2018 Focused Update of the Canadian Cardiovascular Society Guidelines for the Management of Atrial Fibrillation

Abstract

The Canadian Cardiovascular Society (CCS) Atrial Fibrillation Guidelines Committee provides periodic reviews of new data to produce focused updates that address clinically important advances in atrial fibrillation (AF) management. This 2018 Focused Update addresses: (1) anticoagulation in the context of cardioversion of AF; (2) the management of antithrombotic therapy for patients with AF in the context of coronary artery disease; (3) investigation and management of subclinical AF; (4) the use of antidotes for the reversal of nonvitamin K antagonist oral anticoagulants; (5) acute pharmacological cardioversion of AF; (6) catheter ablation for AF, including patients with concomitant AF and heart failure; and (7) an integrated approach to R ESUM E Le comit e des lignes directrices en matière de fibrillation auriculaire de la Soci et e canadienne de cardiologie (SCC) procède à des examens p eriodiques des nouvelles donn ees pour produire des mises à jour th ematiques portant sur des avanc ees cliniquement importantes de la prise en charge de la fibrillation auriculaire (FA). La mise à jour cibl ee 2018 porte sur les aspects suivants : 1) l'anticoagulation dans le contexte de la cardioversion de la FA; 2) la prise en charge du traitement antithrombotique des patients atteints de FA dans le contexte d'une coronaropathie; 3) la recherche et la prise en charge de la FA sub-clinique; 4) les antidotes aux anticoagulants oraux non-vitamine K; 5) cardioversion pharmacologique aiguë de la FA; 6) l'ablation par

Time‐trends and treatment gaps in the antithrombotic management of patients with atrial fibrillation after percutaneous coronary intervention: Insights from the CHUM AF‐STENT Registry

“…The higher TATT prescription rate is in agreement with the CCS 2016 AF guidelines recommendation of TATT for 3 to 6 months in these patients with CHADS2 score ≥ 2, placing greater weight on reduction of thromboembolic events and comparatively lesser weight on risk of major bleeding . A course of TATT of a duration of up to 6 months in patients at high risk of thrombosis was also advocated subsequently in the 2018 update of the CCS antiplatelet guidelines . The emergence of dual pathway antithrombotic therapy (anticoagulant plus a single antiplatelet agent) in clinical practice, on the other hand, represents an integration of randomized trial data from PIONEER AF‐PCI (rivaroxaban) and REDUAL (dabigatran) that showed that such a regimen could minimize bleeding risk without a signal for increase in clinical ischemic events .…”

“…10,11 A shift to dual pathway antithrombotic management is also advocated in the 2018 updates of the CCS antiplatelet and atrial fibrillation guidelines. 16,17 The recently published AUGUSTUS trial (apixaban), that also included medically managed ACS patients, also supports the safety advantage of dual pathway therapy over triple therapy. 12 The ENTRUST-PCI AF trial (edoxaban) furtherly reinforced the safety and anti-ischemic efficacy of dual pathway regimens of dual pathway over triple therapy, with no significant difference in ischemic events between the two groups.…”

“…3 A course of TATT of a duration of up to 6 months in patients at high risk of thrombosis was also advocated subsequently in the 2018 update of the CCS antiplatelet guidelines. 16 The emergence of dual pathway antithrombotic therapy (anticoagulant plus a single antiplatelet agent) in clinical practice, on the other hand, represents an integration of randomized trial data from PIONEER AF-PCI (rivaroxaban) and REDUAL (dabigatran) that showed that such a regimen could minimize bleeding risk without a signal for increase in clinical ischemic events. 10,11 A shift to dual pathway antithrombotic management is also advocated in the 2018 updates of the CCS antiplatelet and atrial fibrillation guidelines.…”

“…The emergence of dual pathway antithrombotic therapy (anticoagulant plus a single antiplatelet agent) in clinical practice, on the other hand, represents an integration of randomized trial data from PIONEER AF‐PCI (rivaroxaban) and REDUAL (dabigatran) that showed that such a regimen could minimize bleeding risk without a signal for increase in clinical ischemic events . A shift to dual pathway antithrombotic management is also advocated in the 2018 updates of the CCS antiplatelet and atrial fibrillation guidelines . The recently published AUGUSTUS trial (apixaban), that also included medically managed ACS patients, also supports the safety advantage of dual pathway therapy over triple therapy .…”

Comment on “The Canadian Cardiovascular Society 2018 guideline update for atrial fibrillation – A different perspective”

“…We read with interest the commentary of Stiell et al 1 regarding the 2018 Canadian Cardiovascular Society (CCS) Atrial Fibrillation (AF) guidelines. 2 While we recognise that these guidelines present challenges to emergency physicians, they are supported by the evidence. 3 Stiell et al appear most concerned regarding the recommendation for four weeks of oral anticoagulation therapy following cardioversion of atrial fibrillation, even for episodes <48 hours in duration and in patients without thromboembolic risk factors.…”