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Management of atrial fibrillation 

New data prompts an update of ESC Guidelines

Topics: Atrial Fibrillation
Date: 29 Aug 2010
New data derived from recent clinical trials have prompted an update of ESC Guidelines on AF published in 2006.

 Panos Vardas

Prof. Panos Vardas
Heraklion University Hospital
Heraklion, Greece

The Task Force, which comprised 24 European experts in arrhythmias led by Professor John Camm, has developed a comprehensive document applicable not only to cardiologists but to all physicians interested in the field.

There are a number of important features which distinguish this Guideline from its predecessor. First, based on the presentation and duration of the arrhythmia, five types of AF are clinically distinguished: first diagnosed, paroxysmal, persistent, long-standing, and permanent AF.

On the subject of initial management, the new Guidelines state that clinical evaluation should include a determination of the EHRA score of AF-related symptoms, an estimation of strokebleeding risk, and a check for conditions that predispose to AF and for complications.

The most important addition on antithrombotic treatment is a recommendation to use the CHA2DS2- VASc scoring system in patients with a CHAD S2 score of 0-1. The CHAD S2 stroke risk stratification scheme is recommended as a simple means of assessing risk, particularly suited to primary care and non-specialists. Chronic oral anticoagulation therapy is recommended in patients with a CHAD S2 score of ≥2, unless contraindicated. For a more detailed stroke risk assessment, the CHA2DS2- VASc score is recommended.
Atrial Fibrillation Guidelines
The Guidelines also highlight the importance of bleeding risk assessment prior to the initiation of anticoagulation, and the HAS-BLED bleeding risk score is recommended. A score of ≥3 is considered indicative of ‘high risk’ patients who require caution and regular review following the initiation of antithrombotic therapy.

Another important subject covered is the choice of anti-arrhythmic therapy for recurrent AF. Recommendations are on the basis of choosing safer - although possibly less effective - medication prior to more effective but less safe therapy. The completion of a number of important clinical trials with dronedarone have now made it possible to include for the first time recommendations in AF. However, special caution is needed in heart failure patients. More specifically, it is stated that dronedarone is not recommended for treatment of AF in patients in NYHA Classes III and IV, or with recently unstable NYHA class II heart failure. Finally, the new Guidelines recommend that catheter ablation for paroxysmal AF should be considered in symptomatic patients who have previously failed a trial of anti-arrhythmic medication (Class IIa, level of evidence B). The Task Force recognised that, although several prospective trials have now confirmed the superiority of catheter ablation over anti-arrhythmic medication, there is no evidence so far that successful AF ablation will result in reduced mortality.

The 2010 AF Guidelines set new standards of clinical excellence and their implementation is likely to have a major impact on reducing the complications of this arrhythmia.

Download the Atrial Fibrillation ESC Guidelines here

Authors: Panos Vardas, Heraklion University Hospital Heraklion, Greece