Abstract

Atrial fibrillation (AF) is an extremely common clinical problem with an important population morbidity and mortality burden. The management of AF is complex and fraught with many uncertain and contentious issues, which are being addressed by extensive ongoing basic and clinical research. The Canadian Cardiovascular Society AF Guidelines Committee produced an extensive set of evidence-based AF management guidelines in 2010 and updated them in the areas of anticoagulation and rate/rhythm control in 2012. In late 2013, the committee judged that sufficient new information regarding AF management had become available since 2012 to warrant an update to the Canadian Cardiovascular Society AF Guidelines. After extensive evaluation of the new evidence, the committee has updated the guidelines for:

1. Stroke prevention principles.
2. Anticoagulation of AF patients with chronic kidney disease.
3. Detection of AF in patients with stroke.
4. Investigation and management of subclinical AF.
5. Left atrial appendage closure in stroke prevention.
6. Emergency department management of AF.
7. Periprocedural anticoagulation management.
8. Rate and rhythm control including catheter ablation.

This report presents the details of the updated recommendations, along with their background and rationale. In addition, a complete set of presently applicable recommendations, those that have been updated and those that remain in force from previous guideline versions, is provided in the Supplementary Material.

Introduction

The management of atrial fibrillation (AF) has changed dramatically over the past 5-10 years, with the introduction of novel direct oral anticoagulants (NOACs), the wide application of AF ablation as an effective therapeutic approach, and the development of new technologies to detect AF. These innovations have the potential to lead to substantially reduced morbidity and mortality among AF patients. Since the 2012 iteration of the Canadian Cardiovascular Society (CCS) AF guidelines, progress has shifted somewhat from the introduction of new therapies to a more refined understanding of how to better apply recent innovations. New developments have nevertheless occurred, including the successful development of another NOAC, edoxaban. There have also been important studies showing the benefits of various monitoring technologies to detect AF in high-risk populations, such as patients with cryptogenic stroke.

The 2014 Focused Update of the CCS Guidelines deals with advances in oral anticoagulant (OAC) therapy and presents a new “CCS algorithm” that will allow clinicians to easily determine which AF patients will benefit from OAC therapy. The update also outlines the optimal approach to perioperative OAC management and updates rate and rhythm management in AF including catheter ablation.

This document is also linked to the Complete Guidelines Listing as Supplementary Material, which summarizes all presently applicable CCS AF guidelines including the most recently updated version for recommendations that have changed, and recommendations that remain in force unmodified since 2010.