ESC Guidelines for the Management of Atrial Fibrillation

Authors:
Kirchhof P, Benussi S, Kotecha D, et al.
Citation:
2016 ESC Guidelines for the Management of Atrial Fibrillation Developed in Collaboration With EACTS. Eur Heart J 2016;Aug 27:[Epub ahead of print].

The following are key points to remember about the 2016 European Society of Cardiology Guidelines for the Management of Atrial Fibrillation (AF):

  1. About 20–30% of all strokes are due to AF. A growing number of patients with stroke are diagnosed with “silent” paroxysmal AF. It is recommended to interrogate pacemakers and implantable cardioverter-defibrillators (ICDs) on a regular basis for atrial high rate episodes (AHREs). Patients with AHREs should undergo further electrocardiogram (ECG) monitoring to document AF before initiating AF therapy (Class I, Level of Evidence B). ECG documentation is required to establish the diagnosis of AF (Class I, Level of Evidence B). There is good evidence that prolonged ECG monitoring enhances the detection of undiagnosed AF, e.g., monitoring for 72 hours after a stroke, or even longer periods. By accepted convention, an episode lasting at least 30 seconds is diagnostic.
  2. In obese patients with AF, weight loss together with management of other risk factors should be considered to reduce AF burden and symptoms (Class IIa, Level of Evidence B). Interrogation for clinical signs of obstructive sleep apnea should be considered in all AF patients (Class IIa, Level of Evidence B). Obstructive sleep apnea treatment should be optimized to reduce AF recurrences and improve AF treatment results (Class IIa, Level of Evidence B). Intensive weight reduction in addition to the management of other cardiovascular risk factors (in the range of 10–15 kg weight loss achieved), led to fewer AF recurrences and symptoms compared with an approach based on general advice in obese patients with AF.
  3. Oral anticoagulation should be considered in patients with a CHA2DS2-VASc score of 1 in men and 2 in women (Class IIa, Level of Evidence B). Novel oral anticoagulants (NOACs) (apixaban, dabigatran, edoxaban, and rivaroxaban) are not recommended in patients with mechanical heart valves (Class III, Level of Evidence B) or moderate to severe mitral stenosis (Class III, Level of Evidence C).
  4. Anticoagulation for stroke prevention should be continued indefinitely after apparently successful catheter or surgical ablation of AF in patients at high risk of stroke (Class IIa, Level of Evidence C). After surgical occlusion or exclusion of the left atrial appendage, it is recommended to continue anticoagulation in at-risk patients with AF for stroke prevention (Class I, Level of Evidence B).
  5. Anticoagulation with heparin or low molecular weight heparin immediately after an ischemic stroke is not recommended in AF patients (Class III). In patients who suffer a moderate to severe ischemic stroke while on anticoagulation, anticoagulation should be interrupted for 3–12 days based on a multidisciplinary assessment of acute stroke and bleeding risk (Class IIa, Level of Evidence C). NOACs should be avoided in pregnancy and in women planning a pregnancy (Class III, Level of Evidence C).
  6. Cognitive decline and vascular dementia can develop even in anticoagulated AF patients. Falls and dementia are associated with increased mortality in AF patients, without evidence that these conditions markedly increase the risk of intracranial hemorrhage. Hence, anticoagulation should only be withheld from patients with severe uncontrolled falls (e.g., epilepsy or advanced multisystem atrophy with backwards falls), or in selected patients with dementia where compliance and adherence cannot be ensured by a caregiver.
  7. After an acute coronary syndrome with stent implantation in AF patients at risk of stroke, combination triple therapy with aspirin, clopidogrel, and an OAC should be considered for 1–6 months to prevent recurrent coronary and cerebral ischemic events (Class IIa, Level of Evidence C).
  8. Dronedarone, flecainide, propafenone, or sotalol are recommended for prevention of recurrent symptomatic AF in patients with normal left ventricular function and without pathological left ventricular hypertrophy (Class I, Level of Evidence A). Dronedarone is recommended for prevention of recurrent symptomatic AF in patients with stable coronary artery disease, and without heart failure (Class I, Level of Evidence B). Amiodarone is recommended for prevention of recurrent symptomatic AF in patients with heart failure (Class I, Level of Evidence B).
  9. Catheter ablation of symptomatic paroxysmal AF is recommended to improve AF symptoms in patients who have symptomatic recurrences of AF on antiarrhythmic drug therapy (i.e., amiodarone, dronedarone, flecainide, propafenone, sotalol) and who prefer further rhythm control therapy (Class I, Level of Evidence A). Catheter or surgical ablation should be considered in patients with symptomatic persistent or long-standing persistent AF refractory to antiarrhythmic drug therapy to improve symptoms, considering patient choice, benefit, and risk, supported by an AF Heart Team (Class IIa, Level C).

Clinical Topics: Acute Coronary Syndromes, Anticoagulation Management, Arrhythmias and Clinical EP, Heart Failure and Cardiomyopathies, Prevention, Valvular Heart Disease, Anticoagulation Management and ACS, Anticoagulation Management and Atrial Fibrillation, Implantable Devices, EP Basic Science, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Acute Heart Failure, Sleep Apnea

Keywords: Acute Coronary Syndrome, Anti-Arrhythmia Agents, Anticoagulants, Arrhythmias, Cardiac, Aspirin, Atrial Appendage, Atrial Fibrillation, Catheter Ablation, Coronary Artery Disease, Defibrillators, Implantable, Dementia, Vascular, Electrocardiography, Epilepsy, Flecainide, Heart Failure, Heparin, Heparin, Low-Molecular-Weight, Intracranial Hemorrhages, Mitral Valve Stenosis, Obesity, Propafenone, Secondary Prevention, Risk Factors, Sleep Apnea, Obstructive, Stroke, Ventricular Function, Left, Weight Loss


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