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New Guidance Issued for Atrial Fibrillation

The American Heart Association (AHA), American College of Cardiology (ACC), and the Heart Rhythm Society (HRS) have issued updated guidelines on the management of patients with atrial fibrillation (AF) that include recommendations on new oral anticoagulants. The guidance replaces the previous full document released in 2006 and 2 focused updates from 2011.
 
The new guidelines rate dabigatran (Pradaxa), rivaroxaban (Xarelto), and apixaban (Eliquis) alongside warfarin as recommended for patients with nonvalvular AF with a history of stroke or transient ischemic attack or an otherwise elevated risk of stroke.
 
"Because what we say in the guideline can affect how a drug is used, we were careful to be even-handed and evidence-based in presenting new drugs," Craig T. January, MD, PhD, professor of Medicine in the Division of Cardiovascular Medicine at the University of Wisconsin-Madison, a fellow of the ACC, a member of the AHA and HRS, and chair of the writing committee, said in a statement. "Our goal was to provide useful, non-biased information."
 
For AF patients who have mechanical heart valves, the guidelines recommend warfarin, 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.
 
The guidelines also advise clinicians use one of the newer anticoagulants for patients who can’t maintain a therapeutic INR between 2.0 and 3.0 on warfarin.
 
Dabigatran should not be used in patients with a mechanical heart valve, and dabigatran and rivaroxaban are not recommended for use in patients with end-stage chronic kidney disease or who are on hemodialysis.
 
Preferences were not provided for any of the 3 newer agents because there is a lack of head-to-head trials. Choice of antithrombotics should be based on shared decision making that considers risk factors, cost, tolerability, patient preference, potential for drug interactions, and other clinical characteristics.
 
The guidelines are to be published in the Journal of the American College of Cardiology, Circulation, Journal of the American Heart Association, and Heart Rhythm.

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