2018 Korean Guideline of Atrial Fibrillation Management

Abstract

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia in the general population. The Korean Heart Rhythm Society organized a Korean AF 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: Anticoagulants; Atrial fibrillation; Guideline; Therapy.

Figure 1. Annual prevalence (A) and incidence (B) of AF, 2006–2015, stratified by sex.

AF = atrial fibrillation. ^*p value for increasing trends <0.001. ^†p value for decreasing trends <0.001.

Figure 2. Annual incidence (A) and prevalence (B) of AF, 2006–2015, stratified by age.

AF = atrial fibrillation. ^*p value for increasing trends <0.001. ^†p value for decreasing trends <0.001.

Figure 3. The projected prevalence of atrial fibrillation.

Figure 4. Temporal trends of newly diagnosed AF patient by CHA₂DS₂-VASc and HAS-BLED scores, 2006–2015.

AF = atrial fibrillation.

Figure 5. Temporal trends of medical costs, 2006–2015. (A) Korean NHIS total expenditures (million €), (B) total AF hospitalization costs (million €), and (C) the proportion of total AF hospitalization costs to Korean NHIS total expenditures (%).

AF = atrial fibrillation; NHIS = National Health Insurance Service. ^*p value for trends <0.001.

Figure 6. Temporal trends in 1-year adverse event rates of prevalent AF Korean population each year.

AF = atrial fibrillation; HF = heart failure ^*p value for trends <0.001.

Figure 7. The basic concept of acute and chronic management of AF. Modified from Lip et al.

AF = atrial fibrillation; NOAC = non-vitamin K antagonist oral anticoagulant; OAC = oral anticoagulation therapy; TTR = time in therapeutic range.

Figure 8. Stroke prevention strategy in patients with AF.

AF = atrial fibrillation; HF = heart failure; NOAC = non-vitamin K oral anticoagulant; OAC = oral anticoagulation. ^*CHA₂DS₂-VASs score: a congestive HF, hypertension, age ≥75 (doubled), diabetes mellitus, prior stroke or transient ischemic attack (doubled), vascular disease, age 65–74, female.

Figure 9. Practical management algorithm in light of the 2018 American College of Chest Physicians guidelines, which are evidence based and GRADE.

AF = atrial fibrillation; INR = international normalized ratio; NOAC = non-vitamin K antagonist oral anticoagulant; OAC = oral anticoagulation therapy. ^*HAS-BLED: hypertension, abnormal renal/liver function (1 point each), stroke, bleeding history or predisposition, labile INR, elderly (0.65), drugs/alcohol concomitantly (1 point each).

Figure 10. Receiver operating characteristic curves of Δ CHA₂DS₂-VASc score for predicting ischemic stroke during the entire second follow-up period.

AUC = area under the curve; CI = confidence interval; SE = standard error.

Figure 11. AF rate control management.

AF = atrial fibrillation; LVEF = left ventricular ejection fraction.

Figure 12. AF rhythm control management. (A) acute onset AF and (B) long-term AF.

AF = atrial fibrillation.

Figure 13. Suggested algorithm for antithrombotic therapy in patients undergoing PCI.

NOAC = non-vitamin K antagonist oral anticoagulant; OAC = oral anticoagulant; PCI = percutaneous coronary intervention; TTR = time in therapeutic range.