National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand: Australian clinical guidelines for the diagnosis and management of atrial fibrillation 2018

Abstract

Introduction: Atrial fibrillation (AF) is increasing in prevalence and is associated with significant morbidity and mortality. The optimal diagnostic and treatment strategies for AF are continually evolving and care for patients requires confidence in integrating these new developments into practice. These clinical practice guidelines will assist Australian practitioners in the diagnosis and management of adult patients with AF. Main recommendations: These guidelines provide advice on the standardised assessment and management of patients with atrial fibrillation regarding: screening, prevention and diagnostic work‐up; acute and chronic arrhythmia management with antiarrhythmic therapy and percutaneous and surgical ablative therapies; stroke prevention and optimal use of anticoagulants; and integrated multidisciplinary care. Changes in management as a result of the guideline: Opportunistic screening in the clinic or community is recommended for patients over 65 years of age. The importance of deciding between a rate and rhythm control strategy at the time of diagnosis and periodically thereafter is highlighted. β‐Blockers or non‐dihydropyridine calcium channel antagonists remain the first line choice for acute and chronic rate control. Cardioversion remains first line choice for acute rhythm control when clinically indicated. Flecainide is preferable to amiodarone for acute and chronic rhythm control. Failure of rate or rhythm control should prompt consideration of percutaneous or surgical ablation. The sexless CHA2DS2‐VA score is recommended to assess stroke risk, which standardises thresholds across men and women; anticoagulation is not recommended for a score of 0, and is recommended for a score of ≥ 2. If anticoagulation is indicated, non‐vitamin K oral anticoagulants are recommended in preference to warfarin. An integrated care approach should be adopted, delivered by multidisciplinary teams, including patient education and the use of eHealth tools and resources where available. Regular monitoring and feedback of risk factor control, treatment adherence and persistence should occur.

Risk of ischemic stroke and utility of CHA2DS2‐VASc score in women and men with atrial fibrillation

“…In summary, the higher risk for ischemic stroke in women than in men seems to be lower than reflected by the The aim of our study was to evaluate the risk for stroke and death in women and men, but not to revise the CHA 2 DS 2 -VASc risk score, for example, without sex category as has been suggested in some recent publications. 11,19 As already pointed out, all CHA 2 DS 2 -VASc This study has limitations. It was observational and should thereby be interpreted with caution, despite careful selection of diagnosis codes for estimation of the CHA 2 DS 2 -VASc score, the selection of robust outcomes of ischemic stroke and death, and the extensive statistical analyses.…”

Sustained resolution of anticoagulation related iron deficiency anemia with the use of apixaban

“…19 Additionally, The Australian Clinical Guidelines for the Diagnosis and Management of Atrial Fibrillation suggested using different doses or agents other than high-dose dabigatran or rivaroxaban in patients with prior GIT bleeding. 10 The American College of Chest Physician guidelines refer to the indirect comparisons between NOACs in VTE management, favoring apixaban due to the lower risk of bleeding. 20 Standard treatment for IDA includes blood transfusion and iron replacement either orally, as first-line therapy, or intravenously for more profound IDA or in elderly patients.…”

“…9 Apixaban has the most favorable GIT bleeding risk profile and is recently recommended as the NOAC of choice in high-risk GIT bleeding patients by the Australian atrial fibrillation management guidelines. 10 Iron deficiency anemia (IDA) in developed countries is usually related to overt or covert GIT blood loss. 11 There is limited research investigating the association between the use of NOACs and IDA in the absence of major GIT bleeding.…”

Frequency of Clinical Monitoring of Serum Concentrations of Digoxin, Potassium, and Creatinine, and Recording of Electrocardiograms in Digoxin-Treated Patients: A Japanese Claims Database Analysis

“…1,2) It is also used to reduce the incidence of hospitalization in HF patients with reduced ejection fraction, 3) as well as to maintain the heart rate in patients with atrial fibrillation. 4) However, emergency visits and hospitalization due to adverse reactions to digoxin occur frequently, 5,6) since it has a very narrow therapeutic range. 7) In addition, a higher serum digoxin concentration (SDC, ≥1.2 ng/mL) appears to increase the risk of hospitalization or all-cause mortality.…”

“…9) The package insert of digoxin and guidelines recommend TDM for digoxin. 3,4,10) Studies from Japan and the United States (US) indicated that TDM was performed in 17−50% of patients receiving digoxin. 7,11,12) However, there is not much information in the literature regarding the frequency of TDM for digoxin.…”