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jordan heart November 22, 2025 0

Jordan Cardiac Society (JCS) Taskforce Congress, October 2025 Atrial Fibrillation Management Protocols

Jordan Cardiac Society (JCS) Taskforce Congress, October 2025

Atrial Fibrillation Management Protocols

 

This is the full draft of the Jordanian National Protocol for Atrial Fibrillation Managementand incorporating the latest international guidelines and technologies with adaptation to crucial Jordan-specific operational details.

Basil Abu El Haija, MD and Mohammad Hajjiri, MD

Purpose and Scope

This protocol aims to establish a unified, evidence-based standard of care for Atrial Fibrillation (AF) management across all healthcare institutions in the Hashemite Kingdom of Jordan (public, private, and military).

The core objectives are to:

1. Standardize diagnostic criteria and management strategies.
2. Optimize stroke prevention by ensuring the correct and safe utilization of Direct Oral Anticoagulants (DOACs).
3. Reduce cardiovascular morbidity and mortality associated with AF.

Diagnosis and Initial Workup

• AF is confirmed by a 12-lead ECG or rhythm strip of 30 seconds duration showing irregularly irregular R-R intervals and the absence of discernible P waves.
• Subclinical AF: Asymptomatic atrial high-rate episodes (AHRE) or short runs of AF lasting < 30 seconds are classified as subclinical and do not automatically mandate chronic anticoagulation but require dedicated long-term monitoring.
• Extended Monitoring: Recommended for patients with suspected paroxysmal AF or after cryptogenic stroke: Holter monitoring (24–48 h), external patch monitoring (up to 14 days), or Implantable Loop Recorder (ILR) for prolonged periods (up to 3 years).

Initial Diagnostic Panel

Every patient with a new AF diagnosis requires:

• Full History and Physical Examination: Including a functional assessment (e.g., EHRA class).
• Laboratory Tests: Complete blood count (CBC), renal function tests (Creatinine/eGFR), liver function tests, thyroid function tests (TSH), and electrolytes.
• Transthoracic Echocardiogram (TTE): Recommended for all patients (Class I) to evaluate chamber size, Left Ventricular Ejection Fraction (LVEF), valve function, and assess for underlying structural heart disease.

Stroke and Bleeding Risk Stratification

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.

 

Bleeding Risk

•​HAS-BLED has limited predictive value.

•​Focus on modifiable risk factors instead of score alone.

 

Anticoagulation (OAC) Strategy

General Principles

• First-Line: Direct Oral Anticoagulants (DOACs) are the preferred choice for stroke prevention (Class I, Level A).
• Warfarin: Reserved only for patients with mechanical prosthetic heart valves or moderate-to-severe mitral stenosis (rheumatic AF).
• Contraindicated Combination: Routine combination therapy of OAC + antiplatelet therapy for stroke prevention is not recommended.
• Anticoagulation for Special Cases: OAC is recommended for all patients with AF and Hypertrophic Cardiomyopathy (HCM) or Cardiac Amyloidosis, irrespective of their CHA₂DS₂-VA score.

 

 

Jordan-Specific DOAC Availability and Dosing

DOAC Class

Agent

Availability in Jordan

Standard Dose

Reduced Dose Criteria

Factor Xa Inhibitors

Apixaban

Available (Widely Used)

5 mg BID

Must meet 2 of 3: Age > 80 years, Weight < 60 kg, SCr > 1.5 mg/dL (2.5 mg BID)

Factor Xa Inhibitors

Rivaroxaban

Available

20 mg OD

15 mg OD for CrCl 30–49mL/min

Direct Thrombin Inhibitors

Dabigatran

Available

150 mg BID

110 mg BID for Age > 80 years or CrCl 30-50 mL/min

Unavailable

Edoxaban

Not Available

N/A

N/A

Crucial Note: Off-label dose reduction of any DOAC is strongly discouraged as it significantly increases the risk of stroke without proven bleeding benefit.

Rate and Rhythm Control

Rate Control Strategy

Acute:

​•​Beta-blockers or Diltiazem/Verapamil (avoid if EF < 40%).

​•​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, severe LV dysfunction, or young.

 

 

 

Rhythm Control Strategy

Rhythm control (restoring and maintaining Sinus Rhythm) is favored.

• Pharmacological AADs:
o Amiodarone: Remains the dominant and widely utilized AAD in the Jordanian setting, necessitating careful monitoring for long-term toxicity.
o Flecainide/Propafenone: Used increasingly in patients with structurally normal hearts; must be combined with an AV-nodal blocker.
o Pill-in-the-Pocket: Acceptable for infrequent, symptomatic paroxysmal AF in selected patients with structurally normal hearts, provided tolerance and safety were established in a monitored environment.
• Unavailable/Limited AADs: Vernakalant, Dofetilide, Ibutilide, and Sotalol have limited to no commercial availability in Jordan.
• Electrical Cardioversion (ECV): Class I recommendation for hemodynamically unstable patients or highly symptomatic AF unresponsive to acute rate control measures.

 

Catheter Ablation

Ablation is a Class I recommended treatment option for:

1. Symptomatic AF (paroxysmal or persistent) refractory to, or intolerant of, Antiarrhythmic Drug (AAD) therapy.
2. AF in patients with Heart Failure with Reduced Ejection Fraction (HFrEF) (proven benefit on LVEF and hospitalization).
3. Selected patients with Paroxysmal AF as a first-line therapy (after thorough discussion of risks/benefits).
• Operational Requirement: Ablation procedures must only be performed in specialized cardiac centers with established Electrophysiology (EP) programs.
• Technology Standard: Procedures require advanced mapping systems (e.g., 3D electroanatomical mapping) and appropriate energy sources.

 

 

Pulsed-Field Ablation (PFA)

• Inclusion: PFA is recognized as an advanced, non-thermal, tissue-selective technology that may offer advantages in reducing collateral injury (e.g., lower risk of esophageal or phrenic nerve injury).
• Implementation: Its adoption is encouraged in specialized centers, provided the necessary infrastructure and operator training are in place.

Lifestyle and Comorbidity Management

Given the high prevalence of non-communicable diseases (NCDs) in Jordan (e.g., diabetes and hypertension), aggressive risk factor modification is mandatory (Class I):

• Hypertension: Target Blood Pressure (BP) of < 130/80 mmHg.
• Obesity: Weight loss is mandatory for overweight/obese patients to reduce AF burden and improve ablation success.
• Diabetes and Heart Failure: Optimize guideline-directed medical therapy (GDMT) for these conditions.
• Ramadan/Fasting: For patients undergoing Ramadan or other periods of fasting, the healthcare provider must counsel on the appropriate timing of DOAC and other medication doses (e.g., Apixaban BID, Dabigatran BID, or Rivaroxaban OD) to maintain therapeutic levels and ensure compliance.

This protocol will be reviewed periodically to incorporate new international evidence and local clinical experience.

 

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