2014 Aha/Acc/Hrs Guideline for the Management of Patients with Atrial Fibrillation: Executive Summary

HomeCirculationVol. 130, No. 232014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: Executive Summary Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissionsDownload Articles + Supplements ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toSupplemental MaterialFree AccessResearch ArticlePDF/EPUB2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: Executive SummaryA Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society Craig T. January, MD, PhD, FACC, L. Samuel Wann, MD, MACC, FAHA, Joseph S. Alpert, MD, FACC, FAHA, Hugh Calkins, MD, FACC, FAHA, FHRS, Joaquin E. Cigarroa, MD, FACC, Joseph C. ClevelandJr, MD, FACC, Jamie B. Conti, MD, FACC, FHRS, Patrick T. Ellinor, MD, PhD, FAHA, Michael D. Ezekowitz, MB, ChB, FACC, FAHA, Michael E. Field, MD, FACC, FHRS, Katherine T. Murray, MD, FACC, FAHA, FHRS, Ralph L. Sacco, MD, FAHA, William G. Stevenson, MD, FACC, FAHA, FHRS, Patrick J. Tchou, MD, FACC, Cynthia M. Tracy, MD, FACC, FAHA and Clyde W. Yancy, MD, FACC, FAHA Craig T. JanuaryCraig T. January Search for more papers by this author , L. Samuel WannL. Samuel Wann *Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information. Search for more papers by this author , Joseph S. AlpertJoseph S. Alpert Search for more papers by this author , Hugh CalkinsHugh Calkins Search for more papers by this author , Joaquin E. CigarroaJoaquin E. Cigarroa †ACC/AHA Representative. Search for more papers by this author , Joseph C. ClevelandJrJoseph C. ClevelandJr ‖Society of Thoracic Surgeons Representative. Search for more papers by this author , Jamie B. ContiJamie B. Conti Search for more papers by this author , Patrick T. EllinorPatrick T. Ellinor ‡Heart Rhythm Society Representative. Search for more papers by this author , Michael D. EzekowitzMichael D. Ezekowitz Search for more papers by this author , Michael E. FieldMichael E. Field †ACC/AHA Representative. Search for more papers by this author , Katherine T. MurrayKatherine T. Murray †ACC/AHA Representative. Search for more papers by this author , Ralph L. SaccoRalph L. Sacco †ACC/AHA Representative. Search for more papers by this author , William G. StevensonWilliam G. Stevenson Search for more papers by this author , Patrick J. TchouPatrick J. Tchou ‡Heart Rhythm Society Representative. Search for more papers by this author , Cynthia M. TracyCynthia M. Tracy †ACC/AHA Representative. Search for more papers by this author and Clyde W. YancyClyde W. Yancy †ACC/AHA Representative. Search for more papers by this author Originally published28 Mar 2014https://doi.org/10.1161/CIR.0000000000000040Circulation. 2014;130:2071–2104is corrected byCorrectionOther version(s) of this articleYou are viewing the most recent version of this article. Previous versions: January 1, 2014: Previous Version 1 Table of ContentsPreamble 2072Introduction 20741.1. Methodology and Evidence Review 20741.2. Organization of the Writing Committee 20741.3. Document Review and Approval 20751.4. Scope of the Guideline 2075Clinical Characteristics and Evaluation of AF 20762.1. AF Classification 20762.2. Mechanisms of AF and Pathophysiology 20762.3. Risk Factors and Associated Heart Disease 20762.4. Clinical Evaluation: Recommendation 2077Thromboembolic Risk and Treatment 20773.1. Risk-Based Antithrombotic Therapy: Recommendations 20773.2. Risk Stratification Schemes (CHADS2 and CHA2DS2-VASc) 20793.3. Considerations in Selecting Anticoagulants 20793.4. Cardiac Surgery—Left Atrial Appendage Occlusion/Excision: Recommendation 2079Rate Control: Recommendations 2079Rhythm Control: Recommendations 20805.1. Prevention of Thromboembolism 20805.2. Direct-Current Cardioversion 20815.3. Pharmacological Cardioversion 20825.4. Antiarrhythmic Drugs to Maintain Sinus Rhythm 20825.5. Upstream Therapy 20835.6. AF Catheter Ablation to Maintain Sinus Rhythm 20855.7. Surgical Maze Procedures 2085Specific Patient Groups and AF: Recommendations 20866.1. Hypertrophic Cardiomyopathy 20866.2. AF Complicating Acute Coronary Syndromes 20866.3. Hyperthyroidism 20866.4. Pulmonary Disease 20866.5. Wolff-Parkinson-White and Pre-Excitation Syndromes 20866.6. Heart Failure 20886.7. Familial (Genetic) AF 20896.8. Postoperative Cardiac and Thoracic Surgery 2089Evidence Gaps and Future Research Directions 2089References 2090Appendix 1. Author Relationships With Industry and Other Entities (Relevant) 2095Appendix 2. Reviewer Relationships With Industry and Other Entities (Relevant) 2097Appendix 3. Initial Clinical Evaluation in Patients With AF 2104PreambleThe medical profession should play a central role in evaluating the evidence related to drugs, devices, and procedures for the detection, management, and prevention of disease. When properly applied, expert analysis of available data on the benefits and risks of these therapies and procedures can improve the quality of care, optimize patient outcomes, and favorably affect costs by focusing resources on the most effective strategies. An organized and directed approach to a thorough review of evidence has resulted in the production of clinical practice guidelines that assist clinicians in selecting the best management strategy for an individual patient. Moreover, clinical practice guidelines can provide a foundation for other applications, such as performance measures, appropriate use criteria, and both quality improvement and clinical decision support tools.The American College of Cardiology (ACC) and the American Heart Association (AHA) have jointly engaged in the production of guidelines in the area of cardiovascular disease since 1980. The ACC/AHA Task Force on Practice Guidelines (Task Force), whose charge is to develop, update, or revise practice guidelines for cardiovascular diseases and procedures, directs this effort. Writing committees are charged with the task of performing an assessment of the evidence and acting as an independent group of authors to develop, update, or revise written recommendations for clinical practice.Experts in the subject under consideration are selected from both organizations to examine subject-specific data and write guidelines. Writing committees are specifically charged to perform a literature review; weigh the strength of evidence for or against particular tests, treatments, or procedures; and include estimates of expected health outcomes where such data exist. Patient-specific modifiers, comorbidities, and issues of patient preference that may influence the choice of tests or therapies are considered, as well as frequency of follow-up and cost-effectiveness. When available, information from studies on cost is considered; however, review of data on efficacy and outcomes constitutes the primary basis for preparing recommendations in this guideline.In analyzing the data, and developing recommendations and supporting text, the writing committee uses evidence-based methodologies developed by the Task Force.1 The Classification of Recommendation (COR) is an estimate of the size of the treatment effect, with consideration given to risks versus benefits, as well as evidence and/or agreement that a given treatment or procedure is or is not useful/effective or in some situations may cause harm; this is defined in Table 1. The Level of Evidence (LOE) is an estimate of the certainty or precision of the treatment effect. The writing committee reviews and ranks evidence supporting each recommendation, with the weight of evidence ranked as LOE A, B, or C, according to specific definitions that are included in Table 1. Studies are identified as observational, retrospective, prospective, or randomized, as appropriate. For certain conditions for which inadequate data are available, recommendations are based on expert consensus and clinical experience and are ranked as LOE C. When recommendations at LOE C are supported by historical clinical data, appropriate references (including clinical reviews) are cited if available.Table 1. Applying Classification of Recommendations and Level of EvidenceTable 1. Applying Classification of Recommendations and Level of EvidenceFor issues with sparse available data, a survey of current practice among the clinician members of the writing committee is the basis for LOE C recommendations and no references are cited.The schema for COR and LOE is summarized in Table 1, which also provides suggested phrases for writing recommendations within each COR.A new addition to this methodology is the separation of the Class III recommendations to delineate whether the recommendation is determined to be of “no benefit” or is associated with “harm” to the patient. In addition, in view of the increasing number of comparative effectiveness studies, comparator verbs and suggested phrases for writing recommendations for the comparative effectiveness of one treatment or strategy versus another are included for COR I and IIa, LOE A or B only.In view of the advances in medical therapy across the spectrum of cardiovascular diseases, the Task Force has designated the term guideline-directed medical therapy to represent optimal medical therapy as defined by ACC/AHA guideline (primarily Class I)–recommended therapies. This new term, guideline-directed medical therapy, is used herein and throughout subsequent guidelines.Therapies not available in the United States are discussed in the text without a specific COR. For studies performed in large numbers of subjects outside North America, each writing committee reviews the potential impact of different practice patterns and patient populations on the treatment effect and relevance to the ACC/AHA target population to determine whether the findings should inform a specific recommendation.The ACC/AHA practice guidelines are intended to assist clinicians in clinical decision making by describing a range of generally acceptable approaches to the diagnosis, management, and prevention of specific diseases or conditions. The guidelines attempt to define practices that meet the needs of most patients in most circumstances. The ultimate judgment about care of a particular patient must be made by the clinician and patient in light of all the circumstances presented by that patient. As a result, situations may arise in which deviations from these guidelines may be appropriate. Clinical decision making should involve consideration of the quality and availability of expertise in the area where care is provided. When these guidelines are used as the basis for regulatory or payer decisions, the goal should be improvement in quality of care. The Task Force recognizes that situations arise in which additional data are needed to inform patient care more effectively; these areas are identified within each respective guideline when appropriate.Prescribed courses of treatment in accordance with these recommendations are effective only if followed. Because lack of patient understanding and adherence may adversely affect outcomes, clinicians should make every effort to engage the patient’s active participation in prescribed medical regimens and lifestyles. In addition, patients should be informed of the risks, benefits, and alternatives to a particular treatment and should be involved in shared decision making whenever feasible, particularly for COR IIa and IIb, for which the benefit-to-risk ratio may be lower.The Task Force makes every effort to avoid actual, potential, or perceived conflicts of interest that may arise as a result of relationships with industry and other entities (RWI) among the members of the writing committee. All writing committee members and peer reviewers of the guideline are required to disclose all current healthcare-related relationships, including those existing 12 months before initiation of the writing effort.In December 2009, the ACC and AHA implemented a new RWI policy that requires the writing committee chair plus a minimum of 50% of the writing committee to have no relevant RWI (Appendix 1 includes the ACC/AHA definition of relevance). The Task Force and all writing committee members review their respective RWI disclosures during each conference call and/or meeting of the writing committee, and members provide updates to their RWI as changes occur. All guideline recommendations require a confidential vote by the writing committee and require approval by a consensus of the voting members. Members may not draft or vote on any recommendations pertaining to their RWI. Members who recused themselves from voting are indicated in the list of writing committee members, and specific section recusals are noted in Appendix 1. Authors’ and peer reviewers’ RWI pertinent to this guideline are disclosed in Appendixes 1 and 2. In addition, to ensure complete transparency, writing committee members’ comprehensive disclosure information—including RWI not pertinent to this document—is available as an online supplement. Comprehensive disclosure information for the Task Force is also available online at http://www.cardiosource.org/en/ACC/About-ACC/Who-We-Are/Leadership/Guidelines-and-Documents-Task-Forces.aspx. The ACC and AHA exclusively sponsor the work of the writing committee, without commercial support. Writing committee members volunteered their time for this activity. Guidelines are official policy of both the ACC and AHA.In an effort to maintain relevance at the point of care for clinicians, the Task Force continues to oversee an ongoing process improvement initiative. As a result, in response to pilot projects, several changes to this guideline will be apparent, including limited narrative text, a focus on summary and evidence tables (with references linked to abstracts in PubMed), and more liberal use of summary recommendation tables (with references that support the LOE) to serve as a quick reference.In April 2011, the Institute of Medicine released 2 reports: Finding What Works in Health Care: Standards for Systematic Reviews and Clinical Practice Guidelines We Can Trust.2,3 It is noteworthy that the Institute of Medicine cited ACC/AHA practice guidelines as being compliant with many of the proposed standards. A thorough review of these reports and of our current methodology is under way, with further enhancements anticipated.The recommendations in this guideline are considered current until they are superseded by a focused update, the full-text guideline is revised, or until a published addendum declares it out of date and no longer official ACC/AHA policy. The reader is encouraged to consult the full-text guideline4 for additional guidance and details about atrial fibrillation (AF), because the executive summary contains mainly the recommendations.Jeffrey L. Anderson, MD, FACC, FAHAChair, ACC/AHA Task Force on Practice Guidelines1. Introduction1.1. Methodology and Evidence ReviewThe recommendations listed in this document are, whenever possible, evidence based. An extensive evidence review was conducted, focusing on 2006 through October 2012 and selected other references through March 2014. The relevant data are included in evidence tables in the Online Data Supplement. Searches were extended to studies, reviews, and other evidence conducted in human subjects, published in English, and accessible through PubMed, EMBASE, Cochrane, Agency for Healthcare Research and Quality Reports, and other selected databases relevant to this guideline. Key search words included but were not limited to the following: age, antiarrhythmic, atrial fibrillation, atrial remodeling, atrioventricular conduction, atrioventricular node, cardioversion, classification, clinical trial, complications, concealed conduction, cost-effectiveness, defibrillator, demographics, epidemiology, experimental, heart failure, hemodynamics, human, hyperthyroidism, hypothyroidism, meta-analysis, myocardial infarction, pharmacology, postoperative, pregnancy, pulmonary disease, quality of life, rate control, rhythm control, risks, sinus rhythm, symptoms, and tachycardia-mediated cardiomyopathy. Additionally, the writing committee reviewed documents related to AF previously published by the ACC and AHA. References selected and published in this document are representative and not all-inclusive.1.2. Organization of the Writing CommitteeThe 2014 AF writing committee was composed of clinicians with broad expertise related to AF and its treatment, including adult cardiology, electrophysiology, cardiothoracic surgery, and heart failure (HF). The writing committee was assisted by staff from the ACC and AHA. Under the guidance of the Task Force, the Heart Rhythm Society was invited to be a partner organization and provided representation. The writing committee also included a representative from the Society of Thoracic Surgeons. The rigorous methodological policies and procedures noted in the Preamble differentiate ACC/AHA guidelines from other published guidelines and statements.1.3. Document Review and ApprovalThis document was reviewed by 2 official reviewers each nominated by the ACC, AHA, and Heart Rhythm Society, as well as 1 reviewer from the Society of Thoracic Surgeons and 43 individual content reviewers (from the ACC Electrophysiology Section Leadership Council, ACC Adult Congenital and Pediatric Cardiology Section Leadership Council, ACC Association of International Governors, ACC Heart Failure and Transplant Section Leadership Council, ACC Imaging Section Leadership Council, ACC Interventional Section Leadership Council, ACC Surgeons' Council, and the Heart Rhythm Society Scientific Documents Committee). All information on reviewers’ RWI was distributed to the writing committee and is published in this document (Appendix 2).This document was approved for publication by the governing bodies of the ACC, AHA, and Heart Rhythm Society and endorsed by the Society of Thoracic Surgeons.1.4. Scope of the GuidelineThe task of the 2014 writing committee was to establish revised guidelines for optimum management of AF. The new guideline incorporates new and existing knowledge derived from published clinical trials, basic science, and comprehensive review articles, along with evolving treatment strategies and new drugs. This guideline supersedes the “ACC/AHA/ESC 2006 Guidelines for the Management of Patients With Atrial Fibrillation”5 and the 2 subsequent focused updates from 2011.6,7 In addition, the ACC, AHA, American College of Physicians, and American Academy of Family Physicians submitted a proposal to the Agency for Healthcare Research and Quality to perform a systematic review on specific questions related to the treatment of AF. The data from that report were reviewed by the writing committee and incorporated where appropriate.8a,8bThe 2014 AF guideline is organized thematically, with recommendations, where appropriate, provided with each section. Some recommendations from earlier guidelines have been eliminated or updated as warranted by new evidence or a better understanding of earlier evidence. In developing the 2014 AF guideline, the writing committee reviewed prior published guidelines and related statements. Table 2 lists these publications and statements deemed pertinent to this effort and is intended for use as a resource.Table 2. Associated Guidelines and StatementsTitleOrganizationPublication Year/ReferenceGuidelines Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7)NHLBI20039 Assessment of Cardiovascular Risk in Asymptomatic AdultsACC/AHA201010 Coronary Artery Bypass Graft SurgeryACC/AHA201111 Hypertrophic CardiomyopathyACC/AHA201112 Percutaneous Coronary InterventionACC/AHA/SCAI201113 Secondary Prevention and Risk Reduction Therapy for Patients With Coronary and Other Atherosclerotic Vascular DiseaseAHA/ACC201114 Atrial Fibrillation*CCS201215 Atrial FibrillationESC201216 Stable Ischemic Heart DiseaseACC/AHA/ACP/AATS/PCNA/SCAI/STS201217 Antithrombotic TherapyACCP201218 Device-Based TherapyACC/AHA/HRS201219 Heart FailureACC/AHA201320 ST-Elevation Myocardial InfarctionACC/AHA201321 Unstable Angina/Non-ST-Elevation Myocardial InfarctionACC/AHA201422 Valvular Heart DiseaseAHA/ACC201423 Assessment of Cardiovascular RiskACC/AHA201324 Lifestyle Management to Reduce Cardiovascular RiskAHA/ACC201325 Management of Overweight and Obesity in AdultsAHA/ACC/TOS201326 Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in AdultsACC/AHA201327Statements Treatment of Atrial FibrillationAHRQ20138a,8b Oral Antithrombotic Agents for the Prevention of Stroke in Nonvalvular Atrial Fibrillation: A Science Advisory for Healthcare ProfessionalsAHA/ASA201228 Expert Consensus Statement on Catheter and Surgical Ablation of Atrial Fibrillation: Recommendations for Patient Selection, Procedural Techniques, Patient Management and Follow-Up, Definitions, Endpoints, and Research Trial DesignHRS/EHRA/ECAS201229*Includes the following sections: Catheter Ablation for AF/Atrial Flutter; Prevention and Treatment of AF Following Cardiac Surgery; Rate and Rhythm Management; Prevention of Stroke and Systemic Thromboembolism in AF and Flutter; Management of Recent-Onset AF and Flutter in the Emergency Department; Surgical Therapy; The Use of Antiplatelet Therapy in the Outpatient Setting; and Focused 2012 Update of the CCS AF Guidelines: Recommendations for Stroke Prevention and Rate/Rhythm Control.AATS indicates American Association for Thoracic Surgery; ACC, American College of Cardiology; ACCP, American College of Chest Physicians; ACP, American College of Physicians; AF, atrial fibrillation; AHA, American Heart Association; AHRQ, Agency for Healthcare Research and Quality; ASA, American Stroke Association; CCS, Canadian Cardiology Society; ECAS, European Cardiac Arrhythmia Society; EHRA, European Heart Rhythm Association; ESC, European Society of Cardiology; HRS, Heart Rhythm Society; JNC, Joint National Committee; NHLBI, National Heart, Lung, and Blood Institute; PCNA, Preventive Cardiovascular Nurses Association; SCAI, Society for Cardiovascular Angiography and Interventions; STS, Society of Thoracic Surgeons; and TOS, The Obesity Society.2. Clinical Characteristics and Evaluation of AF2.1. AF ClassificationAF may be described in terms of the duration of episodes using a simplified scheme shown in Table 3.5,29,30 Implanted loop recorders, pacemakers, and defibrillators offer the possibility of reporting frequency, rate, and duration of abnormal atrial rhythms, including AF.31,32 Episodes often increase in frequency and duration over time.Table 3. Definitions of AF: A Simplified SchemeTermDefinitionParoxysmal AF• AF that terminates spontaneously or with intervention within 7 d of onset.• Episodes may recur with variable frequency.Persistent AF• Continuous AF that is sustained >7 d.Long-standing persistent AF• Continuous AF >12 mo in duration.Permanent AF• The term “permanent AF” is used when the patient and clinician make a joint decision to stop further attempts to restore and/or maintain sinus rhythm.• Acceptance of AF represents a therapeutic attitude on the part of the patient and clinician rather than an inherent pathophysiological attribute of AF.• Acceptance of AF may change as symptoms, efficacy of therapeutic interventions, and patient and clinician preferences evolve.Nonvalvular AF• AF in the absence of rheumatic mitral stenosis, a mechanical or bioprosthetic heart valve, or mitral valve repair.AF indicates atrial fibrillation.2.2. Mechanisms of AF and PathophysiologyAF occurs when structural and/or electrophysiological abnormalities alter atrial tissue to promote abnormal impulse formation and/or propagation (Figure 1). These abnormalities are caused by diverse pathophysiological mechanisms,29,33,34 such that AF represents a final common phenotype for multiple disease pathways and mechanisms that are incompletely understood.Download figureDownload PowerPointFigure 1. Mechanisms of AF. AF indicates atrial fibrillation; Ca++ ionized calcium; and RAAS, renin-angiotensin-aldosterone system.2.3. Risk Factors and Associated Heart DiseaseMultiple clinical risk factors, electrocardiographic and echocardiographic features, and biochemical markers are associated with an increased risk of AF (Table 4).Table 4. Selected Risk Factors and Biomarkers for AFClinical Risk FactorsReferencesIncreasing age35Hypertension35Diabetes mellitus35MI35VHD35HF35,36Obesity37–39Obstructive sleep apnea39Cardiothoracic surgery40Smoking41Exercise42–44Alcohol use45–47Hyperthyroidism48–50Increased pulse pressure51European ancestry52Family history53Genetic variants54–57ECG LVH58Echocardiographic LA enlargement58,59 Decreased LV fractional shortening58 Increased LV wall thickness58Biomarkers Increased CRP60,61 Increased BNP62,63AF indicates atrial fibrillation; BNP, B-type natriuretic peptide; CRP, C-reactive protein; ECG, electrocardiographic; HF, heart failure; LA, left atrial; LV, left ventricular; LVH, left ventricular hypertrophy; MI, myocardial infarction; and VHD, valvular heart disease.2.4. Clinical Evaluation: RecommendationSee Appendix 3 for information on initial clinical evaluation in patients with AF.Class IElectrocardiographic documentation is recommended to establish the diagnosis of AF. (Level of Evidence: C)3. Thromboembolic Risk and Treatment3.1. Risk-Based Antithrombotic Therapy: RecommendationsSee Table 5 for a summary of recommendations from this section.Table 5. Summary of Recommendations for Risk-Based Antithrombotic TherapyTable 5. Summary of Recommendations for Risk-Based Antithrombotic TherapyClass IIn patients with AF, antithrombotic therapy should be individualized based on shared decision making after discussion of the absolute and relative risks of stroke and bleeding and the patient’s values and preferences. (Level of Evidence: C)Selection of antithrombotic therapy should be based on the risk of thromboembolism irrespective of whether the AF pattern is paroxysmal, persistent, or permanent.64–67(Level of Evidence: B)In patients with nonvalvular AF, the CHA2DS2-VASc*score is recommended for assessment of stroke risk.68–70(Level of Evidence: B)For patients with AF who have mechanical heart valves, warfarin is recommended, and the target international normalized ratio (INR) intensity (2.0 to 3.0 or 2.5 to 3.5) should be based on the type and location of the prosthesis.71–73(Level of Evidence: B)For patients with nonvalvular AF with prior stroke, transient ischemic attack (TIA), or a CHA2DS2-VASc scoreof 2 or greater, oral anticoagulants are recommended. Options include warfarin (INR 2.0 to 3.0)68–70(Level of Evidence: A), dabigatran74(Level of Evidence: B), rivaroxaban75(Level of Evidence: B), or apixaban.76(Level of Evidence: B)Among patients treated with warfarin, the INR should be determined at least weekly during initiation of antithrombotic therapy and at least monthly when anticoagulation (INR in range) is stable.77–79(Level of Evidence: A)For patients with nonvalvular AF unable to maintain a therapeutic INR level with warfarin, use of a direct thrombin or factor Xa inhibitor (dabigatran, rivaroxaban, or apixaban) is recommended. (Level of Evidence: C)Reevaluation of the need for and choice of antithrombotic therapy at periodic intervals is recommended to reassess stroke and bleeding risks. (Level of Evidence: C)Bridging therapy with unfractionated heparin or low-molecular-weight heparin (LMWH) is recommended for patients with AF and a mechanical heart valve undergoing procedures that require interruption of warfarin. Decisions on bridging therapy should balance the risks of stroke and bleeding. (Level of Evidence: C)For patients with AF without mechanical heart valves who require interruption of warfarin or new anticoagulants for procedures, decisions about bridging therapy (LMWH or unfractionated heparin) should balance the risks of stroke and bleeding and the duration of time a patient will not be anticoagulated. (Level of Evidence: C)Renal function should be evaluated before initiation of direct thrombin or factor Xa inhibitors and should be reevaluated when clinically indicated and at least annually.80–82(Level of Evidence: B)For patients with atrial flutter, antithrombotic therapy is recommended according to the same risk profile used for AF. (Level of Evidence: C)Class IIaFor patients with nonvalvular AF and a CHA2DS2-VASc score of 0, it is reasonable to omit antithrombotic therapy.80,81(Level of Evidence: B)For patients with nonvalvular AF with a CHA2DS2-VASc score of 2 or greater and who have end-stage chronic kidney disease (CKD) (creatinine clearance <15 mL/min) or are on hemodialysis, it is reasonable to prescribe warfarin (INR 2.0 to 3.0) for oral anticoagulation.82 (Level of Evidence: B)Class IIbFor patients with nonvalvular AF and a CHA2DS2-VASc score of 1, no antithrombotic therapy or treatment with an oral anticoagulant or aspirin may be considered. (Level of Evidence: C)For patients with nonvalvular AF and moderate-to-severe CKD with CHA2DS2-VASc scores of 2 or greater, treatment with reduced doses of direct thrombin or factor Xa inhibitors may be considered (eg, dabigatran, rivaroxaban, or apixaban), but safety and efficacy have not been established. (Level of Evidence: C)In patients with AF undergoing percutaneous coronary intervention,†bare-metal stents may be considered to minimize the required duration of dual antiplatelet therapy. Anticoagulation may be interrupted at the time of the procedure to reduce the risk of bleeding at the site of peripheral arterial puncture. (Level of Evidence: C)Following coronary