New ESC/EACTS guidelines on atrial fibrillation

The ESC, in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS), published new guidelines on atrial fibrillation, which are also endorsed by the European Stroke Organisation (ESO). The new guidelines include important changes compared with the previous version, due to new data and insights that were disclosed in the meantime, including the broader implementation of novel oral anticoagulants (NOACs) in clinical practice, as well as due to the emergent need of a better integration and co-ordination of AF management.
A multidisciplinary Task Force commissioned external systematic reviews, which informed specific recommendations to address the growing demand for effective care. Only recommendations that were supported by at least 75% of the Task Force members made it into the guidelines.
We briefly touch on some of the current recommendations below.
 The AF prevalence is growing rapidly, making ECG screening for AF necessary in patients > 65 years, and patients with stroke or TIA (I B class recommendation).

Clinical evaluation requirement

Transthoracic echocardiography should be used in all AF patients (I C), with the objective to assess concomitant CV diseases, and to guide the selection of pharmacotherapy (anticoagulants, rate-controlling and rhythm-controlling agents).

Stroke risk evaluation

Anticoagulation for stroke prevention is indicated in males with a CHA2DS2–VASc score≥2 and in females with a CHA2D2S-VASc score≥3. No antithrombotic therapy should be given to patients with a CHA2D2S-VASc score of 0 (males) or 1 (females). In the rest of the patients anticoagulation should be considered.

Antithrombotic therapy

NOACs have a first-line recommendation in eligible patients (I A). Patients who are ineligible for NOAC therapy, should be treated with vitamin-K antagonists (I B). Aspirin and other antiplatelets have no role in stroke prevention (III A).

Bleeding risk management

A list of modifiable bleeding risk factors, including hypertension, concomitant antiplatelet or NSAID therapy, alcohol consumption, and anaemia, was developed. Recommendations for the initiation and/or resumption of anticoagulation 3–12 days after ischaemic stroke (IIa C), and 4–8 weeks after intracranial haemorrhage (IIb B) have been included.

Choice of rate-controlling therapy

Beta-blockers and digoxin are preferred in patients with EF <40%, with an initial heart rate target of <110 beats/min (IIa B), and combination therapy is recommended if necessary for symptom and heart rate control (IIa C).

Choice of rhythm-controlling therapy

Antiarrhythmic drugs, supplemented with cardioversion, are the recommended treatment options (I A/I B). Catheter ablation is the rhythm control therapy of choice in patients with symptomatic recurrences of AF on antiarrhythmic drug therapy (I A paroxysmal; IIa C persistent), and a valid first-line alternative to antiarrhythmic drugs in selected patients with symptomatic paroxysmal AF (IIa B). The complete isolation of the pulmonary veins in patients undergoing AF ablation with radiofrequency or cryothermy is important (IIa B).

Integrated AF management

The creation of local ‘AF Heart Teams’ is proposed to provide optimal, multidisciplinary advice, and improve AF outcomes, and smartphone applications are provided to encourage patient involvement (I C and IIa C).

Atar, Benussi, and Kirchhof, members of the Guideline Task Force, have formulated 10 commandments based on the new guidelines, which can be found here.

Sources

Atrial fibrillation: today’s guideline-based management
Thomas F. Lüscher. Eur Heart J 2016 37: 2847-2850

What’s new in the 2016 ESC Guidelines on atrial fibrillation?
Eur Heart J 2016 37: 2851-2852

Ten Commandments’ of 2016 ESC Guidelines for the management of atrial fibrillation
Atar, Benussi, and Kirchhof. Eur Heart J 2016 37: 2853