Guideline of atrial fibrillation management

Boyoung Joung

doi:10.5124/jkma.2019.62.5.265

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Joung: Guideline of atrial fibrillation management

Continuing Education Column

Journal of the Korean Medical Association 2019; 62(5): 265-274.

Published online: 16 May 2019

DOI: https://doi.org/10.5124/jkma.2019.62.5.265

Guideline of atrial fibrillation management

Boyoung Joung, MD

Division of Cardiology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea.

Corresponding author: Boyoung Joung. cby6908@yuhs.ac

Received 2 February 2019 Accepted 9 April 2019

Korean Medical Association

(open-access):

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia in the general population. The Korean Heart Rhythm Society organized a Korean Atrial Fibrillation Management Guideline Committee and analyzed all available studies regarding the management of AF, including studies on Korean patients. This guideline is based on recent data of the Korean population and the recent guidelines of the European Society of Cardiology, European Association for Cardio-Thoracic Surgery, American Heart Association, and Asia Pacific Heart Rhythm Society. Expert consensus or guidelines for the optimal management of Korean patients with AF were achieved after a systematic review with intensive discussion. This article provides general principles for appropriate risk stratification and selection of anticoagulation therapy in Korean patients with AF. This guideline deals with optimal stroke prevention, screening, rate and rhythm control, risk factor management, and integrated management of AF.

Keywords: Atrial fibrillation, Guideline, Anticoagulants, Therapy

Figures and Tables

Figure 1

Annual prevalence (A) and incidence (B) of atrial fibrillation (AF), 2006–2015, stratified by sex. Reproduced from Joung B et al. Korean Cir J 2018;48:1033-1080, according to the Creative Commons license [1]. ^a)P<0.05. ^b)P<0.001.

Figure 2

Annual incidence (A) and prevalence (B) of atrial fibrillation (AF), 2006–2015, stratified by age. Reproduced from Joung B et al. Korean Cir J 2018;48:1033-1080, according to the Creative Commons license [1]. ^a)P<0.05. ^b)P<0.001.

Figure 3

The projected prevalence of atrial fibrillation. Reproduced from Joung B et al. Korean Cir J 2018;48:1033-1080, according to the Creative Commons license [1].

Figure 4

Temporal trends of newly diagnosed atrial fibrillation patient by CHA₂DS₂-VASc (A) and HAS-BLED scores (B), 2006–2015. Reproduced from Joung B et al. Korean Cir J 2018;48:1033-1080, according to the Creative Commons license [1].

Figure 5

Temporal trends in 1-year adverse event rates of prevalent atrial fibrillation Korean population each year. HF, heart failure. ^a)P-value for trends <0.001. Reproduced from Joung B et al. Korean Cir J 2018;48:1033-1080, according to the Creative Commons license [1].

Figure 6

The basic concept of acute and chronic management of atrial fibrillation. OAC, oral anticoagulation therapy; VKA, vitamin K antagonist; TTR, time in therapeutic range; NOAC, non-vitamin K antagonist oral anticoagulant. Reproduced from Joung B et al. Korean Cir J 2018;48:1033-1080, according to the Creative Commons license [1].

Figure 7

Stroke prevention strategy in patients with atrial fibrillation. NOAC, non-vitamin K oral anticoagulant; OAC, oral anticoagulation. ^a)A congestive heart failure, hypertension, age ≥75 (doubled), diabetes mellitus, prior stroke or transient ischemic attack (doubled), vascular disease, age 65–74, female. Reproduced from Joung B et al. Korean Cir J 2018;48:1033-1080, according to the Creative Commons license [1].

Figure 8

Management of bleeding in patients taking oral anticoagulants. INR, international normalized ratio; IV, intravenous; NOAC, non-vitamin K oral anticoagulant. Adapted from Joung B et al. Korean Cir J 2018;48:1033-1080 [1].

Table 1

CHA₂DS₂-VASc scoring system

Adapted from Kirchhof P et al. Eur Heart J 2016;37:2893-2962 [11].

^a)≥4 mm or ulcerative or mobile plaque.

Table 2

Indication and contraindication for NOAC in patient with atrial fibrillation

NOAC, non-vitamin K antagonist oral anticoagulant; PTAV, percutaneous transluminal aortic valvuloplasty; TAVI, transcatheter aortic valve implantation.

Adapted from Steffel J et al. Eur Heart J 2018;39:1330-1393 [13].

Table 3

Dose reduction of non-vitamin K antagonist oral anticoagulants

Reproduced from Joung B et al. Korean Cir J 2018;48:1033-1080, according to the Creative Commons license [1]. bid, bis in die (twice a day); qd, quaque die (once a day).

^a)Amiodarone, verapamil, dronedarone, etc. ^b)Coagulopathy, thrombocytopenia, platelet dysfunction, recent major trauma or biopsy, infective endocarditis. ^c)Should be used with caution in patients with significant renal impairment (creatinine clearance 15–29 mL/min).

References

1. Joung B, Lee JM, Lee KH, Kim TH, Choi EK, Lim WH, Kang KW, Shim J, Lim HE, Park J, Lee SR, Lee YS, Kim JB. KHRS Atrial Fibrillation Guideline Working Group. 2018 Korean guideline of atrial fibrillation management. Korean Circ J. 2018; 48:1033–1080.

2. Kim D, Yang PS, Jang E, Yu HT, Kim TH, Uhm JS, Kim JY, Pak HN, Lee MH, Joung B, Lip GY. 10-Year nationwide trends of the incidence, prevalence, and adverse outcomes of non-valvular atrial fibrillation nationwide health insurance data covering the entire Korean population. Am Heart J. 2018; 202:20–26.

3. Kim D, Yang PS, Jang E, Yu HT, Kim TH, Uhm JS, Kim JY, Pak HN, Lee MH, Joung B, Lip GYH. Increasing trends in hospital care burden of atrial fibrillation in Korea, 2006 through 2015. Heart. 2018; 104:2010–2017.

4. Yang PS, Ryu S, Kim D, Jang E, Yu HT, Kim TH, Hwang J, Joung B, Lip GY. Variations of prevalence and incidence of atrial fibrillation and oral anticoagulation rate according to different analysis approaches. Sci Rep. 2018; 8:6856.

5. Lee H, Kim TH, Baek YS, Uhm JS, Pak HN, Lee MH, Joung B. The trends of atrial fibrillation-related hospital visit and cost, treatment pattern and mortality in Korea: 10-year nationwide sample cohort data. Korean Circ J. 2017; 47:56–64.

6. Lee SR, Lee YS, Lim WH, Kim TH, Cha MJ, Lee JH, Baek YS, Lim HE, Joung B, Kim JS, Lee MY. 2018 Korean Heart Rhythm Society guidelines for detection and management of risk factors and concomitant cardiovascular diseases in Korean patients with atrial fibrillation. Korean J Med. 2018; 93:324–335.

7. Kim D, Yang PS, Kim TH, Jang E, Shin H, Kim HY, Yu HT, Uhm JS, Kim JY, Pak HN, Lee MH, Joung B, Lip GY. Ideal blood pressure in patients with atrial fibrillation. J Am Coll Cardiol. 2018; 72:1233–1245.

8. Kim TH, Yang PS, Yu HT, Jang E, Shin H, Kim HY, Uhm JS, Kim JY, Sung JH, Pak HN, Lee MH, Joung B, Lip GY. Effect of hypertension duration and blood pressure level on ischaemic stroke risk in atrial fibrillation: nationwide data covering the entire Korean population. Eur Heart J. 2019; 40:809–819.

9. Baek YS, Yang PS, Kim TH, Uhm JS, Park J, Pak HN, Lee MH, Joung B. Associations of abdominal obesity and new-onset atrial fibrillation in the general population. J Am Heart Assoc. 2017; 6:e004705.

10. Park J, Joung B, Kim J, Kim JB, Park HW, Park YM, Uhm JS, Ahn J, Lee DI, Kim JS, Lee MY. The 2018 Korean Heart Rhythm Society guidelines for integrated management of Korean patients with nonvalvular atrial fibrillation. Korean J Med. 2018; 93:336–343.

11. Kirchhof P, Benussi S, Kotecha D, Ahlsson A, Atar D, Casadei B, Castella M, Diener HC, Heidbuchel H, Hendriks J, Hindricks G, Manolis AS, Oldgren J, Popescu BA, Schotten U, Van Putte B, Vardas P. ESC Scientific Document Group. 2016 ESC guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J. 2016; 37:2893–2962.

12. Lee JM, Joung B, Cha MJ, Lee JH, Lim WH, Kim TH, Shin SY, Uhm JS, Lim HE, Kim JB, Kim JS. 2018 KHRS guidelines for stroke prevention therapy in Korean patients with nonvalvular atrial fibrillation. Korean J Med. 2018; 93:87–109.

13. Steffel J, Verhamme P, Potpara TS, Albaladejo P, Antz M, Desteghe L, Haeusler KG, Oldgren J, Reinecke H, Roldan-Schilling V, Rowell N, Sinnaeve P, Collins R, Camm AJ, Heidbuchel H. ESC Scientific Document Group. The 2018 European Heart Rhythm Association Practical Guide on the use of non-vitamin K antagonist oral anticoagulants in patients with atrial fibrillation. Eur Heart J. 2018; 39:1330–1393.

14. Lee KH, Joung B, Lee SR, Hwang YM, Park J, Baek YS, Park YM, Park JK, Park HC, Park HW, Lee YS, Choi KJ. 2018 KHRS Expert Consensus recommendation for oral anticoagulants choice and appropriate doses: specific situation and high risk patients. Korean J Med. 2018; 93:110–132.

15. Lim WH, Choi EK, Joung B, Choi KJ. 2018 Korean Heart Rhythm Society guidelines for the rate control of atrial fibrillation. Korean J Med. 2018; 93:133–139.

16. Kang KW, Shim J, Ahn J, Lee DI, Kim J, Joung B, Choi KJ. 2018 Korean Heart Rhythm Society guidelines for antiarrhythmic drug therapy in non-valvular atrial fibrillation. Korean J Med. 2018; 93:140–152.

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ORCID iDs: Boyoung Joung
https://orcid.org/0000-0001-9036-7225
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Guideline of atrial fibrillation management

Abstract

Figures and Tables

Figure 1

Annual prevalence (A) and incidence (B) of atrial fibrillation (AF), 2006–2015, stratified by sex. Reproduced from Joung B et al. Korean Cir J 2018;48:1033-1080, according to the Creative Commons license [1]. a)P<0.05. b)P<0.001.

Figure 2

Annual incidence (A) and prevalence (B) of atrial fibrillation (AF), 2006–2015, stratified by age. Reproduced from Joung B et al. Korean Cir J 2018;48:1033-1080, according to the Creative Commons license [1]. a)P<0.05. b)P<0.001.

Figure 3

The projected prevalence of atrial fibrillation. Reproduced from Joung B et al. Korean Cir J 2018;48:1033-1080, according to the Creative Commons license [1].

Figure 4

Temporal trends of newly diagnosed atrial fibrillation patient by CHA2DS2-VASc (A) and HAS-BLED scores (B), 2006–2015. Reproduced from Joung B et al. Korean Cir J 2018;48:1033-1080, according to the Creative Commons license [1].

Figure 5

Temporal trends in 1-year adverse event rates of prevalent atrial fibrillation Korean population each year. HF, heart failure. a)P-value for trends <0.001. Reproduced from Joung B et al. Korean Cir J 2018;48:1033-1080, according to the Creative Commons license [1].

Figure 6

Figure 7

Figure 8

Management of bleeding in patients taking oral anticoagulants. INR, international normalized ratio; IV, intravenous; NOAC, non-vitamin K oral anticoagulant. Adapted from Joung B et al. Korean Cir J 2018;48:1033-1080 [1].

Table 1

CHA2DS2-VASc scoring system

Table 2

Indication and contraindication for NOAC in patient with atrial fibrillation

Table 3

Dose reduction of non-vitamin K antagonist oral anticoagulants

References

Annual prevalence (A) and incidence (B) of atrial fibrillation (AF), 2006–2015, stratified by sex. Reproduced from Joung B et al. Korean Cir J 2018;48:1033-1080, according to the Creative Commons license [1]. ^a)P<0.05. ^b)P<0.001.

Annual incidence (A) and prevalence (B) of atrial fibrillation (AF), 2006–2015, stratified by age. Reproduced from Joung B et al. Korean Cir J 2018;48:1033-1080, according to the Creative Commons license [1]. ^a)P<0.05. ^b)P<0.001.

Temporal trends of newly diagnosed atrial fibrillation patient by CHA₂DS₂-VASc (A) and HAS-BLED scores (B), 2006–2015. Reproduced from Joung B et al. Korean Cir J 2018;48:1033-1080, according to the Creative Commons license [1].

Temporal trends in 1-year adverse event rates of prevalent atrial fibrillation Korean population each year. HF, heart failure. ^a)P-value for trends <0.001. Reproduced from Joung B et al. Korean Cir J 2018;48:1033-1080, according to the Creative Commons license [1].

CHA₂DS₂-VASc scoring system