Draft – Jordanian AF Management Framework 2025 (Adapted from ESC and AHA Guidelines using the PIPOH Model)
Draft – Jordanian AF Management Framework 2025
(Adapted from ESC and AHA Guidelines using the PIPOH Model)
Speaker: Dr. Mohammad Hajjiri
EP Task Force – Jordanian Cardiac Society (JCS)
Interventional Electrophysiology – Abdali Hospital
Keynotes :
1. Purpose and Scope
• Standardize AF management across public, private, and military sectors in Jordan.
• Reduce stroke risk, improve outcomes, and ensure proper DOAC utilization.
2. PIPOH Framework
Used by WHO, and aligned with AHA principles, the PIPOH framework helps adapt global cardiovascular guidelines to local healthcare systems by defining the following elements:
• P – Population: Patients with atrial fibrillation (AF).
• I – Interventions: Diagnosis, risk scoring, anticoagulation, rate/rhythm control, and ablation.
• P – Professionals: Internists, family physicians, cardiologists, electrophysiologists.
• O – Outcomes: Improved rhythm control, reduced stroke burden, and standardized national practice.
• H – Healthcare Setting: Primary, secondary, and tertiary care levels.
3. Diagnosis
• ECG ≥ 30 seconds confirms atrial fibrillation (AF).
This duration ensures diagnostic accuracy and distinguishes true, clinically significant AF from brief atrial runs that do not warrant anticoagulation or formal labeling as AF.
• If < 30 seconds: classify as subclinical AF, which requires further evaluation but is not diagnostic of AF.
• Extended ECG monitoring (Holter 24–48 h, patch up to 14 days, and Implantable Loop Recorder (ILR) for several months up to 3 years) is recommended in patients with suspected silent or paroxysmal AF, or following a cryptogenic stroke.
4. Stroke Risk Stratification
• Use CHA₂DS₂-VA (sex removed) as per ESC 2024 update.
• Reassess stroke and bleeding risks annually (Class I).
• Consider AF burden, comorbidities, and atrial imaging (size or fibrosis) when assessing stroke risk.
These factors help refine individual risk beyond the CHA₂DS₂-VA(S)c score.
5. Bleeding Risk
• HAS-BLED has limited predictive value.
• Focus on modifiable risk factors instead of score alone.
6. Anticoagulation
• DOACs are first-line (Class I).
• Warfarin only for mechanical valves or severe mitral stenosis.
• Continue indefinitely unless contraindicated or LAA occlusion done.
Available in Jordan:
• ✅ Apixaban, Dabigatran, Rivaroxaban
• ❌ Edoxaban (not available)
Apixaban dosing:
• Standard: 5 mg BID
• Reduce to 2.5 mg BID if 2 of 3:
• Age ≥ 80 years
• Weight ≤ 60 kg
• Serum creatinine ≥ 1.5 mg/dL
7. Rate Control
• Acute:
• Beta-blockers or Diltiazem/Verapamil (avoid if EF < 40%).
• Amiodarone or Digoxin for severe LV dysfunction.
• Chronic:
• Use Beta-blockers mainly (Bisoprolol, Metoprolol).
• Diltiazem: limited by local shortage.
• Target HR:
• <110 bpm (lenient) for most.
• <80 bpm (strict) if symptomatic or young.
8. Rhythm Control
• Amiodarone remains dominant in Jordan.
• Flecainide increasing use in structurally normal hearts (with AV-nodal blocker).
• Unavailable: Vernakalant, Dofetilide, Sotalol (limited), Ibutilide.
• Electrical cardioversion: Class I for unstable or symptomatic cases.
• “Pill-in-the-pocket” (Flecainide/Propafenone): acceptable if previously tested safe.
9. Catheter Ablation
• Class I: Symptomatic AF refractory/intolerant to antiarrhythmic drugs (AADs).
• Class I: In patients with HFrEF (proven benefit in trials).
• Perform only in specialized centers.
• 3D mapping and image-guided ablation now standard practice.
10. Pulsed-Field Ablation (PFA)
• FDA-approved (Dec 2023) – Medtronic PulseSelect system.
• Non-thermal, tissue-selective, and reduces collateral injury.
• Safety: 0.7% event rate — lowest among AF ablation trials.
• Efficacy: ~70% freedom from recurrent AF/AT at follow-up.
11. Key Jordan-Specific Adaptations
1. Anticoagulation: DOACs first-line; Apixaban widely used; Edoxaban unavailable.
2. Rate control: Beta-blockers are mainstay; Diltiazem often in shortage.
3. Rhythm control: Amiodarone still common; Flecainide use expanding.
4. Ablation: Rapid growth, especially for HFrEF and symptomatic patients.