Dr. Stefan Agewall,
Prof. John Camm,
The new ESC/EACTS Guidelines for the management of atrial fibrillation are presented during this congress. The work has been led by Paulus Kirchhof and Stefano Benussi and is a full rewrite following on from the 2010 and 2012 guidelines on atrial fibrillation.
What’s new? The 2016 Atrial Fibrillation guidelines reflect the increasing need to integrate and coordinate the care of AF patients. This is reflected in the multidisciplinary input of the Task Force, which included expert cardiologists and electrophysiologists, stroke neurologists, specialist AF nurses and cardiac surgeons.
There is now more emphasis on early detection of asymptomatic ‘silent’ AF. Diagnosis of AF requires an ECG (IB evidence), with the value of atrial high rate episodes picked up by implanted devices unclear at present. Silent, undiagnosed AF is a common cause of stroke, and the guidelines recommend both opportunistic and targeted intensive ECG screening for AF in all patients over the age of 65 or those with stroke or transient ischemic attack (IB).
Oral anticoagulation remains a major treatment component in AF, and, apart from patients at the lowest risk of stroke (women and men without any clinical risk factors), most others will derive a net clinical benefit from anticoagulation (IA).
Patients with a single stroke risk factor (CHA2DS2-VASc score of 2 for women and 1 for men) should be considered for anticoagulation, taking account of individual characteristics and patient preferences (IIaB); men with a CHA2DS2-VASc score of 2 and women with a score of 3 should be recommended for anticoagulation (IA). Non vitamin-K oral anticoagulants (NOACs) are now recommended as the first-line anticoagulant in eligible patients (IA) as a result of their better safety profile.
Patients who are ineligible for NOAC therapy, such as those with moderate-severe mitral stenosis, mechanical heart valves and severe chronic kidney disease, should be treated with vitamin-K antagonists, maintaining a high time in therapeutic range (IB). Aspirin and other antiplatelets have no role in stroke prevention (III A). Preventing major bleeding events in anticoagulated AF patients is extremely important. To reduce the risk of bleeding, the guidelines provide a list of modifiable bleeding risk factors that clinicians should minimise in anticoagulated patients, but a specific bleeding score is no longer recommended. Importantly, bleeding and stroke risk factors overlap and patients at high risk of bleeding are likely to benefit from anticoagulation (IIaB).
The guidelines also provide suggestions for initiation and/ or resumption of treatment after ischaemic strokes and after intracranial haemorrhage. These difficult decisions should be taken by interdisciplinary teams.
Symptoms should be assessed by the modified EHRA score (IC), including AF-related tiredness and breathlessness, which are common symptoms in AF patients. Catheter ablation is now reaching the mainstream of AF management and data underpinning its use have expanded in number and quality.
Catheter ablation is the rhythm control therapy of choice in patients with symptomatic recurrences of AF on antiarrhythmic drug therapy (IA paroxysmal; IIaC persistent), and emerges as a valid first-line alternative to anti-arrhythmic drugs in selected patients with symptomatic paroxysmal AF (IIa B).
To support clinical decision making in line with the 2016 atrial fibrillation guideline, new state-of-the-art tools are available in the ESC Pocket Guidelines app. These include an overall treatment manager which has been developed by the EU-funded project CATCH ME.* These impressive features, which are both novel and intuitive, will help healthcare professionals personalise prevention and management of their AF patients and implement best clinical practice, even when under pressure to make a rapid decision.
CATCH ME (Characterising Atrial Fibrillation by Translating its Causes into Health Modifiers in the Elderly, www. catch-me.info) brings together the expertise of leading academic institutions, healthcare organisations and professional societies with an aim to improve the care of patients with AF.
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