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2020 Guidelines for Management of Atrial Fibrillation

ESC Clinical Practice Guidelines

Atrial fibrillation (AF) poses a significant burden to patients, physicians, and healthcare systems globally. Substantial research efforts and resources are being directed towards gaining detailed information about the mechanisms underlying AF, its natural course and effective treatments.  New evidence is continuously generated and published.

The complexity of AF requires a multifaceted, holistic, and multidisciplinary approach to the management of AF patients, with their active involvement in partnership with clinicians. Streamlining the care of patients with AF in daily clinical practice is a challenging but essential requirement for effective management of AF. In recent years, substantial progress has been made in the detection of AF and its management, and timely new evidence is integrated in this third edition of the ESC Guidelines on AF.

Arrhythmias, General
Antiarrhythmic Pharmacotherapy
Atrial Fibrillation
Pharmacology and Pharmacotherapy
Invasive Imaging and Functional Assessment
Arrhythmias and Device Therapy
Guidelines version available to download
Published in 2020
Reference 10.193/eurheartj/ehaa612
Published in 2021
Reference 10.1093/eurheartj/ehaa798
Published in 2020
Reference 10.1093/eurheartj/ehaa945
Published in 2020
Reference Table of Contents
Published in 2020
Reference Pocket Guidelines App
Published in 2020
Reference 166 Slides
Table of contents: Full Text (ESC Clinical Practice Guidelines)

Table of Contents



  • What is new in the 2020 ESC Guidelines?

Definition and Diagnosis of Atrial Fibrillation             

  • Definition
  • Diagnostic criteria for atrial fibrillation
  • Diagnosis of atrial high-rate episodes/subclinical atrial fibrillation


  • Prediction of incident atrial fibrillation
  • Pathophysiology of atrial fibrillation

Clinical Features of Atrial Fibrillation

Atrial Fibrillation Subtypes, Burden, and Progression          

  • Classification of atrial fibrillation
  • Definition and assessment of atrial fibrillation burden
  • Atrial fibrillation progression
  • Atrial cardiomyopathy − definition, classification, clinical implications, and diagnostic assessment

Screening for Atrial Fibrillation           

  • Screening tools
  • Screening types and strategies
  • Benefits from and risks of screening for atrial fibrillation
  • Cost-effectiveness of screening for atrial fibrillation
  • Screening in high-risk populations

Diagnostic Assessment in Atrial Fibrillation

  • Symptoms and quality of life
  • Substrate

Integrated Management of Patients with Atrial Fibrillation

  • Definitions and components of integrated management of atrial fibrillation patients
  • Multidisciplinary atrial fibrillation teams
    • Role of healthcare systems and budget constraints
  • Patient involvement and shared decision-making
    • Patient values and preferences
    • Patient education
  • Healthcare professional education
  • Adherence to treatment
  • Technology tools supporting atrial fibrillation management
  • Advantages of integrated management of atrial fibrillation patients
  • Measures (or approaches) for implementation of integrated management
  • Treatment burden
  • Patient-reported outcomes

Patient Management – the Integrated ABC Pathway           

  • ‘A’ – Anticoagulation/Avoid stroke
    • Stroke risk assessment
    • Bleeding risk assessment
    • Absolute contraindications to oral anticoagulants
    • Management of anticoagulation-related bleeding risk
    • Decision-making to avoid stroke
  • ’B’ – Better symptom control
    • Rate control
    • Rhythm control
  • ‘C‘ – Cardiovascular risk factors and concomitant diseases – detection and management  
    • Lifestyle interventions
    • Specific cardiovascular risk factors/comorbidities

The ABC Pathway in Specific Clinical Settings/Conditions/Patient Populations    

  • Atrial fibrillation with haemodynamic instability
  • First-diagnosed (new onset) atrial fibrillation
  • Acute coronary syndromes, percutaneous coronary intervention, and chronic coronary syndromes in patients with atrial fibrillation
  • Acute stroke or intracranial haemorrhage in patients with atrial fibrillation
    • Patients with atrial fibrillation and acute ischaemic stroke or transient ischaemic attack
    • Cryptogenic stroke/embolic stroke with undetermined source
    • Post-stroke patients without known atrial fibrillation
    • Management of patients with atrial fibrillation post-intracranial haemorrhage
  • Active bleeding on anticoagulant therapy – management and reversal drugs
  • Atrial fibrillation and heart failure
  • Atrial fibrillation and valvular heart disease
  • Atrial fibrillation and chronic kidney disease
  • Atrial fibrillation and peripheral artery disease
  • Atrial fibrillation and endocrine disorders
  • Atrial fibrillation and gastrointestinal disorders
  • Atrial fibrillation and haematological disorders
  • The elderly and frail with atrial fibrillation
  • Patients with cognitive impairment/dementia
  • Atrial fibrillation and congenital heart disease
  • Atrial fibrillation in inherited cardiomyopathies and primary arrhythmia syndromes
  • Atrial fibrillation during pregnancy
  • Atrial fibrillation in professional athletes
  • Postoperative atrial fibrillation
    • Prevention of postoperative AF
    • Prevention of thromboembolic events

Prevention of Atrial Fibrillation          

  • Primary prevention of atrial fibrillation
  • Secondary prevention of atrial fibrillation

Sex-Related Differences in Atrial Fibrillation 

Implementation of the Atrial Fibrillation Guidelines

Quality Measures and Clinical Performance Indicators in the Management of Atrial Fibrillation     

Epidemiology, Clinical Implications, and Management of Atrial High-Rate Episodes/Subclinical Atrial Fibrillation  

Atrial Fibrillation and other Atrial Tachyarrhythmias (Atrial Flutter and Atrial Tachycardias)          

Key Messages

Gaps in Evidence         

 ‘What To Do’ and ‘What Not To Do’ Messages from the Guidelines

Supplementary Data  




Previous version available to download
Published in 2020
Reference Memo Card AFIB
Published in 2016
Reference European Heart Journal (2016) 37, 2893–2962 doi:10.1093/eurheartj/ehw210
Published in 2016
Reference .doi:10.1093/eurheartj/ehw21
Published in 2012
Reference Corrigendum-AFib-Focused-Update-2012-EHJ-doi:10.1093/eurheartj/eht027
Published in 2012
Reference European Heart Journal (2012) 33, 2719–2747
Published in 2011
Reference doi:10.1093/eurheartj/ehq512
Published in 2010
Reference European Heart Journal (2010) 31, 2369–2429
Published in 2010
Reference AFIB - Additional References
Published in 2011
Reference ESC Statement on Dronedarore