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What Concerns the General Cardiologist in the new 2016 ESC Atrial Fibrillation Management Guidelines?

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?

Atrial Fibrillation
The Cardiac Consult


Diagnosis

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.

Anticoagulation

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.

Rate Control

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.

Rhythm Control

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).

AF Heart Teams

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.

‘Ten Commandments’ of 2016 ESC Guidelines for the management of atrial fibrillation

  1. Actively use ECG screening and monitoring whenever atrial fibrillation (AF) might be suspected, including in patients with unspecific complaints, particularly in elderly patients, and in survivors of an ischemic stroke.
  2. Therapeutic strategies in AF often comprise a variety of options representing reasonable alternatives. The involvement and empowerment of patients, the education and shared decision-making are key features of a successful physician–patient relationship in an integrated AF care.
  3. Initiate and indefinitely continue anticoagulation in all patients with documented AF/atrial flutter at increased risk of stroke.
  4. Stroke risk evaluation is based on the CHADS-VASc score. With a score of 2 in male and 3 in female patients, anticoagulation for stroke prevention is strictly recommended; in a score of 1 in males or 2 in females anticoagulation should be considered case by case; no antithrombotic therapy of any kind should be prescribed in patients with a CHADS-VASc score of 0 (males) or 1 (females). There are no indications for aspirin or other antiplatelet therapy.
  5. Minimize modifiable bleeding risk factors: Hypertension should be tightly controlled, concomitant antiplatelet or NSAID therapy should be as short in duration as possible, alcohol use avoided, and anaemia treated and normalized.
  6. Ventricular rate in patients with AF should be reduced according to a lenient target heart rate (<110 beats/min at rest). When symptoms persist, a lower heart rate might be attempted but at the same time bradycardia avoided. Use betablockers and/or Digoxin if EF < 40%. Verapamil and Diltiazem may be used in PEFHF.
  7. Rhythm control therapy is indicated for symptom improvement with electrical or pharmacological cardioversion. In symptomatic patients with persistent or longstanding-persistent AF, use long-term antiarrhythmic drug therapy, catheter ablation, AF surgery, ablation and pacing, generally in this order.
  8. Before cardioversion of AF, verify effective anticoagulation with a NOAC or VKA for a minimum of 3 weeks. After cardioversion, a minimum of 4 weeks of anticoagulation is required. As an alternative to pre-procedural anticoagulation, transoesophageal echocardiography can be utilized to exclude cardiac thrombus.
  9. For long-term antiarrhythmic drug therapy to maintain sinus rhythm are recommended: dronedarone, flecainide, propafenone, sotalol, or amiodarone. Catheter ablation is a reasonable alternative. Each of these drugs has its particular indications and safety warnings.
  10. Use peri-operative oral beta-blockers for the prevention, and restore sinus rhythm by cardioversion in postoperative AF.