The following are key points to remember from the 2020 European Society of Cardiology (ESC) and European Association of Cardio-Thoracic Surgery (EACTS) guidelines for the diagnosis and management of atrial fibrillation (AF):

1. “Clinical AF” is defined as symptomatic or asymptomatic AF that is documented by surface electrocardiogram (ECG) (at least seconds on ambulatory monitor, including wearable-recorded ECG or a 12-lead ECG). “Subclinical AF” refers to individuals without symptoms, whose pacemaker or implantable cardioverter-defibrillator (ICD) interrogation reveals “atrial high rate episode (AHRE)," and in whom AF has not been detected on surface ECG. While there is a significant amount of data on the management of “clinical AF,” data on optimal management of AHRE and subclinical AF are lacking.
2. Opportunistic screening for AF is recommended in patients ≥65 years old, hypertensive patients, and in patients with obstructive sleep apnea. Systematic ECG screening should be considered to detect AF in patients aged ≥75 years, or those at high risk of stroke.
3. All patients diagnosed with AF should undergo a “structured characterization,” which includes stroke risk, symptom severity, AF burden, and AF substrate assessment. Patient values should be considered, and an assessment of “patient-reported outcome” measures is recommended. Integrated, patient-centered AF management may be accomplished through the coordination of a cardiologist, AF nurse, general practitioner, and pharmacist. The introduction of tools to measure quality of care and identify opportunities for improved treatment quality and AF patient outcome should be considered by practitioners and institutions.
4. CHA₂DS₂-VASc clinical stroke risk score should be used to identify patients at “low risk” (CHA₂DS₂-VASc score = 0 in men, or 1 in women), who should not be offered antithrombotic therapy. Antiplatelet therapy alone is not recommended for stroke prevention in AF (Class III). Oral anticoagulation (OAC) is recommended for stroke prevention in AF patients with CHA₂DS₂-VASc score ≥2 in men or ≥3 in women, and it should be considered in patients with a CHA₂DS₂-VASc score of 1 in men or 2 in women, with treatment individualized based on net clinical benefit and patient values/preferences.
5. A risk score-based bleeding risk assessment (HAS-BLED) is recommended to help identify patients at high risk of bleeding who should be scheduled for more frequent clinical follow-up. Estimated bleeding risk, in the absence of absolute contraindications to OAC, should not in itself guide treatment decisions to avoid using OAC.
6. Nonvitamin K antagonist oral anticoagulants (NOACs) are recommended in preference to VKAs (excluding patients with mechanical heart valves or moderate-to-severe mitral stenosis). In AF patients with acute coronary syndrome (ACS) undergoing an uncomplicated percutaneous coronary intervention, early cessation (≤1 week) of aspirin and continuation of dual therapy with an OAC and a P2Y12 inhibitor (preferably clopidogrel) for up to 12 months is recommended. Triple therapy with aspirin, clopidogrel, and an OAC for longer than 1 week after an ACS should be considered when risk of stent thrombosis outweighs the bleeding risk, with the total duration (≤1 month).
7. Long-term OAC therapy to prevent thromboembolic events should be considered in patients at risk for stroke with postoperative AF after noncardiac surgery, considering the anticipated net clinical benefit of OAC and informed patient preferences. Beta-blockers should not be used routinely for the prevention of postoperative AF in patients undergoing noncardiac surgery (Class III).
8. Lenient rate control (heart rate <110 bpm on ECG) is often sufficient to improve AF-related symptoms. The primary indication for rhythm control is reduction in AF-related symptoms and improvement of quality of life. Catheter ablation is a well-established, safe, and superior alternative to antiarrhythmic drugs for maintenance of sinus rhythm.
9. In patients with AF and normal left ventricular function, catheter ablation has not been shown to reduce total mortality or stroke; in patients with tachycardia-induced cardiomyopathy, catheter ablation reverses left ventricular dysfunction in most cases.
10. Obesity and obstructive sleep apnea are major risk factors for AF. Weight loss improves outcomes in patients with AF. Aggressive risk factor reduction programs focusing on weight management, hyperlipidemia, obstructive sleep apnea, hypertension, diabetes, smoking cessation, and alcohol intake reduction significantly reduced AF burden after ablation.

Clinical Topics: Acute Coronary Syndromes, Anticoagulation Management, Arrhythmias and Clinical EP, Dyslipidemia, 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, Sleep Apnea

Keywords: ESC Congress, ESC20, Acute Coronary Syndrome, Anti-Arrhythmia Agents, Anticoagulants, Arrhythmias, Cardiac, Aspirin, Atrial Fibrillation, Cardiomyopathies, Catheter Ablation, Defibrillators, Implantable, Electrocardiography, Hyperlipidemias, Mitral Valve Stenosis, Pacemaker, Artificial, Platelet Aggregation Inhibitors, Quality of Life, Risk Assessment, Risk Factors, Secondary Prevention, Sleep Apnea, Obstructive, Smoking Cessation, Stroke, Ventricular Function, Left, Weight Loss

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