{"id":9237,"date":"2025-11-22T13:45:59","date_gmt":"2025-11-22T10:45:59","guid":{"rendered":"https:\/\/jordan-cardiac.org\/?p=9237"},"modified":"2025-11-22T13:45:59","modified_gmt":"2025-11-22T10:45:59","slug":"jordan-cardiac-society-jcs-taskforce-congress-october-2025-atrial-fibrillation-management-protocols","status":"publish","type":"post","link":"https:\/\/jordan-cardiac.org\/en\/jordan-cardiac-society-jcs-taskforce-congress-october-2025-atrial-fibrillation-management-protocols\/","title":{"rendered":"Jordan Cardiac Society (JCS) Taskforce Congress, October 2025 Atrial Fibrillation Management Protocols"},"content":{"rendered":"

Jordan Cardiac Society (JCS) Taskforce Congress, October 2025<\/span><\/p>\n

Atrial Fibrillation Management Protocols<\/span><\/p>\n

\u00a0<\/span><\/p>\n

Th<\/span>i<\/span>s is the full draft of the <\/span>Jordanian National Protocol for Atrial Fibrillation Management<\/span><\/span>and incorporating the latest international guidelines and <\/span>technologies with adaptation to <\/span>crucial Jordan-specific operational details.<\/span><\/p>\n

Basil Abu El Haija, MD and Mohammad <\/span>Hajjiri<\/span>, MD<\/span><\/p>\n

Purpose and Scope<\/span><\/p>\n

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).<\/span><\/p>\n

The core objectives are to:<\/span><\/p>\n

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

Diagnosis and Initial Workup<\/span><\/p>\n

\u2022 <\/span>AF is confirmed by a <\/span>12-lead ECG or rhythm strip of 30 seconds<\/span> duration showing irregularly irregular R-R intervals and the absence of discernible P waves.<\/span><\/div>\n
\u2022 <\/span>Subclinical AF:<\/span> Asymptomatic atrial high-rate episodes (AHRE) or short runs of AF lasting < 30 seconds are classified as subclinical and <\/span>do not automatically mandate chronic anticoagulation<\/span> but require dedicated long-term monitoring.<\/span><\/div>\n
\u2022 <\/span>Extended Monitoring:<\/span> Recommended for patients with suspected paroxysmal AF or after cryptogenic stroke: Holter monitoring (24\u201348 h), external patch monitoring (up to 14 days), or Implantable Loop Recorder (ILR) for prolonged periods (up to 3 years).<\/span><\/div>\n

Initial Diagnostic Panel<\/span><\/p>\n

Every patient with a new AF diagnosis requires:<\/span><\/p>\n

\u2022 <\/span>Full History and Physical Examination:<\/span> Including a functional assessment (e.g., EHRA class).<\/span><\/div>\n
\u2022 <\/span>Laboratory Tests:<\/span> Complete blood count (CBC), renal function tests (Creatinine\/eGFR), liver function tests, thyroid function tests (TSH), and electrolytes.<\/span><\/div>\n
\u2022 <\/span>Transthoracic Echocardiogram (TTE):<\/span> Recommended for all patients (Class I) to evaluate chamber size, Left Ventricular Ejection Fraction (LVEF), valve function, and assess for underlying structural heart disease.<\/span><\/div>\n

Stroke and Bleeding Risk Stratification<\/span><\/p>\n

Stroke Risk Stratification<\/span><\/p>\n

\u2022<\/span>\u200b<\/span>Use CHA\u2082DS\u2082-VA (sex removed) as per ESC 2024 update.<\/span><\/p>\n

\u2022<\/span>\u200b<\/span>Reassess stroke and bleeding risks annually (Class I).<\/span><\/p>\n

\u2022<\/span>\u200b<\/span>Consider AF burden, comorbidities, and atrial imaging (size or fibrosis) when assessing stroke risk.<\/span><\/p>\n

These factors help refine individual risk beyond the CHA\u2082DS\u2082-VA(S)c score.<\/span><\/p>\n

\u00a0<\/span><\/p>\n

Bleeding Risk<\/span><\/p>\n

\u2022<\/span>\u200b<\/span>HAS-BLED has limited predictive value.<\/span><\/p>\n

\u2022<\/span>\u200b<\/span>Focus on modifiable risk factors instead of score alone.<\/span><\/p>\n

\u00a0<\/span><\/p>\n

Anticoagulation (OAC) Strategy<\/span><\/p>\n

General Principles<\/span><\/p>\n

\u2022 <\/span>First-Line:<\/span> Direct Oral Anticoagulants (DOACs) are the preferred choice for stroke prevention (Class I, Level A).<\/span><\/div>\n
\u2022 <\/span>Warfarin:<\/span> Reserved only for patients with <\/span>mechanical prosthetic heart valves<\/span> or <\/span>moderate-to-severe mitral stenosis<\/span> (rheumatic AF).<\/span><\/div>\n
\u2022 <\/span>Contraindicated Combination:<\/span> Routine combination therapy of OAC + antiplatelet therapy for stroke prevention is <\/span>not recommended<\/span>.<\/span><\/div>\n
\u2022 <\/span>Anticoagulation for Special Cases:<\/span> OAC is recommended for all patients with AF and Hypertrophic Cardiomyopathy (HCM) or Cardiac Amyloidosis, irrespective of their CHA\u2082DS\u2082-VA score.<\/span><\/div>\n

\u00a0<\/span><\/p>\n

\u00a0<\/span><\/p>\n

Jordan-Specific DOAC Availability and Dosing<\/span><\/p>\n\n\n\n\n\n\n\n
\n
\n

DOAC Class<\/span><\/p>\n<\/div>\n<\/td>\n

\n
\n

Agent<\/span><\/p>\n<\/div>\n<\/td>\n

\n
\n

Availability in Jordan<\/span><\/p>\n<\/div>\n<\/td>\n

\n
\n

Standard Dose<\/span><\/p>\n<\/div>\n<\/td>\n

\n
\n

Reduced Dose Criteria<\/span><\/p>\n<\/div>\n<\/td>\n<\/tr>\n

\n
\n

Factor Xa Inhibitor<\/span>s<\/span><\/p>\n<\/div>\n<\/td>\n

\n
\n

Apixaban<\/span><\/p>\n<\/div>\n<\/td>\n

\n
\n

Available (Widely Used)<\/span><\/p>\n<\/div>\n<\/td>\n

\n
\n

5 mg BID<\/span><\/p>\n<\/div>\n<\/td>\n

\n
\n

Must meet 2 of 3:<\/span> Age <\/span>><\/span> 80 years, Weig<\/span>ht < <\/span>60 kg, <\/span>SCr<\/span> ><\/span> 1.5 mg\/dL<\/span> (2.5 mg BID)<\/span><\/p>\n<\/div>\n<\/td>\n<\/tr>\n

\n
\n

Factor Xa Inhibitor<\/span>s<\/span><\/p>\n<\/div>\n<\/td>\n

\n
\n

Rivaroxaban<\/span><\/p>\n<\/div>\n<\/td>\n

\n
\n

Available<\/span><\/p>\n<\/div>\n<\/td>\n

\n
\n

20 mg OD<\/span><\/p>\n<\/div>\n<\/td>\n

\n
\n

15 mg OD for <\/span>CrCl<\/span> 30<\/span>–<\/span>49<\/span><\/span>mL\/min<\/span><\/p>\n<\/div>\n<\/td>\n<\/tr>\n

\n
\n

Direct Thrombin Inhibitors<\/span><\/p>\n<\/div>\n<\/td>\n

\n
\n

Dabigatran<\/span><\/p>\n<\/div>\n<\/td>\n

\n
\n

Available<\/span><\/p>\n<\/div>\n<\/td>\n

\n
\n

150 mg BID<\/span><\/p>\n<\/div>\n<\/td>\n

\n
\n

110 mg BID for Age <\/span>><\/span> 80 years or <\/span>CrCl<\/span> 30-50 mL\/min<\/span><\/p>\n<\/div>\n<\/td>\n<\/tr>\n

\n
\n

Unavailable<\/span><\/p>\n<\/div>\n<\/td>\n

\n
\n

Edoxaban<\/span><\/p>\n<\/div>\n<\/td>\n

\n
\n

Not Available<\/span><\/p>\n<\/div>\n<\/td>\n

\n
\n

N\/A<\/span><\/p>\n<\/div>\n<\/td>\n

\n
\n

N\/A<\/span><\/p>\n<\/div>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

Crucial Note:<\/span> Off-label dose reduction of any DOAC is strongly discouraged as it significantly increases the risk of stroke without proven bleeding benefit.<\/span><\/p>\n

Rate and Rhythm Control<\/span><\/p>\n

Rate Control Strategy<\/span><\/p>\n

Acute:<\/span><\/p>\n

\u200b<\/span>\u2022<\/span>\u200b<\/span>Beta-blockers or Diltiazem\/Verapamil (avoid if EF < 40%).<\/span><\/p>\n

\u200b<\/span>\u2022<\/span>\u200b<\/span>Digoxin for severe LV dysfunction.<\/span><\/p>\n

Chronic:<\/span><\/p>\n

\u200b<\/span>\u2022<\/span>\u200b<\/span>Use Beta-blockers mainly (Bisoprolol, Metoprolol).<\/span><\/p>\n

\u200b<\/span>\u2022<\/span>\u200b<\/span>Diltiazem: limited by local shortage.<\/span><\/p>\n

Target HR:<\/span><\/p>\n

\u200b<\/span>\u2022<\/span>\u200b<\/span><110 bpm (lenient) for most.<\/span><\/p>\n

\u200b<\/span>\u2022<\/span>\u200b<\/span><80 bpm (strict) if symptomatic<\/span>, severe LV dysfunction,<\/span> or young.<\/span><\/p>\n

\u00a0<\/span><\/p>\n

\u00a0<\/span><\/p>\n

\u00a0<\/span><\/p>\n

Rhythm Control Strategy<\/span><\/p>\n

Rhythm control (restoring and maintaining Sinus Rhythm) is favored<\/span>.<\/span><\/p>\n

\u2022 <\/span>Pharmacological AADs:<\/span><\/div>\n
o <\/span>Amiodarone:<\/span> Remains the <\/span>dominant and widely utilized AAD<\/span> in the Jordanian setting, necessitating careful monitoring for long-term toxicity.<\/span><\/div>\n
o <\/span>Flecainide\/Propafenone:<\/span> Used increasingly in patients with <\/span>structurally normal hearts<\/span>; must be combined with an AV-nodal blocker.<\/span><\/div>\n
o <\/span>Pill-in-the-Pocket:<\/span> Acceptable for infrequent, symptomatic paroxysmal AF in selected patients with structurally normal hearts, provided tolerance and safety were established in a monitored environment.<\/span><\/div>\n
\u2022 <\/span>Unavailable\/Limited AADs:<\/span> Vernakalant, <\/span>Dofetilide<\/span>, <\/span>Ibutilide<\/span>, and Sotalol have limited to no commercial availability in Jordan.<\/span><\/div>\n
\u2022 <\/span>Electrical Cardioversion (ECV):<\/span> Class I recommendation for hemodynamically unstable patients or highly symptomatic AF unresponsive to acute rate control measures.<\/span><\/div>\n

\u00a0<\/span><\/p>\n

Catheter Ablation<\/span><\/p>\n

Ablation is a Class I recommended treatment option for:<\/span><\/p>\n

1. <\/span>Symptomatic AF (paroxysmal or persistent) refractory to, or intolerant of, Antiarrhythmic Drug (AAD) therapy.<\/span><\/div>\n
2. <\/span>AF in patients with <\/span>Heart Failure with Reduced Ejection Fraction (<\/span>HFrEF<\/span>)<\/span> (proven benefit on LVEF and hospitalization).<\/span><\/div>\n
3. <\/span>Selected patients with Paroxysmal AF as a <\/span>first-line therapy<\/span> (after thorough discussion of risks\/benefits).<\/span><\/div>\n
\u2022 <\/span>Operational Requirement:<\/span> Ablation procedures must only be performed in <\/span>specialized cardiac centers<\/span> with established Electrophysiology (EP) programs.<\/span><\/div>\n
\u2022 <\/span>Technology Standard:<\/span> Procedures require advanced mapping systems (e.g., 3D <\/span>electroanatomical<\/span> mapping) and appropriate energy sources.<\/span><\/div>\n

\u00a0<\/span><\/p>\n

\u00a0<\/span><\/p>\n

Pulsed-Field Ablation (PFA)<\/span><\/p>\n

\u2022 <\/span>Inclusion:<\/span> 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).<\/span><\/div>\n
\u2022 <\/span>Implementation:<\/span> Its adoption is encouraged in specialized centers, provided the necessary infrastructure and operator training are in place.<\/span><\/div>\n

Lifestyle and Comorbidity Management <\/span><\/p>\n

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

\u2022 <\/span>Hypertension:<\/span> Target Blood Pressure (BP) of < 130\/80 mmHg<\/span>.<\/span><\/div>\n
\u2022 <\/span>Obesity:<\/span> Weight loss is mandatory for overweight\/obese patients to reduce AF burden and improve ablation success.<\/span><\/div>\n
\u2022 <\/span>Diabetes and Heart Failure:<\/span> Optimize guideline-directed medical therapy (GDMT) for these conditions.<\/span><\/div>\n
\u2022 <\/span>Ramadan\/Fasting:<\/span> 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.<\/span><\/div>\n

This protocol will be reviewed <\/span>periodically <\/span>to incorporate new international evidence and local clinical experience.<\/span><\/p>\n

\u00a0<\/span><\/p>\n","protected":false},"excerpt":{"rendered":"

Jordan Cardiac Society (JCS) Taskforce Congress, October 2025 Atrial Fibrillation Management Protocols \u00a0 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 […]<\/p>\n","protected":false},"author":145,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[1],"tags":[],"class_list":["post-9237","post","type-post","status-publish","format-standard","hentry","category-uncategorized"],"_links":{"self":[{"href":"https:\/\/jordan-cardiac.org\/en\/wp-json\/wp\/v2\/posts\/9237","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/jordan-cardiac.org\/en\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/jordan-cardiac.org\/en\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/jordan-cardiac.org\/en\/wp-json\/wp\/v2\/users\/145"}],"replies":[{"embeddable":true,"href":"https:\/\/jordan-cardiac.org\/en\/wp-json\/wp\/v2\/comments?post=9237"}],"version-history":[{"count":1,"href":"https:\/\/jordan-cardiac.org\/en\/wp-json\/wp\/v2\/posts\/9237\/revisions"}],"predecessor-version":[{"id":9238,"href":"https:\/\/jordan-cardiac.org\/en\/wp-json\/wp\/v2\/posts\/9237\/revisions\/9238"}],"wp:attachment":[{"href":"https:\/\/jordan-cardiac.org\/en\/wp-json\/wp\/v2\/media?parent=9237"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/jordan-cardiac.org\/en\/wp-json\/wp\/v2\/categories?post=9237"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/jordan-cardiac.org\/en\/wp-json\/wp\/v2\/tags?post=9237"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}