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Case Reports, Lead Article

New American AF Guidelines Lag Behind Europe

New guidelines[1] for managing atrial fibrillation (AF) have been jointly published by the American Heart Association (AHA), American College of Cardiology (ACC), and Heart Rhythm Society (HRS), containing some information which may not be as comprehensive as the recently released AF guidelines from the Canadian Cardiovascular Society (CCS) and the European Society of Cardiology (ESC) in September and October respectively.

Aiming to highlight new drugs and treatments for AF which have been developed since previous guidelines were published in 2006, the twenty-page report recommends that a combination of clopidogrel and aspirin might serve as an alternative treatment for AF, used to “reduce the risk of vascular events in AF patients who were considered unsuitable for therapy with oral anticoagulation with warfarin” (p.163). The recommendation is based on studies including the ACTIVE-A trial[2] in which significantly fewer major vascular events occurred in patients randomised to receive clopidogrel compared with those who received a placebo.

This recommendation may be sidelined by the current availability of dabigatran, now approved in some countries as a potential substitute for warfarin in AF treatment. The committee behind the new guidelines made its decisions on this issue before the Food and Drug Administration (FDA) had approved the drug. The report’s authors therefore admit that although they reviewed the RE-LY (Randomized Evaluation of Long-Term Anticoagulation Therapy) trial of dabigatran[3], “recommendations about its use are not included in this focused update because dabigatran was not approved for clinical use by the FDA at the time of organizational approval” [1] (p.163).

flag2The update also recommends that catheter ablation “is useful in maintaining sinus rhythm in selected patients with significantly symptomatic, paroxysmal AF who have failed treatment with an antiarrhythmic drug and have normal or mildly dilated left atria, normal or mildly reduced LV function, and no severe pulmonary disease” (p.166). Catheter ablation is already widely recommended and practiced in the treatment of atrial fibrillation patients without severe lung disease who have not had success with drug therapy.

Amongst other recommendations, it is asserted that strict heart rate control has no benefit over less aggressive control in patients with atrial fibrillation. Previous guidelines advised keeping the heart rate of an atrial fibrillation patient at less than 80 beats/min at rest and less than 110 beats/min during a 6-minute walk. The updated guidelines advise keeping a resting heart rate of less than 110 beats/min in patients with persistent AF who also have stable ventricular function and have no symptoms, or symptoms deemed acceptable, related to their arrhythmia.

The updated guidelines also suggest the use of dronedarone to reduce hospitalizations for cardiovascular events in patients with paroxysmal AF or after conversion of persistent AF. However, the study also recommends that dronedarone “should not be administered to patients with class IV heart failure or patients who have had an episode of decompensated heart failure in the past 4 weeks, especially if they have depressed left ventricular function” (p.163).


  1. 2011 ACCF/AHA/HRS Focused Update on the Management of Patients With Atrial Fibrillation (Updating the 2006 Guideline), Wann et al, (Heart Rhythm 2011;8:157–176)
  2. Effect of Clopidogrel Added to Aspirin in Patients with Atrial Fibrillation, The ACTIVE Investigators, (N Engl J Med 2009;360:2066­78)
  3. Dabigatran versus warfarin in patients with atrial fibrillation, Connolly SJ, Ezekowitz MD, Yusuf S, et al., (N Engl J Med. 2009;361:1139 –51)

Published on: January 13, 2011

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  • ArrhythmiaAlliance
  • Stars
  • Anticoagulation Europe
  • Atrial Fibrillation Association

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