The following are 12 of the many important points to remember from this contemporary review of atrial fibrillation (AF):

1. Lifestyle/risk modification studies that have included weight loss and exercise in obese AF patients (LEGACY, CARDIOFIT, ARREST-AF) have demonstrated significant reductions in AF burden.
2. Detection of subclinical AF lasting >5 minutes in patients with an implanted device are associated with a risk of silent ischemic brain lesions. Ongoing clinical trials with apixaban (ARTESiA) or the other direct oral anticoagulants (DOACs) (NOAH-AF NET 6) will clarify whether anticoagulation is beneficial for patients with device-detected subclinical AF.
3. Because of a primary or secondary atrial myopathy that promotes atrial stasis and/or affects the hemostatic profile, some patients with a history of AF can remain at risk of thromboembolic events even when AF is successfully suppressed by medications or ablation.
4. In the most recent US and European guidelines, a DOAC is preferred over warfarin in the absence of a contraindication, and aspirin is no longer recommended for stroke prevention in low-risk patients.
5. Left atrial appendage (LAA) closure not only reduces the risk of thromboembolic events but also may reduce AF burden. The ongoing aMAZE trial should be helpful in clarifying the incremental benefit of LAA closure in patients with persistent AF undergoing ablation.
6. The only rhythm-control medications that do not increase mortality in heart failure patients are amiodarone and dofetilide.
7. Atrioventricular node ablation/pacemaker is indicated in patients with a reduced ejection fraction and a rapid ventricular rate that cannot be controlled pharmacologically and are not candidates for AF ablation. Because of the deleterious effects of right ventricular dyssynchrony, biventricular pacing is indicated.
8. Pulmonary vein (PV) isolation remains the most appropriate initial ablation strategy for paroxysmal AF. The use of contact-force-sensing ablation catheters has improved the durability of PV isolation. However, the single-procedure clinical success rate at 1 year still tops out at 80-85%, with recurrences being due to either reconnection of PVs or non-PV sources of triggers or drivers of AF.
9. PV isolation using a cryoballoon catheter or a balloon-based laser endoscopic ablation system have similar efficacy and safety as radiofrequency ablation.
10. The best ablation strategy beyond PV isolation for persistent AF remains unsettled. A wide range of efficacy has been reported with various approaches, including isolation of the LA posterior wall, ablation of complex fractionated atrial electrograms, empiric linear ablation, ablation of non-PV triggers, superior vena cava or LAA isolation, mapping and ablation of rotors and focal sources of AF, atrial scar ablation, and alcohol ablation of the vein of Marshall.
11. In an intention-to-treat analysis, the CABANA trial demonstrated no difference between catheter ablation and a pharmacologic rhythm-control strategy in the primary endpoint of mortality, stroke, serious bleeding, or cardiac arrest over a 5-year period. However, an on-treatment analysis demonstrated an advantage of catheter ablation. In addition, the secondary endpoint of death and cardiovascular hospitalization was significantly reduced in the ablation arm.
12. Late recurrences of AF >3 years post-ablation continue to occur in a substantial proportion of patients, with risk factors including obesity, untreated sleep apnea, physical inactivity, and genetic factors.

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

Keywords: Anticoagulants, Arrhythmias, Cardiac, Atrial Appendage, Atrial Fibrillation, Atrioventricular Node, Cardiac Resynchronization Therapy, Catheter Ablation, Electrophysiologic Techniques, Cardiac, Heart Failure, Obesity, Primary Prevention, Pulmonary Veins, Risk Factors, Sleep Apnea, Obstructive, Stroke, Thromboembolism, Warfarin, Weight Loss

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