should betaken with dinner

No No

Druginteractions Many Few Few Few Few

Routine labmonitoring Yes No No No No

Reversalagents

Yes Vitamin K, fresh frozenplasma, prothrombin

complex concentrates

Yes Idarucizumab

YesCoagulation factor Xa

(recombinant),inactivated-zhzo[andexanet alfa]

YesCoagulation factor Xa

(recombinant),inactivated-zhzo[andexanet alfa]

SoonMay use prothrombincomplex concentrates

in emergencies


Atrial Fibrillation Screening: Risk Calculators, Tools, and Additional Resources

PRACTICE AID


Risk Factor Points

CHF 1

Hypertension 1

Age ≥75 years 1

Diabetes mellitus 1

Stroke/TIA/embolism 2

Maximum score 6

Risk Factor Points

CHF/LV dysfunction 1

Hypertension 1

Age ≥75 years 2

Diabetes mellitus 1

Stroke/TIA/embolism 2

Vascular disease 1

Age 65-74 years 1

Sex category (female) 1

Maximum score 9

Clinical Characteristic Points

H Hypertension 1

A Abnormal liver and/orrenal function

1 each;max. of 2

S Stroke 1

B Bleeding 1

L Labile INR 1

E Elderly (age >65) 1

D Drugsa and/or alcohol 1 each;max. of 2

Maximum score 9

CHADS2 Risk Score forPrediction of Stroke Risk in AF

CHA2DS2-VASc Risk Score forPrediction of Stroke Risk in AF

HAS-BLED Risk Calculator forPredicting Risk of Bleeding

With Anticoagulation

Additional Resources for Physicians• NATF Atrial Fibrillation Action Initiative• NATF AF Action Initiative Document• Arrhythmia Alliance Homepage• Arrhythmia Alliance “AF and How AF Causes Stroke” (video)• AAFP Clinical Practice Guideline on Atrial Fibrillation

a Aspirin/NSAIDs.

Atrial Fibrillation Screening: Risk Calculators, Tools, and Additional Resources

AAFP: American Academy of Family Physicians; AF: atrial fibrillation; BP: blood pressure; CHA2DS2-VASc: congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, stroke/transient ischemic attack/thromboemolic event, vascular disease, age 65 to 74 years, sex category; CHADS2: congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, stroke/transient ischemic attack/thromboembolic event; HAS-BLED: hypertension, abnormal renal and liver function, stroke history, bleeding (prior major bleeding or predisposition to bleeding), labile INR, elderly (age >65 years), medication usage predisposing to bleeding and prior alcohol or drug usage history; INR: International Normalized Ratio; LV: left ventricular; NATF: North American Thrombosis Forum.

1. https://www.microlife.com/consumer-products/blood-pressure/upper-arm-automatic/bp-a200-afib. Accessed March 3, 2020.2. https://www.cnet.com/news/best-blood-pressure-monitors-for-at-home-use/. Accessed March 3, 2020.3. https://www.mobihealthnews.com/news/north-america/verily-irhythm-ink-deal-create-fib-screening-diagnosis-tools. Accessed March 3, 2020. 4. Sandesara CM et al. J Innov Card Rhythm Manag. 2017;8:2824-2834.

PRACTICE AID


Different Screening Tools for AF1-4

Radial artery


moderate-quality evidence

Documents