Integrated Care of Patients With Atrial Fibrillation
- Kirchhof P.
- Integrated Care of Patients With Atrial Fibrillation: The 2016 ESC Atrial Fibrillation Guidelines. Heart 2017;Jan 11:[Epub ahead of print].
The following are key points to remember from this editorial about the integrated care of patients with atrial fibrillation (AF), based on the 2016 European Society of Cardiology (ESC) AF guidelines:
- Electrocardiogram (ECG) screening can help detect asymptomatic AF, allowing timely initiation of therapy, especially oral anticoagulation. The ESC guidelines recommend opportunistic ECG screening whenever a person aged ≥65 years is seen by a healthcare professional. Patients with stroke or transient ischemic attack (TIA) should undergo ECG monitoring for at least 72 hours, but preferably even longer.
- Optimal management of patients with AF requires input from a multidisciplinary team consisting of: AF specialists, stroke physicians, AF surgeons, general cardiologists, general practitioners, allied healthcare professionals, patients, and family members.
- Initial assessment of patients with AF should include a complete history, physical examination, careful analysis of an ECG, and an echocardiogram.
- Patients with two of the CHA2DS2-VASc stroke risk factors: congestive heart failure, hypertension, diabetes, or vascular disease; as well as survivors of a stroke or TIA and those aged ≥75 years should receive oral anticoagulation. Anticoagulation should be considered in patients with AF and one additional stroke risk factor of either sex, weighing the likely benefit of anticoagulation and the risk of bleeding.
- Patients with mechanical heart valves and those with moderate or severe mitral stenosis should be treated with vitamin K antagonists. Considering their superior safety compared with warfarin (10% lower mortality, approximately 50% lower risk of intracranial hemorrhage or hemorrhagic stroke), patients who are eligible for therapy with the nonvitamin K antagonist oral anticoagulants (NOACs: apixaban, dabigatran, edoxaban, or rivaroxaban) should preferentially be treated with one of these agents.
- There are four modifiable bleeding risk factors in anticoagulated patients: 1) systolic blood pressure >160 mm Hg; 2) labile international normalized ratio (INR) or time in therapeutic range <60% in patients on vitamin K antagonists; 3) antiplatelet and nonsteroidal anti-inflammatory medications; and 4) ≥8 alcoholic drinks per week.
- There are no major changes to the recommendations for rate control therapy in the 2016 ESC AF guidelines. Catheter ablation targeting pulmonary veins should be discussed with patients in need of rhythm control therapy. When AF recurs, the options include adding an antiarrhythmic agent or redo catheter ablation. Patients who need a third attempt at rhythm control therapy should discuss this with an AF Heart Team, and include consideration of AF surgery.
- The new ESC AF guidelines suggest a very similar approach to rhythm control in patients with paroxysmal and persistent AF, as catheter ablation appears to have higher efficacy than antiarrhythmic agents in both types of AF.
- Implementation of evidence-based management using integrated AF care models has the potential to substantially improve outcomes in patients with AF.
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