Afib 2019 Guidelines Update: 5 Questions for Primary Care

At the 2019 American College of Cardiology Annual Scientific Sessions in New Orleans in mid-March, there was plenty of excitement around the great jazz in the French Quarter and of course the St Patrick’s Day celebrations. In the convention center, though, the focus was on breaking news across cardiology disciplines. 

For atrial fibrillation (AF) that included announcement of the 2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients with Atrial Fibrillation. The revisions reflect new findings in AF treamtment including the addition of newly approved oral anticoagulant therapy, treatment  modifications in special populations, balancing the benefits of a combined antithrombotic/anticoagulation regimen, plus other developments that will affect daily management of your patients with AF.

Test your knowledge of the changes to the guidelines here:

1. Based on the 2019 update, which of the following is/are NOT among the guideline-recommended novel oral anticoagulants (NOACs) for use in patients with nonvalvular atrial fibrillation?A. Dabigatran (Pradaxa)
B.  Apixaban (Eliquis)
C.  Rivaroxaban (Xarelto)
D.  Edoxaban (Savaysa)
E.  Warfarin
F.  None of the above (ie, all options are guideline-approved for nonvalvular AF).

Please click here for answer, discussion, and next question.

(Image ©Garsya/Shutterstock.com)

Answer: F. None of the above (ie, all options are guideline-approved for nonvalvualr AF). The 2019 focused update added edoxaban to the list of NOACs that can be used for patients with AF and did not exclude any of the already recommended NOACs. A warning was added, however, about the use of the direct thrombin inhibitor dabigatran or the factor Xa inhibitors rivaroxaban or edoxaban in patients with AF and end stage renal disease for who they are no longer recommended. 

2. The NOACs are now recommended over warfarin in all eligible patients with AF.

A.  True
B.  False

Please click here for answer, discussion, and next question.

(Image ©Garsya/Shutterstock.com)

Answer: A. True.  The NOACs as listed are now recommended as the first-line agents for oral anticoagulation in patients with AF except in patients with moderate to severe mitral stenosis or a mechanical heart valve.

3. Based on the guideline update, which of the following would be a reasonable next step in an 82-year-old with CHA₂DS₂-Vasc score of 5 and recurrent GI bleeding while on apixaban?

A.  Stop anticoagulation
B.  Initiate a trial of warfarin
C.  Percutaneous left atrial appendage occlusion
D.  Catheter ablation

Please click here for answer, discussion, and next question.

(Image ©Garsya/Shutterstock.com)

Answer: C. Percutaneous left atrial appendage occlusion. Discontinuing anticoagulation (option A) is not recommended in this patient who has high thromboembolic risk.  Warfarin (option B) is associated with the potential for widely variable INRs, and so has an unfavorable bleeding profile as compared with the NOACs. AF ablation (option D) may treat the arrhythmia but does not treat the thromboembolic risk. Percutaneous left atrial appendage occlusion (ie, with the Watchman device) is now formally recommended as part of the 2019 update as a reasonable alternative to oral anticoagulation in those patients who have a high thromboembolic risk and contraindications to long term anticoagulation.

4. According to the guideline update, which of the following is NOT a reasonable recommendation in patients with AF undergoing PCI?

A.  If triple therapy is prescribed post-PCI, clopidogrel is preferred over prasugrel
B.  Double therapy with a P2Y12 inhibitor plus warfarin
C.  Double therapy with a clopidogrel plus rivaroxaban 15 mg once daily
D.  Double therapy with a P2Y12 inhibitor plus dabigatran 150 mg twice daily
E.  If triple therapy is used, a transition to double therapy should be considered 4-6 weeks post-PCI
F.  None of the above (ie, all are reasonable options in AF patients post-PCI)

Please click here for answer, discussion, and next question.

(Image ©Garsya/Shutterstock.com)

Answer: F. None of the above (ie, all are reasonable options in AF patients post-PCI). All of the options listed are now guideline-recommended choices to reduce risk of bleeding post-PCI in AF patients while balancing the benefits of a combined antithrombotic/anticoagulation regimen.

5. How often should renal and hepatic function be tested after initiation of a NOAC?

A.  At initiation
B.  At initiation and annually thereafter
C.  At initiation and every 2 years thereafter
D.  At initiation and thereafter only if abnormal

Please click here for answer and discussion.

(Image ©Garsya/Shutterstock.com)

Answer: B. At initiation and then annually afterwards. Renal and hepatic function should be assessed at NOAC initiation and monitored at least annually or more frequently as deemed appropriate by the treating doctor.

Source: January CT, Wann LS, Calkins H, et al.  2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. [published online ahead of print January 28, 2019]. Circulation. doi:10.1161/CIR.0000000000000665.

(Image ©Garsya/Shutterstock.com)