Atrial Fibrillation Clinical Practice Guidelines (ESC/EACTS, 2020)

European Society of Cardiology (ESC), European Association of Cardio-Thoracic Surgery (EACTS)

This is a quick summary of the guidelines without analysis or commentary. For more information, go directly to the guidelines by clicking the link in the reference.

September 30, 2020

Recommendations for the diagnosis and management of atrial fibrillation (AF) were released in August 2020 by the European Society of Cardiology (ESC) in collaboration with the European Association of Cardio-Thoracic Surgery (EACTS).[1,2]

Diagnosis of AF

The diagnosis of AF requires confirmation with a conventional 12-lead electrocardiogram tracing or rhythm strip that demonstrates AF for at least 30 seconds.

Evaluation of Thromboembolic Risk

In patients with AF, the CHA2DS2-VASc (congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, stroke, vascular disease, age 65-74 years, sex category) score is recommended for the assessment of thromboembolic risk.

Prevention of Thromboembolic Events

Oral anticoagulants are recommended for the prevention of thromboembolic events in patients with AF who have risk factors for stroke. Non–vitamin K antagonist oral anticoagulants (NOACs) are preferred over vitamin K antagonists for NOAC-eligible patients with AF.

Assessment of Bleeding Risk

To identify risk factors for bleeding in patients with AF, a formal structured risk assessment score, such as the HAS-BLED (hypertension, abnormal renal/liver function, stroke, bleeding history or predisposition, labile international normalized ratio, elderly [>65 years], drugs/alcohol concomitantly) score is useful. For patients who are found to be at increased risk for bleeding, modifiable risk factors should be addressed and more frequent clinical follow-up should be scheduled.

Rate and Rhythm Control of AF

Rate control is often sufficient to reduce symptoms that are related to AF. The primary indication for rhythm control with cardioversion, antiarrhythmic drugs (AADs), and/or catheter ablation is a reduction in AF-related symptoms and an improvement in quality of life.

Factors to consider in the decision to start long-term AAD therapy are symptom burden; possible adverse drug reactions, particularly drug-induced proarrhythmia or extracardiac adverse effects; and patient preferences.

Catheter ablation is a well-established, safe, and superior alternative to AAD therapy for the maintenance of sinus rhythm, as well as the reduction of symptoms. Although catheter ablation has not been shown to reduce total mortality or lower the risk of stroke in patients with AF who have a normal left ventricular ejection fraction, it reverses left ventricular dysfunction in most patients with AF and tachycardia-induced cardiomyopathy.

For overweight and obese patients with AF, weight loss, in addition to risk factor modification and avoidance of AF triggers, is recommended to improve rhythm control.

Recommendations for Patients With AF Undergoing PCI

In patients with AF who are undergoing an uncomplicated percutaneous coronary intervention (PCI) for an acute coronary syndrome, early discontinuation of aspirin therapy and initiation of dual antithrombotic therapy with an oral anticoagulant and a P2Y12 inhibitor are recommended.

Management of Atrial High-Rate Episodes

Patients with atrial high-rate episodes (AHREs) require regular monitoring to detect progression to clinical AF and changes in their risk of thromboembolic events, such as an increase in their CHA2DS2-VASc score. Oral anticoagulant therapy is a reasonable option for patients who have longer AHREs (especially >24 hours) and a high CHA2DS2-VASc score.

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