Dr. Riccardo Asteggiano,
Only four years after the publication of the 2012 ‘focused update of the ESC Guidelines for the management of Atrial Fibrillation’ a new version of these Guidelines was presented in August 2016.
A huge amount of new evidence in every field of Atrial Fibrillation (AF) management lead to a process of re-writing the previous guidelines.
Concomitant cardiovascular conditions, anticoagulation, rate control, and rhythm control chapters required the most attention.
What are the most important aspects, from a clinical point of view, that can be of interest to General Cardiologists?
Taking into account the rapidly growing population of patients (over 2% of the European population) there is a great need for intensive clinic and ECG screening for AF in patients over the age of 65 or those with stroke or transient ischemic attack both opportunistic and targeted. This is a typical issue facing GPs and General Cardiologists working in out-of-hospital settings, which are seeing patients without the knowledge of AF.
The use of transthoracic echocardiography is required in all AF patients to guide management , to assess concomitant cardiovascular diseases, to guide the use of anticoagulants, the choice of rate controlling agent, and rhythm control therapy.
Oral anticoagulation is still the major treatment component in AF patients. Women without any clinical risk factors are considered the patients at the lowest risk of stroke and as not requiring treatment. The issue of anticoagulation in patients with a single risk factor (CHA2DS2-VASc score of 2 for women and 1 for men) is less supported by data: considering individual characteristics and patient preferences many patients are likely to benefit from it (IIa B).
Non-vitamin-K oral anticoagulants (NOACs) are associated with half intracranial bleeding events compared to VKI, and are also slightly better at preventing strokes. Therefore, NOACs are now recommended as the first-line anticoagulant in eligible patients (I A).
Patients with moderate-severe mitral stenosis, mechanical heart valves, and severe chronic kidney disease, are ineligible for NOAC therapy and should be treated with VKI, maintaining a high time in therapeutic range.
It is definitively stated that Aspirin and other antiplatelets have no role in stroke prevention (III A).
The combination of anticoagulation with antiplatelets agents increases bleeding risk and is only accepted in selected patients with an acute coronary syndrome or a coronary stenting for a short time, balancing the risk of bleeding, stroke and myocardial ischaemia.
Bleeding and stroke risk factors often overlap and patients at high risk of bleeding are often those at the highest benefit from anticoagulation. Guidelines show recommendations about the difficult task for the initiation and/or resumption of anticoagulation 3–12 days after ischaemic stroke, and 4–8 weeks after intracranial haemorrhage. A permanent discontinuation of anticoagulation should be based on multidisciplinary team decisions.
The choice of a rate controlling agent is determined mainly by an ejection fraction: betablockers and digoxin are preferred when <40%, achieving an initial heart rate <110 beats/min considering however the lack of demonstration of a better survival in patients with heart failure. The use of combination therapy may be required for symptom and heart rate control; Verapamil and Diltiazem are better than betablockers in patients with heart failure with preserved ejection fraction.
Antiarrhythmic drugs supplemented with cardioversion are recommended treatment options but their choice is strictly related to safety considerations.
Catheter ablation is now considered the rhythm control therapy of choice in patients with symptomatic recurrences of AF on antiarrhythmic drug therapy if paroxysmal (I A) and if persistent (IIa C). It is also a first-line alternative to antiarrhythmic drugs in selected patients with symptomatic paroxysmal AF (IIa B).
The new guidelines are proposing the creation of local ‘AF Heart Teams’ to discuss and take difficult decisions regarding stroke prevention and rhythm control rhythm interventions, including antiarrhythmic drugs choice, repetition of a second catheter ablation, thoracoscopic ablation, and AF surgery.
The ESC acknowledges the new smartphone applications for AF usable from both AF patients and their healthcare professionals. This new tool encourages patient involvement in the management and improves patient to doctor communication.
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