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type=\u0022text\/css\u0022 rel=\u0022stylesheet\u0022 href=\u0022\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/advagg_css\/css__ce2QY63WIanKyr8eSq7eavr1XQRRmFD6ZSmwpyJi8lM__zXwFqpqmxrZOXXcd_TpBQpjuELbmIP9wBR5UuTDWAO4__YJWWMMdfCJuAFm5cUEp88OsodhO3ZA-2lzRfoBsSlk4.css\u0022 media=\u0022all\u0022 \/\u003E\n\u003Clink rel=\u0027stylesheet\u0027 type=\u0027text\/css\u0027 href=\u0027\/sites\/all\/modules\/contrib\/panels\/plugins\/layouts\/onecol\/onecol.css\u0027 \/\u003E\u003C\/head\u003E\u003Cbody\u003E\u003Cdiv class=\u0022panels-ajax-tab-panel panels-ajax-tab-panel-sageoa-tab-art\u0022\u003E\u003Cdiv class=\u0022panel-display panel-1col clearfix\u0022 \u003E\n  \u003Cdiv class=\u0022panel-panel panel-col\u0022\u003E\n    \u003Cdiv\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-markup\u0022 \u003E\n  \n      \n  \n  \u003Cdiv class=\u0022pane-content\u0022\u003E\n    \u003Cdiv class=\u0022highwire-markup\u0022\u003E\u003Cdiv xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block-markup\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv class=\u0022article fulltext-view \u0022\u003E\u003Cspan class=\u0022highwire-journal-article-marker-start\u0022\u003E\u003C\/span\u003E\u003Cdiv class=\u0022section abstract\u0022 id=\u0022abstract-1\u0022\u003E\u003Ch2\u003ESummary\u003C\/h2\u003E\u003Cp id=\u0022p-1\u0022\u003EThis article discusses new research on atrial fibrillation (AF) and how it may contribute to disease management, the use of novel oral anticoagulants in periprocedural anticoagulation management, the clinical overlap between AF and heart failure, as well as an overview of new ACC\/AHA\/HRS guideline recommendations.\u003C\/p\u003E\u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003Earrhythmias\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Ecardiology guidelines\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Eheart failure\u003C\/li\u003E\u003C\/ul\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-1\u0022\u003E\u003Cp id=\u0022p-2\u0022\u003EStanley Nattel, MD, Montreal Heart Institute, Montreal, Quebec, Canada, reviewed new research on atrial fibrillation (AF) and how it may contribute to disease management. He focused on 3 lessons: First, using the reentrant rotor concept is necessary and applicable to understand important aspects of AF; second, targeting dormant conduction can prevent AF recurrence; and, third, AF substrate progression owing to underlying risk factors is preventable.\u003C\/p\u003E\u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-2\u0022\u003E\u003Ch2 class=\u0022\u0022\u003ENEW RESEARCH ON AF\u003C\/h2\u003E\u003Cp id=\u0022p-3\u0022\u003EAlthough the standard wavelength theory of reentry suggests that Na\u003Csup\u003E+\u003C\/sup\u003E channel blockers should make AF more persistent, recent data indicate that Na\u003Csup\u003E+\u003C\/sup\u003E channel inhibition can terminate AF through its effect on reentrant rotors [Kneller J et al. \u003Cem\u003ECirc Res.\u003C\/em\u003E 2005]. This concept is supported by the CONFIRM trial [Narayan SM et al. \u003Cem\u003EJ Am Coll Cardiol.\u003C\/em\u003E 2012], which showed that localized electrical rotors and focal impulse sources are prevalent, sustaining mechanisms for AF and that ablation at patient-specific sources acutely terminated or slowed AF and improved the outcome.\u003C\/p\u003E\u003Cp id=\u0022p-4\u0022\u003EAF recurs in \u2264 50% of patients after catheter ablation, usually as a result of recovery from pulmonary vein conduction. In the ADVICE randomized trial [Macle L et al. HRS 2014. (abstr LB01-02)], the use of intravenous adenosine elicited dormant conduction in \u0026gt; 50% of patients. After a mean follow-up of 1 year, 69% of these patients who received a single additional adenosine-guided ablation were free of AF, compared with 42% of those who received no additional ablation (\u003Cem\u003EP\u003C\/em\u003E \u0026lt; .0001).\u003C\/p\u003E\u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-3\u0022\u003E\u003Ch2 class=\u0022\u0022\u003ENOACs IN PERIPROCEDURAL ANTICOAGULATION MANAGEMENT\u003C\/h2\u003E\u003Cp id=\u0022p-5\u0022\u003EIn deciding whether it is necessary to interrupt anticoagulation therapy for procedures including ablation, the following aspects of procedures must be considered: bleeding risk (\u003Ca id=\u0022xref-table-wrap-1-1\u0022 class=\u0022xref-table\u0022 href=\u0022#T1\u0022\u003ETable 1\u003C\/a\u003E), duration of interrupted therapy (if there is an interruption), and whether bridging is necessary. Elaine Hylek, MD, MPH, Boston University Medical Center, Boston, Massachusetts, USA, discussed the use of novel oral anticoagulants (NOACs) in periprocedural anticoagulation management.\u003C\/p\u003E\u003Cdiv id=\u0022T1\u0022 class=\u0022table pos-float\u0022\u003E\u003Cdiv class=\u0022table-inline\u0022\u003E\u003Cdiv class=\u0022callout\u0022\u003E\u003Cspan\u003EView this table:\u003C\/span\u003E\u003Cul class=\u0022callout-links\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022\/\u0022 class=\u0022table-expand-inline\u0022 data-table-url=\u0022\/highwire\/markup\/15212\/expansion?postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media%2Chighwire_embed\u0026amp;table-expand-inline=1\u0022 html=\u00221\u0022 fragment=\u0022#\u0022 external=\u00221\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView inline\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022\/highwire\/markup\/15212\/expansion?width=1000\u0026amp;height=500\u0026amp;iframe=true\u0026amp;postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media\u0022 class=\u0022colorbox colorbox-load table-expand-popup\u0022 rel=\u0022gallery-fragment-tables\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView popup\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/15212\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cdiv class=\u0022table-caption\u0022\u003E\u003Cspan class=\u0022table-label\u0022\u003ETable 1.\u003C\/span\u003E \u003Cp id=\u0022p-6\u0022 class=\u0022first-child\u0022\u003EProcedure-Related Bleeding Risk\u003C\/p\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cp id=\u0022p-7\u0022\u003EDr Hylek noted that several studies have shown similar periprocedural bleeding with vitamin K antagonists and NOACs, including RE-LY [Healey JS et al. \u003Cem\u003ECirculation.\u003C\/em\u003E 2012], ROCKET AF [Sherwood MW et al. \u003Cem\u003ECirculation.\u003C\/em\u003E 2014], and ARISTOTLE [Garcia D et al. \u003Cem\u003EBlood.\u003C\/em\u003E 2014].\u003C\/p\u003E\u003Cp id=\u0022p-8\u0022\u003EWith respect to the need for bridging, she suggested that the short time to maximum plasma concentration with NOACs versus warfarin obviates the need for bridging but highlights the importance of hemostasis before resumption of treatment. For urgent reversal of vitamin K antagonist therapy in major bleeding events, Dr Hylek believes that there is good evidence for the use of a 4-factor prothrombin complex concentrate as an effective alternative to plasma [Sarode R et al. \u003Cem\u003ECirculation.\u003C\/em\u003E 2013].\u003C\/p\u003E\u003Cp id=\u0022p-9\u0022\u003EAs for their use in cardioversion, Dr Hylek concluded that the data to date suggest that NOACs are efficacious and safe [Flaker G et al. \u003Cem\u003EJ Am Coll Cardiol.\u003C\/em\u003E 2014; Nagarakanti R et al. \u003Cem\u003ECirculation.\u003C\/em\u003E 2011]. Future studies are planned for cardioversion and catheter ablation.\u003C\/p\u003E\u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-4\u0022\u003E\u003Ch2 class=\u0022\u0022\u003ERELATIONSHIP BETWEEN AF AND HF\u003C\/h2\u003E\u003Cp id=\u0022p-10\u0022\u003EThere is an important mechanistic and clinical overlap between AF and heart failure (HF; \u003Ca id=\u0022xref-fig-1-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F1\u0022\u003EFigure 1\u003C\/a\u003E). Clyde W. Yancy Jr, MD, Northwestern University, Chicago, Illinois, USA, discussed what is known about this relationship.\u003C\/p\u003E\u003Cdiv id=\u0022F1\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/52\/30\/F1.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022The Overlapping Pathology of AF and HF\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-259995696\u0022 data-figure-caption=\u0022The Overlapping Pathology of AF and HF\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 1.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/52\/30\/F1.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/52\/30\/F1.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 1.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/52\/30\/F1.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/15211\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption attrib\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 1.\u003C\/span\u003E \u003Cp id=\u0022p-11\u0022 class=\u0022first-child\u0022\u003EThe Overlapping Pathology of AF and HF\u003C\/p\u003E\u003Cq class=\u0022attrib\u0022 id=\u0022attrib-1\u0022\u003EAF, atrial fibrillation; HF, heart failure.\u003C\/q\u003E\u003Cq class=\u0022attrib\u0022 id=\u0022attrib-2\u0022\u003EReproduced with permission from CW Yancy, Jr, MD.\u003C\/q\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cp id=\u0022p-12\u0022\u003EThe prevalence of AF in patients enrolled in HF studies varies from a low of \u0026lt; 10% to a high of 50% [Trulock KM et al. \u003Cem\u003EJ Am Coll Cardiol.\u003C\/em\u003E 2014]. The 2 conditions share many of the same risk factors, including coronary disease, hypertension, tobacco use, obesity, diabetes, kidney disease, and sleep apnea. The presence of both AF and HF is associated with a worse prognosis than that for either condition alone [Wang TJ et al. \u003Cem\u003ECirculation.\u003C\/em\u003E 2003].\u003C\/p\u003E\u003Cp id=\u0022p-13\u0022\u003EThe current treatment guidelines for AF emphasize rate control and anticoagulation [January CT et al. \u003Cem\u003ECirculation.\u003C\/em\u003E 2014]. However, quality improvement data in the IMPROVE HF study [Fonarow GC et al. \u003Cem\u003ECirc Heart Fail.\u003C\/em\u003E 2008] show that the use of guideline-recommended therapies for patients with AF and HF vary widely. In particular, the use of anticoagulation therapy varies in clinical practice, especially among older patients [Hernandez AF et al. \u003Cem\u003ECirc Cardiovasc Qual Outcomes.\u003C\/em\u003E 2014].\u003C\/p\u003E\u003Cp id=\u0022p-14\u0022\u003EThe benefits of rhythm control in patients with both AF and HF remain uncertain [Trulock KM et al. \u003Cem\u003EJ Am Coll Cardiol.\u003C\/em\u003E 2014]. In the AFFIRM study [Wyse DG et al. \u003Cem\u003EN Engl J Med.\u003C\/em\u003E 2002], there was a potential advantage with rhythm control among patients with AF and HF, while in the AF-CHF study [Talajic M et al. \u003Cem\u003EJ Am Coll Cardiol.\u003C\/em\u003E 2010], no differences were noted for a rate-versus-rhythm approach on the primary or secondary end points. More recently, in a meta-analysis of 26 studies in patients (n = 1838) with left ventricular systolic dysfunction undergoing catheter ablation for AF, left ventricular ejection fraction improved significantly during follow-up by 13% (\u003Cem\u003EP\u003C\/em\u003E \u0026lt; .001) [Anselmino M et al. \u003Cem\u003ECirc Arrhythm Electrophysiol.\u003C\/em\u003E 2014]. Ongoing studies, such as RAFT-AF [\u003Ca class=\u0022external-ref external-ref-type-clintrialgov\u0022 href=\u0022\/lookup\/external-ref?link_type=CLINTRIALGOV\u0026amp;access_num=NCT01420393\u0026amp;atom=%2Fspmdc%2F14%2F52%2F30.atom\u0022\u003ENCT01420393\u003C\/a\u003E] and CASTLE-AF [\u003Ca class=\u0022external-ref external-ref-type-clintrialgov\u0022 href=\u0022\/lookup\/external-ref?link_type=CLINTRIALGOV\u0026amp;access_num=NCT00643188\u0026amp;atom=%2Fspmdc%2F14%2F52%2F30.atom\u0022\u003ENCT00643188\u003C\/a\u003E], may provide important answers concerning the benefit of a rhythm strategy in these patients.\u003C\/p\u003E\u003Cp id=\u0022p-15\u0022\u003EBoth obesity and obstructive sleep apnea are additional risk factors for AF but are reversible. Recent studies have shown that weight reduction combined with intensive management of cardiometabolic risk factors reduces AF symptom burden and severity [Abed HS et al. \u003Cem\u003EJAMA.\u003C\/em\u003E 2013], while treatment with continuous positive airway pressure in patients with obstructive sleep apnea is associated with a lower recurrence of AF [Naruse Y et al. \u003Cem\u003EHeart Rhythm.\u003C\/em\u003E 2013].\u003C\/p\u003E\u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-5\u0022\u003E\u003Ch2 class=\u0022\u0022\u003EOAC THERAPY IN PATIENTS WITH AF\u003C\/h2\u003E\u003Cp id=\u0022p-16\u0022\u003EJeff S. Healey, McMaster University, Hamilton, Ontario, Canada, noted that the benefit of oral anticoagulants (OACs) in the AF population is unclear and depends on several factors, including the burden of the AF (singular or ongoing episodes), the presence of other stroke risk factors, and the individual risk\/benefit of OAC therapy.\u003C\/p\u003E\u003Cp id=\u0022p-17\u0022\u003EAmong elderly individuals with AF, short subclinical atrial fibrillation (SCAF) episodes are frequently detected on pacemaker readouts. Despite the absence of clinical symptoms and their short duration, according to the ASSERT study [Healey JS et al. \u003Cem\u003EN Engl J Med.\u003C\/em\u003E 2012], these episodes are associated with an increased risk of stroke and systemic embolism (\u003Ca id=\u0022xref-table-wrap-2-1\u0022 class=\u0022xref-table\u0022 href=\u0022#T2\u0022\u003ETable 2\u003C\/a\u003E). There is a suggestion that embolism risk is greater in patients with longer episodes of SCAF; however, the small number of events in ASSERT precludes definitive conclusions.\u003C\/p\u003E\u003Cdiv id=\u0022T2\u0022 class=\u0022table pos-float\u0022\u003E\u003Cdiv class=\u0022table-inline\u0022\u003E\u003Cdiv class=\u0022callout\u0022\u003E\u003Cspan\u003EView this table:\u003C\/span\u003E\u003Cul class=\u0022callout-links\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022\/\u0022 class=\u0022table-expand-inline\u0022 data-table-url=\u0022\/highwire\/markup\/15167\/expansion?postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media%2Chighwire_embed\u0026amp;table-expand-inline=1\u0022 html=\u00221\u0022 fragment=\u0022#\u0022 external=\u00221\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView inline\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022\/highwire\/markup\/15167\/expansion?width=1000\u0026amp;height=500\u0026amp;iframe=true\u0026amp;postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media\u0022 class=\u0022colorbox colorbox-load table-expand-popup\u0022 rel=\u0022gallery-fragment-tables\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView popup\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/15167\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cdiv class=\u0022table-caption\u0022\u003E\u003Cspan class=\u0022table-label\u0022\u003ETable 2.\u003C\/span\u003E \u003Cp id=\u0022p-18\u0022 class=\u0022first-child\u0022\u003EASSERT Outcomes Based on Presence or Absence of Device-Detected Atrial Tachyarrhythmia\u003C\/p\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cp id=\u0022p-22\u0022\u003EThe ARTESIA trial [\u003Ca class=\u0022external-ref external-ref-type-clintrialgov\u0022 href=\u0022\/lookup\/external-ref?link_type=CLINTRIALGOV\u0026amp;access_num=NCT01938248\u0026amp;atom=%2Fspmdc%2F14%2F52%2F30.atom\u0022\u003ENCT01938248\u003C\/a\u003E] is a phase 4 study designed to examine whether treatment with apixaban, compared with aspirin, will reduce the risk of ischemic stroke and systemic embolism in patients with device-detected SCAF and additional risk factors for stroke. The study is not yet open for enrollment but expects to recruit 4000 adults with (1) a permanent pacemaker or defibrillator or insertable cardiac monitor capable of detecting SCAF, (2) at least 1 episode of SCAF \u2265 6 minutes but no single episode \u0026gt; 24 hours, and (3) a CHA\u003Csub\u003E2\u003C\/sub\u003EDS\u003Csub\u003E2\u003C\/sub\u003E-VASc score \u2265 4.\u003C\/p\u003E\u003Cp id=\u0022p-23\u0022\u003EPending the outcome of this study, Dr Healey suggested that it seems reasonable to offer OACs to patients with long episodes (\u0026gt; 24 hours) or those with high stroke risk (ie, recent cryptogenic stroke) regardless of SCAF duration.\u003C\/p\u003E\u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-6\u0022\u003E\u003Ch2 class=\u0022\u0022\u003ENEW ACC\/AHA\/HRS GUIDELINE RECOMMENDATIONS\u003C\/h2\u003E\u003Cp id=\u0022p-24\u0022\u003EFinally, Craig T. January, MD, PhD, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA, discussed some of the new recommendations from the 2014 American College of Cardiology (ACC)\/American Heart Association (AHA)\/ Heart Rhythm Society (HRS) Guideline for the Management of Patients With Atrial Fibrillation [January CT et al. \u003Cem\u003ECirculation.\u003C\/em\u003E 2014], which were developed in collaboration with the society of thoracic surgeons.\u003C\/p\u003E\u003Cp id=\u0022p-25\u0022\u003EThe new ACC\/AHA\/HRS recommendations reflect a paradigm shift from identifying patients at high risk for thromboembolism in need of long-term anticoagulation to identifying low-risk patients not requiring long-term anticoagulation. New class I stroke\/thromboembolism recommendations encourage individualized therapy based on shared decision making (level of evidence [LOE] C), the selection of antithrombotic therapy based on the risk of thromboembolism irrespective of the AF pattern (LOE B), and use of the CHA\u003Csub\u003E2\u003C\/sub\u003EDS\u003Csub\u003E2\u003C\/sub\u003E-VASc score (vs CHADS\u003Csub\u003E2\u003C\/sub\u003E) to assess stroke risk in patients with nonvalvular AF (LOE B).\u003C\/p\u003E\u003Cp id=\u0022p-26\u0022\u003EThere are also new class I anticoagulation recommendations. For patients with nonvalvular AF with a CHA\u003Csub\u003E2\u003C\/sub\u003EDS\u003Csub\u003E2\u003C\/sub\u003E-VASc score \u2265 2, the recommended OACs include warfarin (international normalized ratio, 2.0 to 3.0; LOE A) as well as dabigatran, rivaroxaban, and apixaban (all LOE B). Dabigatran, rivaroxaban, and apixaban are also recommended for patients with nonvalvular AF who are unable to maintain a therapeutic international normalized ratio level with warfarin (LOE C). In patients with atrial flutter, antithrombotic therapy should be managed via the same risk profile used for AF (LOE C).\u003C\/p\u003E\u003Cp id=\u0022p-27\u0022\u003ENew class I recommendations for the use of rate control in patients with AF include use of a \u03b2-blocker or non-dihydropyridine calcium channel antagonist for control of ventricular rate for patients with paroxysmal, persistent, or permanent AF (LOE B). Electrical cardioversion is now indicated in hemodynamically unstable patients (LOE B). Lenient rate control (resting heart rate \u0026lt; 110 beats per minute) may be reasonable when patients remain asymptomatic and left ventricular systolic function is preserved.\u003C\/p\u003E\u003Cp id=\u0022p-28\u0022\u003EKey recommendations for rhythm control now state that in the case of AF \u2265 48 hours or unknown duration, patients should receive anticoagulation with warfarin (INR 2.0 to 3.0; Class I, LOE B). Class I, LOE C recommendations after cardioversion include anticoagulation for \u2265 4 weeks for AF lasting \u0026gt; 48 hours; intravenous heparin or LMWH or a factor Xa or direct thrombin inhibitor for AF 48 hours and a high stroke risk; and long-term anticoagulation based on the thromboembolic risk. Pharmacologic conversion with flecainide, dofetilide, propafenone, and intravenous ibutilide is useful for cardioversion of AF or atrial flutter (LOE A); however, electrical cardioversion has greater initial success.\u003C\/p\u003E\u003C\/div\u003E\u003Cul class=\u0022copyright-statement\u0022\u003E\u003Cli class=\u0022fn\u0022 id=\u0022copyright-statement-1\u0022\u003E\u00a9 2014 MD Conference Express\u00ae\u003C\/li\u003E\u003C\/ul\u003E\u003Cspan class=\u0022highwire-journal-article-marker-end\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Cspan id=\u0022related-urls\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Ca href=\u0022http:\/\/mdc.sagepub.com\/content\/14\/52\/30.abstract\u0022 class=\u0022hw-link hw-link-article-abstract\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView Summary\u003C\/a\u003E\u003C\/div\u003E  \u003C\/div\u003E\n\n  \n  \u003C\/div\u003E\n\u003C\/div\u003E\n  \u003C\/div\u003E\n\u003C\/div\u003E\n\u003C\/div\u003E\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_figures.js?nzm3c1\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_openurl.js?nzm3c1\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_tables.js?nzm3c1\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}