The ESC commissioned external systematic reviews to answer these questions, and these reviews have informed specific recommendations.
Further to adhering to the standards for generating recommendations that are common to all ESC guidelines see preamble , this Task Force discussed each draft recommendation during web-based conference calls dedicated to specific chapters, followed by consensus modifications and an online vote on each recommendation. We hope that these guidelines will help to deliver good care to all patients with AF based on the current state-of-the-art evidence in In , the estimated numbers of men and women with AF worldwide were AF is independently associated with a two-fold increased risk of all-cause mortality in women and a 1.
Death due to stroke can largely be mitigated by anticoagulation, while other cardiovascular deaths, for example due to heart failure and sudden death, remain common even in AF patients treated according to the current evidence base. These costs will increase dramatically unless AF is prevented and treated in a timely and effective manner. Despite these advances, substantial morbidity remains. Timeline of findings from landmark trials in atrial fibrillation management, including treatment of concomitant conditions and prevention green , anticoagulation blue , rate control therapy orange , rhythm control therapy red , and atrial fibrillation surgery purple.
In contemporary, well-controlled, randomized clinical trials in AF, the average annual stroke rate is about 1. In both developed and developing countries, the age-adjusted incidence and prevalence of AF are lower in women, while the risk of death in women with AF is similar to or higher than that in men with AF. Women with diagnosed AF can be more symptomatic than men and are typically older with more comorbidities.
Recommendations relating to gender. AF, especially early-onset AF, has a strong heritable component that is independent of concomitant cardiovascular conditions. These monogenic diseases also convey a risk for sudden death see Chapter 6. Up to one-third of AF patients carry common genetic variants that predispose to AF, albeit with a relatively low added risk. At least 14 of these common variants, often single nucleotide polymorphisms, are known to increase the risk of prevalent AF in populations.
Genetic variants could, in the future, become useful for patient selection of rhythm or rate control. Activation of fibroblasts, enhanced connective tissue deposition, and fibrosis are the hallmarks of this process. Pathophysiological alterations in atrial tissue associated with atrial fibrillation and clinical conditions that could contribute to such alterations. Major mechanisms causing atrial fibrillation that can be considered when choosing therapy. These changes enhance both ectopy and conduction disturbances, increasing the propensity of the atria to develop or maintain AF.
At the same time, some of these alterations are involved in the occurrence of the hypercoagulable state associated with AF.
For example, hypocontractility reduces local endothelial shear stress, which increases PAI-1 expression, and ischaemia-induced inflammation enhances the expression of endothelial adhesion molecules or promotes shedding of endothelial cells, resulting in tissue factor exposure to the blood stream. These changes contribute to the thrombogenic milieu in the atria of AF patients. AF in itself can aggravate many of the mechanisms shown, which may explain the progressive nature of the arrhythmia.
The functional and structural changes in atrial myocardium and stasis of blood, especially in the left atrial appendage LAA , generate a prothrombotic milieu. Furthermore, even short episodes of AF lead to atrial myocardial damage and the expression of prothrombotic factors on the atrial endothelial surface, alongside activation of platelets and inflammatory cells, and contribute to a generalized prothrombotic state. The seminal observation by Haissaguerre et al. The mechanism of focal activity might involve both triggered activity and localized reentry.
Moe and Abildskov proposed that AF can be perpetuated by continuous conduction of several independent wavelets propagating through the atrial musculature in a seemingly chaotic manner. As long as the number of wavefronts does not decline below a critical level, they will be capable of sustaining the arrhythmia.
Numerous experimental and clinical observations can be reconciled with the multiple wavelet hypothesis. ECG-documented AF was the entry criterion in trials forming the evidence for these guidelines. By accepted convention, an episode lasting at least 30 s is diagnostic. Many AF patients have both symptomatic and asymptomatic episodes of AF. Silent, undetected AF is common, , with severe consequences such as stroke and death.
Ongoing studies will determine whether such early detection alters management e. Once the ECG diagnosis of AF has been established, further ECG monitoring can inform management in the context of: 1 a change in symptoms or new symptoms; 2 suspected progression of AF; 3 monitoring of drug effects on ventricular rate; and 4 monitoring of antiarrhythmic drug effects or catheter ablation for rhythm control. Undiagnosed AF is common, especially in older populations and in patients with heart failure. These findings encourage the further evaluation of systematic AF screening programmes in at-risk populations.
Paroxysmal AF is often missed. Implanted pacemakers or defibrillators with an atrial lead allow continuous monitoring of atrial rhythm. Using this technology, patients with atrial high rate episodes AHRE can be identified.
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AF detection is not uncommon in unselected stroke patients 6. Recommendations for screening for atrial fibrillation. Right atrial isthmus-dependent flutter has a typical ECG pattern and ventricular rate. The ventricular rate can be variable usual ratio of atrial to ventricular contraction to , in rare cases and macro-re-entrant tachycardias may be missed in stable conduction. Vagal stimulation or intravenous adenosine can therefore be helpful to unmask atrial flutter. The management of atrial flutter is discussed in chapter Left or right atrial macro re-entrant tachycardia is mainly found in patients after catheter ablation for AF, AF surgery, or after open heart surgery.
In many patients, AF progresses from short, infrequent episodes to longer and more frequent attacks.
Over time, many patients will develop sustained forms of AF. Furthermore, asymptomatic recurrences of AF are common in patients with symptomatic AF.
If patients suffer from both paroxysmal and persistent AF episodes, the more common type should be used for classification. Despite these inaccuracies, the distinction between paroxysmal and persistent AF has been used in many trials and therefore still forms the basis of some recommendations. If both persistent and paroxysmal episodes are present, the predominant pattern should guide the classification.
There is some evidence suggesting that AF burden may influence stroke risk 44 , , and could modify the response to rhythm control therapy. Therefore, AF burden should not be a major factor in deciding on the usefulness of an intervention that is deemed suitable for other reasons. This suggests that stratifying AF patients by underlying drivers of AF could inform management, for example, considering cardiac and systemic comorbidity e. It is recognized that these types of AF will overlap in clinical practice, and that their impact for management needs to be evaluated systematically.
Patients with AF have significantly poorer quality of life than healthy controls, experiencing a variety of symptoms including lethargy, palpitations, dyspnoea, chest tightness, sleeping difficulties, and psychosocial distress. The identification of such conditions, their prevention and treatment is an important leverage to prevent AF and its disease burden. Knowledge of these factors and their management is hence important for optimal management of AF patients.
Heart failure and AF coincide in many patients. Prevention of adverse outcomes and maintenance of a good quality of life are the aims of management in all patients with AF and concomitant heart failure, regardless of LVEF. Of note, the only therapy with proven prognostic value in these patients is anticoagulation, and appropriate OAC should be prescribed in all patients at risk of stroke see Chapter 9. Rate control of AF is discussed in detail in Chapter In brief, only beta-blockers and digoxin are suitable in HFrEF because of the negative inotropic potential of verapamil and diltiazem.
Beta-blockers are usually the first-line option in patients with clinically stable HFrEF, although a meta-analysis using individual patient data from randomized controlled trials RCTs found no reduction in mortality from beta-blockers vs. In a meta-analysis of observational studies, digoxin had a neutral effect on mortality in patients with AF and concomitant heart failure adjusted observational studies HR 0. Patients with AF and HFrEF who present with severe symptoms may require rhythm control therapy in addition to rate control therapy.
For patients who develop HFrEF as a result of rapid AF tachycardiomyopathy , a rhythm control strategy is preferred, based on several relatively small patient cohorts and trials reporting improved LV function after restoration of sinus rhythm.
Initial management of patients presenting acutely with atrial fibrillation and heart failure. Adapted from Kotecha and Piccini. The diagnosis of heart failure with preserved ejection fraction HFpEF in patients with AF is problematic because of the difficulty in separating symptoms that are due to HF from those due to AF. Although diagnostic differentiation can be achieved by cardioversion and clinical reassessment but should be reserved for symptomatic improvement as a specific therapy that improves prognosis in HFpEF is currently lacking.
Echocardiography can support the detection of HFpEF in patients with symptomatic AF by providing evidence of relevant structural heart disease [e.
Further study of this group is required before particular treatment strategies in AF patients with HFmrEF can be recommended. Hypertension is a stroke risk factor in AF; uncontrolled high blood pressure enhances the risk of stroke and bleeding events and may lead to recurrent AF. Therefore, good blood pressure control should form an integral part of the management of AF patients.