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2020 ESC Clinical Practice Guidelines for the diagnosis and management of atrial fibrillation

Four new ESC Clinical Practice Guidelines are being unveiled at ESC Congress 2020, and the first of these, ESC Guidelines on atrial fibrillation (AF), were presented today by Guidelines Task Force Chairs, Professor Gerhard Hindricks (Heart Centre Leipzig, Germany) and Professor Tatjana Potpara (Clinical Centre of Serbia, Belgrade).

Developed in collaboration with the European Association of Cardio-Thoracic Surgery, this timely update comes as substantial progress has been made in AF detection and management since the last guidelines on this topic were published in 2016.

The first new recommendation concerns diagnosis, stressing that documentation from a standard 12-lead ECG recording or a single-lead ECG tracing of ≥30 seconds is required to establish the diagnosis of AF. Another key message of the new guidelines is that while novel tools and technologies for screening and detection of AF such as (micro-)implants and wearables substantially add to the diagnostic opportunities in patients at risk for AF, appropriate management pathways based on these tools are still incompletely defined.

After diagnosis, to facilitate optimal management of AF, structured characterisation of AF should be considered in all patients. This includes clinical assessment of stroke risk, symptom status, burden of AF and evaluation of substrate. As a continuum to the integrated, structured approach to AF care advocated in 2016, the 2020 guidelines recommend the use of the Atrial fibrillation Better Care (ABC) holistic pathway ('A' Anticoagulation/Avoid stroke; 'B' Better symptom management; 'C' Cardiovascular and Comorbidity optimisation). The ABC pathway streamlines integrated care of AF patients across all healthcare levels and among different specialties, with the goal to further improve the structured management of AF patients, promote patient values and improve patient outcomes.

The 2016 Class IIa recommendation about considering placing patients in a central role in the decision-making process is upgraded in the 2020 version – a new Class I recommendation relates to optimising shared decision-making about AF treatment options and ensuring that patient values need to be taken into account. In addition, it is now recommended that patient-reported outcomes are routinely collected to measure treatment success and improve patient care.

There are revisions to guidance for rhythm control/catheter ablation of AF, with many previous Class IIa considerations becoming Class I recommendations. For example, AF catheter ablation for pulmonary vein isolation is now recommended for rhythm control after one failed or intolerant class I or III antiarrhythmic drug in patients with paroxysmal AF, or persistent AF with or without major risk factors. Overall, there is also greater emphasis on the need for lifestyle modifications and targeted therapy of intercurrent conditions to reduce AF burden and improve outcomes.

Keen to know more about the changes in recommendations? The 2020 ESC Guidelines for the diagnosis and management of AF are published in the European Heart Journal today!


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1. Hindricks G, Potpara TS, et al. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association of Cardio-Thoracic Surgery (EACTS). Eur Heart J 2020. doi/10.1093/eurheartj/ehaa612

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.