Guidelines for the management of atrial fibrillation

This 2024 update of the 2020 ESC Guidelines for the management of AF has been developed by the task force of the ESC in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS) and with the special contribution of the European Heart Rhythm Association (EHRA) [1–3]. The new version places a strong focus on individualised care, early intervention, and comprehensive management of concomitant diseases.

The prevalence of AF, one of the most commonly encountered heart conditions, 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 [1]. “First and very important, we recommend treating all our patients with AF according to our patient-centred integrated AF-CARE approach,” explained Prof. Isabel van Gelder (University Medical Center Groningen, the Netherlands). The “C” in the AF-CARE concept stands for a focus on recognising and treating comorbidities and risk factors. The “A” stands for avoidance or prevention of stroke and thromboembolism. The “R” for reduction of symptoms by rate and rhythm control, and a new recommendation “E” for evaluation and dynamic reassessment.

“The first pillar of care is comorbidity and risk factor management. We know that a broad array of comorbidities and risk factors are associated with the recurrence and progression of AF,” said Prof. Michiel Rienstra (University Medical Center Groningen, the Netherlands) [3]. There is a class I recommendation to identify and treat comorbidity and risk factors aggressively as this is crucial for the success of all other aspects of care for patients with AF. Key targets are hypertension, heart failure, obesity, obstructive sleep apnoea, alcohol intake, and diabetes mellitus (see Figure). Healthcare professionals should set individual and achievable targets for comorbidities and risk factors. These targets should be discussed with the patient in a shared decision-making process.

Figure: Management of key comorbidities, the “C” in the AF-CARE concept. Modified from [1]



To avoid stroke and thromboembolism, it is key to prevent adverse outcomes. Therefore, locally validated risk scores or the CHA₂DS₂-VA score should be used in patients with persistent AF. In this novel score, the recommendations do not differentiate between men and women. “This is an enormous simplification, and we assume that this will lead to a better adherence to our guideline recommendations,” said Prof. van Gelder. In contrast, the use of bleeding risk scores is not recommended to decide on starting or withdrawing anticoagulants. There is a class I recommendation for oral anticoagulants in patients with a CHA₂DS₂-VA score of 2 or more and a class IIa for patients with a score of 1. Vitamin K antagonists are only recommended in patients with mechanical heart valves or mitral stenosis. All modifiable risk factors for bleeding should be assessed and managed. To prevent bleeding, the combination of antiplatelet agents and oral anticoagulants is not recommended.

“Thereafter, we move on to the ‘R’,” Prof. Van Gelder said. Reducing symptoms through rate and rhythm control is essential to improve patients’ quality-of-life. In the acute setting, rate-controlling drugs are recommended as initial therapy; as adjunct to rhythm control therapy or as sole treatment. Rhythm control is considered in all suitable patients, but, again, safety first.

The ‘E’ in the AF-CARE concept stands for regular re-evaluation of the patient, which is recommended 6 months after presentation, and then at least annually or based on clinical need.

Interventional rhythm control: always performed following shared decision-making

Many new studies have led to an upgrade in the recommendations for interventional rhythm control. “We now have a class I recommendation for catheter ablation as a first-line option for paroxysmal AF, for paroxysmal and persistent AF after failed anti-arrhythmic drugs, and, of course, for those patients where you have a high probability that tachycardia is inducing some kind of cardiomyopathy,” Prof. Dipak Kotecha (University of Birmingham, UK) pointed out [2]. An endoscopic ablation or hybrid approach got a class IIa recommendation for patients with persistent AF despite anti-arrhythmic therapy. Moreover, there is a class I recommendation for surgical ablation in patients with mitral valve surgery and a class IIa recommendation for those with non-mitral valve surgery.

Prior to interventional rhythm control, a shared decision-making process is recommended (class I) for all patients to consider procedural risks, likely benefits, and risk factors for AF recurrence. Prof. Kotecha also emphasised the importance of periodical reassessment of all patients with AF, as recommended in the novel AF-CARE approach. Equally important is to screen patients for AF after a thromboembolic event and to inform patients about the implications of AF detection.

“AF is a huge burden for patients, but it is also very variable and that can be very challenging,” Prof. Kotecha said. It is often complex to recognise whether symptoms are induced by AF or one of the underlying comorbidities. There is the increased risk of stroke but also a 2-fold increase of heart failure and incremental evidence that AF might contribute to the increasing number of patients with vascular dementia. At the core of the new guideline is the management of patients in a multidisciplinary team of doctors, nurses, and other healthcare professionals.

1. 
   
   1. Van Gelder IC, et al. Eur Heart J 2024; Aug 30. DOI: 10.1093/eurheartj/ehae176.
   2. Presentations in Session ‘2024 ESC Guidelines Overview,’ ESC Congress 2024, 30 Aug–02 Sept, London, UK.
   3. Presentations in Session ‘2024 ESC Guidelines for the Management of Atrial Fibrillation,’ ESC Congress 2024, 30 Aug–02 Sept, London, UK.

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Posted on 7 November 20247 November 2024