2014 Focused Update of the Canadian Cardiovascular Society Guidelines for the Management of Atrial Fibrillation

Verma, Atul; Cairns, John A.; Mitchell, L. Brent; Macle, Laurent; Stiell, Ian G.; Gladstone, David J.; McMurtry, M. Sean; Connolly, Stuart J.; Cox, Jafna L.; Dorian, Paul; Ivers, Noah; Leblanc, Kori; Nattel, Stanley; Healey, Jeff S.

doi:10.1016/j.cjca.2014.08.001

Cited by 382 publications

(296 citation statements)

References 105 publications

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“…First, recommendations in guidelines9, 10, 12 and summaries of product characteristics14, 15 do not strongly advise against bridging therapy. Indeed, several health professionals have criticized the lack of clarity of these guidelines 17, 18, 19, 42, 43…”

Section: Discussionmentioning

confidence: 99%

“…There is an overall consensus in favor of a bridging therapy prior to urgent cardioversion in patients with life‐threatening hemodynamic instability caused by new‐onset NVAF 8, 9, 10, 11, 12, 13. The recommendation in guidelines9, 10, 12 and summaries of product characteristics14, 15 is less clear for those with stable NVAF who do not require rapid anticoagulation.…”

Section: Introductionmentioning

confidence: 99%

“…The recommendation in guidelines9, 10, 12 and summaries of product characteristics14, 15 is less clear for those with stable NVAF who do not require rapid anticoagulation. In real‐life conditions, a bridging regimen is commonly used in those with a low stroke risk 16, 17, 18, 19.…”

Section: Introductionmentioning

confidence: 99%

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Short‐Term Risk of Bleeding During Heparin Bridging at Initiation of Vitamin K Antagonist Therapy in More Than 90 000 Patients With Nonvalvular Atrial Fibrillation Managed in Outpatient Care

Bouillon¹,

Bertrand²,

Boudali³

et al. 2016

JAHA

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BackgroundSeveral studies have recently examined the risks of bleeding and of ischemic stroke and systemic embolism associated with perioperative heparin bridging anticoagulation in patients with nonvalvular atrial fibrillation. However, few studies have investigated bridging risks during vitamin K antagonist initiation in outpatient settings.Methods and ResultsA retrospective cohort study was conducted on individuals starting oral anticoagulation between January 2010 and November 2014 for nonvalvular atrial fibrillation managed in outpatient care and identified from French healthcare insurance. Bleeding and ischemic stroke and systemic embolism events were identified from the hospitalization database. Adjusted hazard ratios with 95% CI were estimated using Cox models during the first and 2 following months of anticoagulation. Of 90 826 individuals, 30% had bridging therapy. A total of 318 (0.35%) cases of bleeding and 151 (0.17%) ischemic stroke and systemic embolism cases were identified during the first month of follow‐up and 231 (0.31%) and 122 (0.16%) during the 2 following months, respectively. At 1 month of follow‐up, the incidence of bleeding was higher in the bridged group compared with the nonbridged group (0.47% versus 0.30%; P<0.001), and this increased risk persisted after adjustment for covariates (hazard ratio=1.60; 95% CI, 1.28–2.01). This difference disappeared after the first month of treatment (0.93; 0.70–1.23). No significant difference in the occurrence of ischemic stroke and systemic embolism was observed either at 1 month of follow‐up or later.ConclusionsAt vitamin K antagonist initiation for nonvalvular atrial fibrillation managed in ambulatory settings, bridging therapy is associated with a higher risk of bleeding and a similar risk of arterial thromboembolism compared with no bridging therapy.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Short‐Term Risk of Bleeding During Heparin Bridging at Initiation of Vitamin K Antagonist Therapy in More Than 90 000 Patients With Nonvalvular Atrial Fibrillation Managed in Outpatient Care

Bouillon¹,

Bertrand²,

Boudali³

et al. 2016

JAHA

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“…Patients with atrial fibrillation (AF) are at increased risk of thromboembolic events including stroke, transient ischemic attack, and systemic emboli, and this risk can be mitigated by antiplatelet and oral anticoagulant medications 1, 2. Although the mainstay of anticoagulation has been warfarin (Coumadin; Bristol‐Myers Squibb) for >20 years, the direct oral anticoagulants (DOACs) have been shown to have similar, or in some cases even superior, efficacy:safety ratios in AF patients without valvular heart disease,3 and this has led to their approval by regulatory agencies; wide adoption in Canadian, American, and European guidelines; and increasing use in clinical practice.…”

Section: Introductionmentioning

confidence: 99%

Use of Direct Oral Anticoagulants in Canadian Primary Care Practice 2010–2015: A Cohort Study From the Canadian Primary Care Sentinel Surveillance Network

McAlister

Garrison

Kosowan

et al. 2018

JAHA

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BackgroundAs questions have been raised about the appropriateness of direct oral anticoagulant (DOAC) dosing among outpatients with atrial fibrillation, we examined this issue in patients being managed by primary care providers.Methods and ResultsThis was a retrospective cohort new‐user study using electronic medical records from 744 Canadian primary care clinicians. Potentially inappropriate DOAC prescribing was defined as prescribing lower or higher doses than those recommended by guidelines for patients with nonvalvular atrial fibrillation. Of the 6658 patients with nonvalvular atrial fibrillation who were prescribed a DOAC (mean age: 74.8; 55% male), 626 (9.4%) had a CHADS 2 score of 0, and 168 (2.5%) had a CHADS‐VASc score of 0. Of the DOAC prescriptions, 527 (7.7%) were deemed potentially inappropriate: 496 (7.2%) were potentially underdosed, and 31 (0.5%) were prescribed a dose that was higher than recommended. Patients were more likely to be prescribed lower‐than‐recommended doses if they were female (adjusted odds ratio [aOR]: 1.3 [95% confidence interval (CI), 1.0–1.5]), had multiple comorbidities (aOR: 1.4 [95% CI, 1.1–1.8])—particularly heart failure (aOR: 1.6 [95% CI, 1.2–2.0]) or dementia (aOR: 1.4 [95% CI, 1.1–1.8])—or if they were also taking aspirin (aOR: 1.7 [95% CI, 1.3–2.1]) or nonsteroidal anti‐inflammatory drugs (aOR: 1.2 [95% CI, 1.02–1.5]). Potentially inappropriate DOAC dosing was more common in rural practices (aOR: 2.1 [95% CI, 1.7–2.6]) or smaller practices (aOR: 1.9 [95% CI, 1.6–2.4] for practices smaller than median).ConclusionsThe vast majority of DOAC prescriptions in our cohort of primary care–managed patients appeared to be for appropriate doses, particularly since prescribing a reduced dose of DOAC may be appropriate in frail patients or those taking other medications that predispose to bleeding.

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“…Catheter ablation is an established therapeutic modality for rhythm control of symptomatic atrial fibrillation (AF) 1, 2, 3. Electrical isolation of the pulmonary veins (PVI) is effective in improving symptoms 4, 5 and is the cornerstone of AF catheter ablation 1, 2.…”

Section: Introductionmentioning

confidence: 99%

Left atrial appendage isolation in atrial fibrillation catheter ablation: A meta‐analysis

AlTurki

Huynh

Dawas

et al. 2018

Journal of Arrhythmia

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A significant proportion of patients’ experience recurrence of atrial fibrillation (AF) despite pulmonary venous isolation (PVI), especially those with persistent AF. Isolation of the left atrial appendage (LAA) may reduce AF recurrence. The aim of this study was to assess the efficacy of LAA isolation in addition to PVI compared with PVI alone. We conducted a comprehensive search of electronic databases, up to April 21st, 2017, for all studies comparing the effect LAA electrical isolation or ligation in addition to PVI, as opposed to PVI alone, on the recurrence of atrial fibrillation after catheter ablation. We used random‐effects meta‐analysis models to summarize the studies. One RCT and four observational studies enrolling 781 patients were retained. Four studies assessed the added effect of LAA catheter ablation, and one study evaluated the effect of LAA ligation with the aim of LAA electrical isolation. Four studies exclusively enrolled patients with persistent atrial fibrillation and one study predominantly enrolled patients with persistent atrial fibrillation. Follow‐up ranged from 12 to 15 months. The addition of LAA isolation to PVI reduced AF recurrence compared with the latter alone (odds ratio (OR) = 0.19; 95% confidence intervals (CI) = 0.10‐0.37; P < 0.00001). Left atrial appendage isolation was also associated with a reduction in AF recurrence after repeat ablation (OR = 0.40; CI = 0.25‐0.65; P = 0.0003). The addition of LAA isolation to PVI was associated with a decrease in AF recurrence in patients with persistent AF. Further studies are needed to assess the effect on long‐term risk of stroke.

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2014 Focused Update of the Canadian Cardiovascular Society Guidelines for the Management of Atrial Fibrillation

Cited by 382 publications

References 105 publications

Short‐Term Risk of Bleeding During Heparin Bridging at Initiation of Vitamin K Antagonist Therapy in More Than 90 000 Patients With Nonvalvular Atrial Fibrillation Managed in Outpatient Care

Short‐Term Risk of Bleeding During Heparin Bridging at Initiation of Vitamin K Antagonist Therapy in More Than 90 000 Patients With Nonvalvular Atrial Fibrillation Managed in Outpatient Care

Use of Direct Oral Anticoagulants in Canadian Primary Care Practice 2010–2015: A Cohort Study From the Canadian Primary Care Sentinel Surveillance Network

Left atrial appendage isolation in atrial fibrillation catheter ablation: A meta‐analysis

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