Spotlight on the 2024 ESC/EACTS management of atrial fibrillation guidelines: 10 novel key aspects
Michiel RienstraStylianos TzeisKarina V BuntingValeria CasoHarry J.G.M. CrijnsTom De PotterPrashanthan SandersEmma SvennbergRubén Casado-ArroyoJeremy DwightLuigina GuastiThorsten HankeTiny JaarsmaMaddalena LettinoMaja‐Lisa LøchenR. Thomas LumbersBart MaesenInge MølgaardGiuseppe RosanoRenate B. SchnabelPiotr SuwalskiJuan TamargoOtilia ȚicaVassil TraykovDipak KotechaIsabelle C. Van Gelder
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Abstract:
Atrial fibrillation (AF) remains the most common cardiac arrhythmia worldwide and is associated with significant morbidity and mortality. The European Society of Cardiology (ESC)/European Association for Cardio-Thoracic Surgery (EACTS) have recently released the 2024 guidelines for the management of AF. This review highlights 10 novel aspects of the ESC/EACTS 2024 Guidelines. The AF-CARE framework is introduced, a structural approach that aims to improve patient care and outcomes, comprising of four pillars: [C] Comorbidity and risk factor management, [A] Avoid stroke and thromboembolism, [R] Reduce symptoms by rate and rhythm control, and [E] Evaluation and dynamic reassessment. Additionally, graphical patient pathways are provided to enhance clinical application. A significant shift is the new emphasis on comorbidity and risk factor control to reduce AF recurrence and progression. Individualized assessment of risk is suggested to guide the initiation of oral anticoagulation to prevent thromboembolism. New guidance is provided for anticoagulation in patients with trigger-induced and device-detected sub-clinical AF, ischaemic stroke despite anticoagulation, and the indications for percutaneous/surgical left atrial appendage exclusion. AF ablation is a first-line rhythm control option for suitable patients with paroxysmal AF, and in specific patients, rhythm control can improve prognosis. The AF duration threshold for early cardioversion was reduced from 48 to 24 h, and a wait-and-see approach for spontaneous conversion is advised to promote patient safety. Lastly, strong emphasis is given to optimize the implementation of AF guidelines in daily practice using a patient-centred, multidisciplinary and shared-care approach, with the simultaneous launch of a patient version of the guideline.Keywords:
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Atrial fibrillation and atrial flutter are the most common dysrhythmias seen in the emergency department. As the aging population continues to grow, atrial fibrillation and atrial flutter are expected to affect 6 million people by 2050. This will lead to an increase in emergency department visits for symptoms from the disease itself or its complications, such as heart failure or thromboembolic disease. This review examines the recent literature on the diagnosis and management of atrial fibrillation. Evidence-based recommendations are provided, including cost-effective strategies to evaluate new-onset arrhythmias and unstable patients with atrial fibrillation, rate control strategies, the use of medical and direct current cardioversion for new-onset atrial fibrillation/atrial flutter, whom and when to anticoagulate, and the use of the novel anticoagulation agents.
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Atrial fibrillation is an abnormal heart rhythm affecting the upper chambers of the heart in which uncoordinated electrical depolarizations lead to ineffective contractions. Approximately five million patients in the US have atrial fibrillation, and this number is expected to double to 10 million over the next 30 years.1 Advancing age is a major risk factor for the development of atrial fibrillation; new cases of atrial fibrillation are diagnosed in men over age 80 at the rate of 2% per year.2 Although several drugs are available for management of atrial fibrillation, the efficacy of these drugs may be limited in elderly patients. In this review, we provide an overview of management of atrial fibrillation, with special emphasis on pharmacologic therapy versus arteriovenous (AV) node ablation in symptomatic elderly patients.
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Objectives. We hypothesized that the time course of the recovery of atrial systolic function may be related to the duration of atrial fibrillation before cardioversion and sought to study noninvesively the recovery of left atrial mechanical function utilizing serial transthoracic Doppler studies. Background. Recovery of atrial mechanical function may be delayed for several weeks after successful cardioversion of atrial fibrillation to sinus rhythm. Methods. After successful cardioversion, 60 patients with atrial fibrillation of brief (≤2 week, 17 patients), moderate (>2 to 6 weeks, 22 patients) or prolonged (>6 weeks, 21 patients) duration were followed up with serial transmitral pulsed Doppler echocardiography immediately (60 patients) and at 24 h (45 patients), 1 week (41 patients), 1 month (31 patients) and >3 months (30 patients) after cardioversion. Results. Atrial mechanical function is greater immediately and at 24 h and 1 week after cardioversion in patients with "brief" compared with "prolonged" atrial fibrillation. In all groups, atrial mechanical function increases over time, ultimately achieving similar levels. Full recovery of atrial mechanical function, however, is achieved within 24 h in patients with brief atrial fibrillation, within 1 week in patients with moderate-duration atrial fibrillation and within 1 month in patients with prolonged atrial fibrillation. Conclusions. Recovery of left atrial mechanical function is related to the duration of atrial fibrillation before cardioversion. These findings have important implications for assessing the early hemodynamic benefit of successful cardioversion.
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This editorial introduces a series of review articles on different diagnostic modalities that can help to personalise the treatment of atrial fibrillation. The editorial outlines the current best evidence-based management of atrial fibrillation, and highlights the huge clinical need to improve outcomes in patients with atrial fibrillation further. It appears that understanding the causes of atrial fibrillation in individual patients would allow to design, test and validate better and personalised strategies for the treatment of this common threat to healthy ageing.
This issue of Heart inaugurates a series of review articles on atrial fibrillation. The reviews will explore different ways to apply existing diagnostic tests to personalise the management of patients with atrial fibrillation. Atrial fibrillation has received a lot of attention by researchers, clinicians, journals and the wider public in recent years, and there are good reasons to think and talk about this common arrhythmia: Assuming that the average reader of Heart is around 40 years old, every fourth of us will suffer from atrial fibrillation in his or her life.1 Those of us who will work in clinical medicine for another 20 years or 30 years will be faced with double or triple the amount of patients with atrial fibrillation that they see today.2 Furthermore, atrial fibrillation, while rarely acutely life-threatening, bears severe consequences for patients and societies: Atrial fibrillation causes …
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THE treatment of atrial fibrillation and the prevention of its complications are primarily pharmacologic problems. Treatment has two principal objectives. One is to use antiarrhythmic therapy to relieve symptoms; the other is to use prophylactic therapy to reduce the risk of stroke that accompanies atrial fibrillation. In planning the management of atrial fibrillation, it is useful to consider patients who are permanently in atrial fibrillation as having chronic atrial fibrillation and patients who have sinus rhythm punctuated by attacks of fibrillation as having paroxysmal atrial fibrillation. The two forms overlap, however, because many patients with chronic atrial fibrillation first present . . .
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Abstract Atrial fibrillation is the most common cardiac arrhythmia managed by emergency and acute general physicians. There is increasing evidence that selected patients with acute atrial fibrillation can be safely managed in the emergency department without the need for hospital admission. Meanwhile, there is significant variation in the current emergency management of acute atrial fibrillation. This review discusses evidence based emergency management of atrial fibrillation. The principles of emergency management of acute atrial fibrillation and the subset of patients who may not need hospital admission are reviewed. Finally, the need for evidence based guidelines before emergency department based clinical pathways for the management of acute atrial fibrillation becomes routine clinical practice is highlighted.
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Atrial fibrillation is the most common sustained disturbance of cardiac rhythm. It is a global epidemic and an evolving problem in cardiovascular medicine. Atrial fibrillation is an independent risk factor for embolic stroke, increasing the risk of stroke five-fold. Despite good evidence for the reduction of stroke risk with anticoagulant therapy, there is significant under treatment. Anticoagulant prescribing is frequently discordant with all current guidelines and decision aids with both over and under use of oral anticoagulants. It is important that GPs have up-to-date knowledge about atrial fibrillation in terms of both its diagnosis and management, and that patients have an understanding of anticoagulant medication. This article aims to update knowledge about atrial fibrillation, the use and benefits of anticoagulation with insights on some barriers to anticoagulation in primary care. This article does not cover management of atrial fibrillation with control of cardiac rate or rhythm to maintain cardiac function.
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