Today, I review and link to The European Society of Cardiology‘s 2024 Guidelines on Atrial Fibrillation, Key Messages.
All that follows is from the above resource.
11. Key messages
General management: optimal treatment according to the AF-CARE pathway, which includes: [C] Comorbidity and risk factor management; [A] Avoid stroke and thromboembolism; [R] Reduce symptoms by rate and rhythm control; and [E] Evaluation and dynamic reassessment.
Shared care: patient-centred AF management with joint decision-making and a multidisciplinary team.
Equal care: avoid health inequalities based on gender, ethnicity, disability, and socioeconomic factors.
Education: for patients, family members, caregivers, and healthcare professionals to aid shared decision-making.
Diagnosis: clinical AF requires confirmation on an ECG device to initiate risk stratification and AF management.
Initial evaluation: medical history, assessment of symptoms and their impact, blood tests, echocardiography/other imaging, patient-reported outcome measures, and risk factors for thromboembolism [CHA2DS2-VA score] and bleeding [HAS-BLED score].
Comorbidities and risk factors: thorough evaluation and management critical to all aspects of care for patients with AF to avoid recurrence and progression of AF, improve success of AF treatments, and prevent AF-related adverse outcomes.
Focus on conditions associated with AF: including hypertension, heart failure, diabetes mellitus, obesity, obstructive sleep apnoea, physical inactivity, and high alcohol intake.
Assessing the risk of thromboembolism: use locally validated risk tools or the CHA2DS2-VA score and assessment of other risk factors, with reassessment at periodic intervals to assist in decisions on anticoagulant prescription.
Oral anticoagulants: recommended for all eligible patients, except those at low risk of incident stroke or thromboembolism (CHA2DS2-VA = 1 anticoagulation should be considered; CHA2DS2-VA ≥2 anticoagulation recommended).
Choice of anticoagulant: DOACs (apixaban, dabigatran, edoxaban, and rivaroxaban) are preferred over VKAs (warfarin and others), except in patients with mechanical heart valves and mitral stenosis.
Dose/range of anticoagulant: use full standard doses for DOACs unless the patient meets specific dose-reduction criteria; for VKAs, keep INR generally 2.0–3.0, and in range for >70% of the time.
Switching anticoagulants: switch from a VKA to DOAC if risk of intracranial haemorrhage or poor control of INR levels.
Bleeding risk: modifiable bleeding risk factors should be managed to improve safety; bleeding risk scores should not be used to decide on starting or withdrawing anticoagulants.
Antiplatelet therapy: avoid combining anticoagulants and antiplatelet agents, unless the patient has an acute vascular event or needs interim treatment for procedures.
Rate control therapy: use beta-blockers (any ejection fraction), digoxin (any ejection fraction), or diltiazem/verapamil (LVEF >40%) as initial therapy in the acute setting, an adjunct to rhythm control therapies, or as a sole treatment strategy to control heart rate and symptoms.
Rhythm control: consider in all suitable AF patients, explicitly discussing with patients all potential benefits and risks of cardioversion, antiarrhythmic drugs, and catheter or surgical ablation to reduce symptoms and morbidity.
Safety first: keep safety and anticoagulation in mind when considering rhythm control; e.g. delay cardioversion and provide at least 3 weeks of anticoagulation beforehand if AF duration >24 h, and consider toxicity and drug interactions for antiarrhythmic therapy.
Cardioversion: use electrical cardioversion in cases of haemodynamic instability; otherwise choose electrical or pharmacological cardioversion based on patient characteristics and preferences.
Indication for long-term rhythm control: the primary indication should be reduction in AF-related symptoms and improvement in quality of life; for selected patient groups, sinus rhythm maintenance can be pursued to reduce morbidity and mortality.
Success or failure of rhythm control: continue anticoagulation according to the patient’s individual risk of thromboembolism, irrespective of whether they are in AF or sinus rhythm.
Catheter ablation: consider as second-line option if antiarrhythmic drugs fail to control AF, or first-line option in patients with paroxysmal AF.
Endoscopic or hybrid ablation: consider if catheter ablation fails, or an alternative to catheter ablation in persistent AF despite antiarrhythmic drugs.
Atrial fibrillation ablation during cardiac surgery: perform in centres with experienced teams, especially for patients undergoing mitral valve surgery.
Dynamic evaluation: periodically reassess therapy and give attention to new modifiable risk factors that could slow/reverse the progression of AF, increase quality of life, and prevent adverse outcomes.
