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Appraisal of the ESC Atrial Fibrillation Guidelines 2010 (Part 1) 

Part 1 - Clinical assessment and thrombo-embolic risk

From Riccardo Asteggiano, Nucleus Member of the Council for Cardiology Practice 

From Riccardo Asteggiano, Nucleus Member of the Council for Cardiology Practice
Topics: Atrial Fibrillation
Date: 22 Apr 2011

The European Society of Cardiology together with the European Heart Rhythm Association presented at the ESC Congress 2010 and published in November 2010 in the European Heart Journal, the new edition of the Guidelines on Atrial Fibrillation (AF).

These guidelines are a true “compendium” on AF and a “state of the art” on this common arrhythmia. There have been many updated references to the literature on AF over the last years, in all fields regarding AF: from physiopathology to prevention of thrombo-embolism; from the problems regarding rate-control or rhythm control to quality of life in AF patients; from dronedarone to catheter ablation and to ‘upstream’ therapy.
Together with this updating there are a lot of useful indications for clinical practice, both for General Practitioners and for expert cardiologists and electrophysiologists, summarized in helpful tables and figures.

Part 1 reports on Chapters 1, 2, 3 and 4. The fourth chapter is the main chapter of these guidelines with the most important news.

Chapters 1 and 2. Epidemiology and Mechanisms of AF

The first two chapters discuss Epidemiology and Mechanisms of AF (both pathophysiological changes preceding atrial fibrillation and pathophysiological changes as a consequence of AF, electrophysiological mechanisms, genetic predisposition and ion channel disease), and the clinical correlates (on atrioventricular conduction, haemodynamic changes, thrombo-embolism).

Chapter 3. Detection, ‘Natural History’ and Acute Management

Chapter 3 analyses the new definitions of AF. It introduces the terms of ‘first diagnosed AF’ and ‘long-standing persistent AF’ defined as an AF lasting for more than 1 year, while ‘paroxysmal AF’ is self-terminating in 48 hours (Figure 1), and of ‘silent AF’.

Natural time course of Atrial Fibrillation

 

The issues for initial management are reported and for the first time the EHRA score of AF-related symptoms is introduced (Table 6). It is recommended that every patient should be classified by the EHRA score.

EHRA score of AF-related symptoms

In the paragraph on diagnostic evaluation the authors point out the need of a periodic re-evaluation of the risk profile (especially with regard to the indication for anticoagulation), of the patient's symptoms (by EHRA score, to improve therapy), of the risk of proarrhythmia, of progression to a persistent/permanent form, and of the rate control.


Chapter 4. Antithrombotic Management, Rate and Rhythm Management, Long Term Management and Upstream Therapy

This is the most important chapter with the more relevant and interesting innovations.
Antithrombotic management is the first step in the treatment of every patient with AF and comes before every other issue. Figure 3 summarizes the major issues of AF  management.

Management cascade for patients with AF

Based on recent publications the authors discuss the re-definition of the CHADS2 score system: the  CHA2DS2VASc score (Table 8) that includes stroke risk factors, and ‘stroke risk modifiers’ for a better stroke risk assessment. This score is useful to clinicians for a better stratification of thrombo-embolic risk in clinical practice and to balance it with haemorraghic risk.

Risk factors for stroke and thrombo-embolism in non-valvular AF

CHA2DS2VASc score [congestive heart failure, hypertension, age 75 (doubled), diabetes, stroke (doubled), vascular disease, age 65–74, and sex category (female)]  and stroke rate.

In the score are considered ‘Major risk factors’, with the introduction of older age (75 years) and  ‘Clinically relevant non-major’ risk factors with the introduction of female sex, myocardial infarction, complex aortic plaque and PAD (Vascular disease). The presence of one major risk factor or two or more ‘clinically relevant non-major’ risk factors requires anticoagulation. These new guidelines criticise the role of antiplatelet therapy. Aspirin has less effect in people older than 75 years and is associated with more adverse events. Aspirin plus clopidogrel therapy is admitted by the guidelines as an interim measure where VKA therapy is unsuitable. Figure 4 summarizes the current recommendations for antithrombotic therapy.

Flowchart for use of oral anticoagulation for stroke prevention in AF


Assessment of bleeding risk is mandatory before starting anticoagulation. The new guidelines show a new simple bleeding risk score, the HAS-BLED score (Table 10), derived using the data of the EuroHeart Survey. A score of 3 indicates ‘high risk’. Matching CHA2DS2VASc score and HAS-BLED score allows the physician to choose the antithrombotic treatment tailored for every patient.

Clinical characteristics of the HAS-BLED risk score

Some special situations are considered in the new guidelines, mainly the problem of the association of VKA and aspirin–clopidogrel combination therapy in ACS and in coronary stenting. The statements are summarized in Table 11.

Anticoagulation regimen in specific situations



The recommendations for cardioversion are the same as previous guidelines.
Patients with contraindications to chronic anticoagulation therapy might be considered as candidates for LAA occlusion.


END OF PART 1

Authors: Riccardo Asteggiano is a private practice cardiologist from Turin, Italy and a nucleus member of the ESC Council for Cardiology Practice.


References VIEW HERE the Guidelines on the Management of Atrial Fibrillation 2010