Today, I review and link to The European Society of Cardiology‘s 2024 Guidelines on Atrial Fibrillation, Introduction.
All that follows is from the above resource.
Introduction
Atrial fibrillation (AF) is one of the most commonly encountered heart conditions, with a broad impact on all health services across primary and secondary care. The prevalence of AF is expected to double in the next few decades as a consequence of the ageing population, an increasing burden of comorbidities, improved awareness, and new technologies for detection.
The effects of AF are variable across individual patients; however, morbidity from AF remains highly concerning. Patients with AF can suffer from a variety of symptoms and poor quality of life. Stroke and heart failure as consequences of AF are now well appreciated by healthcare professionals, but AF is also linked to a range of other thromboembolic outcomes. These include subclinical cerebral damage (potentially leading to vascular dementia), and thromboembolism to every other organ, all of which contribute to the higher risk of mortality associated with AF.
The typical drivers of AF onset and progression are a range of comorbidities and associated risk factors. To achieve optimal care for patients with AF, it is now widely accepted that these comorbidities and risk factors must be managed early and in a dynamic way. Failure to do so contributes to recurrent cycles of AF, treatment failure, poor patient outcomes, and a waste of healthcare resources. In this iteration of the European Society of Cardiology (ESC) practice guidelines on AF, the task force has consolidated and evolved past approaches to develop the AF-CARE framework (Atrial Fibrillation—[C] Comorbidity and risk factor management, [A] Avoid stroke and thromboembolism, [R] Reduce symptoms by rate and rhythm control, [E] Evaluation and dynamic reassessment). Comorbidities and risk factors is placed as the initial and central component of patient management. This should be considered first as it applies to all patients with AF, regardless of their thromboembolic risk factors or any symptoms that might warrant intervention. This is followed by considering how best to [A] avoid stroke and thromboembolism, and then the options available to reduce symptoms, and in some cases improve prognosis, through [R] rate and rhythm control. [E] Evaluation and reassessment should be individualized for every patient, with a dynamic approach that accounts for how AF and its associated conditions change over time.
Patient empowerment is critical in any long-term medical problem to achieve better outcomes, encourage adherence, and to seek timely guidance on changes in clinical status. A patient-centred, shared decision-making approach will facilitate the choice of management that suits each individual patient, particularly in AF where some therapies and interventions improve clinical outcomes, and others are focused on addressing symptoms and quality of life. Education and awareness are essential, not only for patients but also healthcare professionals in order to constrain the impact of AF on patients and healthcare services.
With this in mind, the task force have created a range of patient pathways that cover the major aspects of AF-CARE. At present, these remain based on the time-orientated classification of AF (first-diagnosed, paroxysmal, persistent, and permanent), but ongoing research may allow for pathology-based classifications and a future of personalized medicine. Clinical practice guidelines can only cover common scenarios with an evidence base, and so there remains a need for healthcare professionals to care for patients within a local multidisciplinary team. While guideline-adherent care has repeatedly been shown to improve patient outcomes, the actual implementation of guidelines is often poor in many healthcare settings. This has been demonstrated in the ESC’s first randomized controlled trial (RCT), STEEER-AF (Stroke prevention and rhythm control Therapy: Evaluation of an Educational programme of the European Society of Cardiology in a cluster-Randomised trial in patients with Atrial Fibrillation), which has sought to improve guideline adherence in parallel to guideline production. The task force developing the 2024 AF Guidelines have made implementation a key goal by focusing on the underpinning evidence and using a consistent writing style for each recommendation (the intervention proposed, the population it should be applied to, and the potential value to the patient, followed by any exceptions). Tables 3 and 4 below outline new recommendations and those with important revisions. These initiatives have been designed to make the 2024 ESC Guidelines for the management of AF easier to read, follow, and implement, with the aim of improving the lives of patients with AF. A patient version of these guidelines is also available at http://www.escardio.org/Guidelines/guidelines-for-patients.
