Transcription
European Heart Journal (2020) 00, 1 125doi:10.1093/eurheartj/ehaa612ESC GUIDELINES2020 ESC Guidelines for the diagnosis andmanagement of atrial fibrillation developed incollaboration with the European Association ofCardio-Thoracic Surgery (EACTS)The Task Force for the diagnosis and management of atrialfibrillation of the European Society of Cardiology (ESC)Developed with the special contribution of the European HeartRhythm Association (EHRA) of the ESCAuthors/Task Force Members: Gerhard Hindricks* (Chairperson) (Germany),Tatjana Potpara* (Chairperson) (Serbia), Nikolaos Dagres (Germany), Elena Arbelo(Spain), Jeroen J. Bax (Netherlands), Carina Blomström-Lundqvist (Sweden),Giuseppe Boriani (Italy), Manuel Castella1 (Spain), Gheorghe-Andrei Dan(Romania), Polychronis E. Dilaveris (Greece), Laurent Fauchier (France),Gerasimos Filippatos (Greece), Jonathan M. Kalman (Australia), Mark La Meir1* Corresponding authors: The two chairpersons contributed equally to the document.Gerhard Hindricks, University Clinic of Cardiology, Heart Center Leipzig, Department of Cardiology and Electrophysiology, Leipzig Heart Institute, Strümpellstr. 39, 04289Leipzig, Germany. Tel: þ49 34 1865 1410, Fax: þ49 34 1865 1460, Email: gerhard.hindricks@helios-gesundheit.deTatjana Potpara, School of Medicine, Belgrade University, dr Subotica 8, 11000 Belgrade, Serbia, and Cardiology Clinic, Clinical Centre of Serbia, Visegradska 26, 11000 Belgrade,Serbia. Tel: þ38 11 1361 6319, Email: tatjana.potpara@med.bg.ac.rsESC Committee for Practice Guidelines (CPG) and National Cardiac Societies document reviewers, and Author/Task Force Member affiliations: listed inthe Appendix.1Representing the European Association of Cardio-Thoracic Surgery (EACTS)ESC entities having participated in the development of this document:Associations: Association for Acute CardioVascular Care (ACVC), Association of Cardiovascular Nursing & Allied Professions (ACNAP), European Association ofCardiovascular Imaging (EACVI), European Association of Preventive Cardiology (EAPC), European Association of Percutaneous Cardiovascular Interventions (EAPCI), EuropeanHeart Rhythm Association (EHRA), Heart Failure Association (HFA).Councils: Council on Stroke, Council on Valvular Heart Disease.Working Groups: Cardiac Cellular Electrophysiology, Cardiovascular Pharmacotherapy, Cardiovascular Surgery, e-Cardiology, Thrombosis.The content of these European Society of Cardiology (ESC) Guidelines has been published for personal and educational use only. No commercial use is authorized. No part ofthe ESC Guidelines may be translated or reproduced in any form without written permission from the ESC. Permission can be obtained upon submission of a written request toOxford University Press, the publisher of the European Heart Journal and the party authorized to handle such permissions on behalf of the ESC (journals.permissions@oup.com).Disclaimer The ESC Guidelines represent the views of the ESC and were produced after careful consideration of the scientific and medical knowledge and the evidence available at the time of their publication. The ESC is not responsible in the event of any contradiction, discrepancy and/or ambiguity between the ESC Guidelines and any other official recommendations or guidelines issued by the relevant public health authorities, in particular in relation to good use of healthcare or therapeutic strategies. Healthprofessionals are encouraged to take the ESC Guidelines fully into account when exercising their clinical judgment, as well as in the determination and the implementation of preventive, diagnostic or therapeutic medical strategies; however, the ESC Guidelines do not override, in any way whatsoever, the individual responsibility of health professionals tomake appropriate and accurate decisions in consideration of each patient’s health condition and in consultation with that patient and, where appropriate and/or necessary, thepatient’s caregiver. Nor do the ESC Guidelines exempt health professionals from taking into full and careful consideration the relevant official updated recommendations orguidelines issued by the competent public health authorities, in order to manage each patient’s case in light of the scientifically accepted data pursuant to their respective ethicaland professional obligations. It is also the health professional’s responsibility to verify the applicable rules and regulations relating to drugs and medical devices at the time ofprescription.C The European Society of Cardiology 2020. All rights reserved. For permissions please email: journals.permissions@oup.com.V
2ESC Guidelines(Belgium), Deirdre A. Lane (United Kingdom), Jean-Pierre Lebeau (France),Maddalena Lettino (Italy), Gregory Y. H. Lip (United Kingdom), Fausto J. Pinto(Portugal), G. Neil Thomas (United Kingdom), Marco Valgimigli (Switzerland),Isabelle C. Van Gelder (Netherlands), Bart P. Van Putte1 (Netherlands),Caroline L. Watkins (United Kingdom)Document Reviewers: Paulus Kirchhof (CPG Review Coordinator) (United Kingdom/Germany), MichaelKühne (CPG Review Coordinator) (Switzerland), Victor Aboyans (France), Anders Ahlsson1 (Sweden),Pawel Balsam (Poland), Johann Bauersachs (Germany), Stefano Benussi1 (Italy), Axel Brandes (Denmark),Frieder Braunschweig (Sweden), A. John Camm (United Kingdom), Davide Capodanno (Italy), BarbaraCasadei (United Kingdom), David Conen (Canada), Harry J. G. M. Crijns (Netherlands), Victoria Delgado(Netherlands), Dobromir Dobrev (Germany), Heinz Drexel (Austria), Lars Eckardt (Germany), DonnaFitzsimons (United Kingdom), Thierry Folliguet (France), Chris P. Gale (United Kingdom), Bulent Gorenek(Turkey), Karl Georg Haeusler (Germany), Hein Heidbuchel (Belgium), Bernard Iung (France), Hugo A.Katus (Germany), Dipak Kotecha (United Kingdom), Ulf Landmesser (Germany), Christophe Leclercq(France), Basil S. Lewis (Israel), Julia Mascherbauer (Austria), Jose Luis Merino (Spain), Béla Merkely(Hungary), Llu ıs Mont (Spain), Christian Mueller (Switzerland), Klaudia V. Nagy (Hungary), Jonas Oldgren (Croatia), Roberto F. E. Pedretti (Italy), Steffen E. Petersen (United Kingdom),(Sweden), Nikola PavlovicJonathan P. Piccini (United States of America), Bogdan A. Popescu (Romania), Helmut Pürerfellner(Austria), Dimitrios J. Richter (Greece), Marco Roffi (Switzerland), Andrea Rubboli (Italy), Daniel Scherr(Austria), Renate B. Schnabel (Germany), Iain A. Simpson (United Kingdom), Evgeny Shlyakhto (Russia),Moritz F. Sinner (Germany), Jan Steffel (Switzerland), Miguel Sousa-Uva (Portugal), Piotr Suwalski1(Poland), Martin Svetlosak (Slovakia), Rhian M. Touyz (United Kingdom)The disclosure forms of all experts involved in the development of these guidelines are available on theESC website www.escardio.org/guidelinesFor the Supplementary Data which include background information and detailed discussion of the datathat have provided the basis for the Guidelines see European Heart Journal online.KeywordsGuidelines atrial fibrillation anticoagulation vitamin K antagonists non-vitamin K antagonist oral anticoagulants left atrial appendage occlusion rate control rhythm control cardioversion antiarrhythmicdrugs catheter ablation pulmonary vein isolation left atrial ablation AF surgery upstream therapy ABC pathway screening stroke recommendationsTable of contents1 Preamble . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82.1 What is new in the 2020 Guidelines? . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93 Definition and diagnosis of atrial fibrillation . . . . . . . . . . . . . . . . . . . . . . . . 133.1 Definition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133.2 Diagnostic criteria for atrial fibrillation . . . . . . . . . . . . . . . . . . . . . . . . 143.3 Diagnosis of atrial high-rate episodes/subclinical atrialfibrillation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144 Epidemiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144.1 Prediction of incident atrial fibrillation . . . . . . . . . . . . . . . . . . . . . . . . . 164.2 Pathophysiology of atrial fibrillation . . . . . . . . . . . . . . . . . . . . . . . . . . . 165 Clinical features of atrial fibrillation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166 Atrial fibrillation subtypes, burden, and progression . . . . . . . . . . . . . . . . 186.1 Classification of atrial fibrillation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18.6.2 Definition and assessment of atrial fibrillation burden . . . . . . . . . .6.3 Atrial fibrillation progression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6.4 Atrial cardiomyopathy: definition, classification, clinicalimplications, and diagnostic assessment . . . . . . . . . . . . . . . . . . . . . . . . . . .7 Screening for atrial fibrillation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7.1 Screening tools . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7.2 Screening types and strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7.3 Benefits from and risks of screening for atrial fibrillation . . . . . . . .7.4 Cost-effectiveness of screening for atrial fibrillation . . . . . . . . . . . .7.5 Screening in high-risk populations . . . . . . . . . . . . . . . . . . . . . . . . . . . .7.5.1 Elderly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8 Diagnostic assessment in atrial fibrillation . . . . . . . . . . . . . . . . . . . . . . . . .8.1 Symptoms and quality of life . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8.2 Substrate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9 Integrated management of patients with atrial fibrillation . . . . . . . . . . .1920202020222222232323232326
3ESC Guidelines9.1 Definitions and components of integrated managementof atrial fibrillation patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9.2 Multidisciplinary atrial fibrillation teams . . . . . . . . . . . . . . . . . . . . . . .9.2.1 Role of healthcare systems and budget constraints . . . . . . . .9.3 Patient involvement and shared decision making . . . . . . . . . . . . . . .9.3.1 Patient values and preferences . . . . . . . . . . . . . . . . . . . . . . . . . . .9.3.2 Patient education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9.4 Healthcare professional education . . . . . . . . . . . . . . . . . . . . . . . . . . . .9.5 Adherence to treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9.6 Technology tools supporting atrial fibrillation management . . . .9.7 Advantages of integrated management of atrialfibrillation patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9.8 Measures (or approaches) for implementation ofintegrated management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9.9 Treatment burden . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9.10 Patient-reported outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10 Patient management: the integrated ABC pathway . . . . . . . . . . . . . . .10.1 ‘A’ Anticoagulation/Avoid stroke . . . . . . . . . . . . . . . . . . . . . . . . .10.1.1 Stroke risk assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10.1.2 Bleeding risk assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10.1.3 Absolute contraindications to oral anticoagulants . . . . . . . .10.1.4 Stroke prevention therapies . . . . . . . . . . . . . . . . . . . . . . . . . . . .10.1.4.1 Vitamin K antagonists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10.1.4.2 Non-vitamin K antagonist oral anticoagulants . . . . . . . .10.1.4.3 Other antithrombotic drugs . . . . . . . . . . . . . . . . . . . . . . . .10.1.4.4 Combination therapy with oral anticoagulant andantiplatelet drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10.1.4.5 Left atrial appendage occlusion and exclusion . . . . . . . .10.1.4.5.1 Left atrial appendage occlusion devices . . . . . . . . . .10.1.4.5.2 Surgical left atrial appendageocclusion or exclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10.1.4.6 Long-term oral anticoagulation per atrialfibrillation burden . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10.1.4.7 Long-term oral anticoagulation per symptomcontrol strategy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10.1.5 Management of anticoagulation-related bleeding risk . . . . .10.1.5.1 Strategies to minimize the risk of bleeding . . . . . . . . . . .10.1.5.2 High-risk groups . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10.1.5 Decision-making to avoid stroke . . . . . . . . . . . . . . . . . . . . . . . .10.2 ‘B’ Better symptom control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10.2.1 Rate control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10.2.1.1 Target/optimal ventricular rate range . . . . . . . . . . . . . . .10.2.1.2 Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10.2.1.3 Acute rate control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10.2.1.4 Atrioventricular node ablation and pacing . . . . . . . . . . .10.2.2 Rhythm control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10.2.2.1 Indications for rhythm control . . . . . . . . . . . . . . . . . . . . . .10.2.2.2 Cardioversion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10.2.2.2.1 Immediate cardioversion/elective cardioversion . . .10.2.2.2.2 Electrical cardioversion . . . . . . . . . . . . . . . . . . . . . . . .10.2.2.2.3 Pharmacological cardioversion(including ‘pill in the pocket’) . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10.2.2.2.4 Follow-up after cardioversion . . . . . . . . . . . . . . . . . .10.2.2.3 Atrial fibrillation catheter ablation . . . . . . . . . . . . . . . . . . .10.2.2.3.1 Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10.2.2.3.2 Techniques and technologies . . . . . . . . . . . . . . . . . . .10.2.2.3.3 Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10.2.2.3.4 AF catheter ablation outcome and impact ofmodifiable risk factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10.2.2.3.5 Follow-up after atrial fibrillation ablation . . . . . . . .10.2.2.3.7 Risk assessment for recurrence of AF postcatheter ablation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10.2.2.4 Surgery for atrial fibrillation . . . . . . . . . . . . . . . . . . . . . . . . .10.2.2.4.1 Concomitant surgery for atrial fibrillation:indications, outcome, complications . . . . . . . . . . . . . . . . . . . . . .10.2.2.4.2 Stand-alone surgery for atrial fibrillation:indications, outcome, complications . . . . . . . . . . . . . . . . . . . . . .10.2.2.5 Hybrid surgical/catheter ablation procedures . . . . . . . .10.2.2.6 Peri-procedural stroke risk management inpatients undergoing rhythm control interventions . . . . . . . . . . .10.2.2.6.1 Management of stroke risk and oral anticoagulanttherapy in atrial fibrillation patients undergoingcardioversion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10.2.2.6.2 Management of stroke risk and oralanticoagulant therapy in atrial fibrillation patientsundergoing atrial fibrillation catheter ablation . . . . . . . . . . . . .10.2.2.6.3 Postoperative anticoagulation after surgeryfor atrial fibrillation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10.2.2.7 Long-term antiarrhythmic drug therapy forrhythm control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10.2.2.7.1 Antiarrhythmic drugs . . . . . . . . . . . . . . . . . . . . . . . . . .10.3 ‘C Cardiovascular risk factors and concomitantdiseases: detection and management . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10.3.1 Lifestyle interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10.3.1.1 Obesity and weight loss . . . . . . . . . . . . . . . . . . . . . . . . . . . .10.3.1.2 Alcohol and caffeine use . . . . . . . . . . . . . . . . . . . . . . . . . . . .10.3.1.3 Physical activity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10.3.2 Specific cardiovascular risk factors/comorbidities . . . . . . . .10.3.2.1 Hypertension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10.3.2.2 Heart failure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10.3.2.3 Coronary artery disease . . . . . . . . . . . . . . . . . . . . . . . . . . . .10.3.2.4 Diabetes mellitus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10.3.2.5 Sleep apnoea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11 The ABC pathway in specific clinical settings/conditions/patient populations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11.1 Atrial fibrillation with haemodynamic instability . . . . . . . . . . . . . .11.2 First-diagnosed (new-onset) atrial fibrillation . . . . . . . . . . . . . . . . .11.3 Acute coronary syndromes, percutaneous coronaryintervention, and chronic coronary syndromes in patients withatrial fibrillation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11.4 Acute stroke or intracranial haemorrhage in patients withatrial fibrillation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11.4.1 Patients with atrial fibrillation and acute ischaemicstroke or transient ischaemic attack . . . . . . . . . . . . . . . . . . . . . . . . . . .11.4.2 Cryptogenic stroke/embolic stroke withundetermined source . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11.4.3 Post-stroke patients without known atrial fibrillation . . . . .11.4.4 Management of patients with atrial fibrillationpostintracranial haemorrhage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11.5 Active bleeding on anticoagulant therapy: managementand reversal drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11.6 Atrial fibrillation and heart failure . . . . . . . . . . . . . . . . . . . . . . . . . . . .11.7 Atrial fibrillation and valvular heart disease . . . . . . . . . . . . . . . . . . .11.8 Atrial fibrillation and chronic kidney disease . . . . . . . . . . . . . . . . . 0606061646464656567686869
411.9 Atrial fibrillation and peripheral artery disease . . . . . . . . . . . . . . . .11.10 Atrial fibrillation and endocrine disorders . . . . . . . . . . . . . . . . . . .11.11 Atrial fibrillation and gastrointestinal disorders . . . . . . . . . . . . . .11.12 Atrial fibrillation and haematological disorders . . . . . . . . . . . . . .11.13 The elderly and frail with atrial fibrillation . . . . . . . . . . . . . . . . . . .11.14 Patients with cognitive impairment/dementia . . . . . . . . . . . . . . .11.15 Atrial fibrillation and congenital heart disease . . . . . . . . . . . . . . .11.16 Atrial fibrillation in inherited cardiomyopathies andprimary arrhythmia syndromes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11.17 Atrial fibrillation during pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . .11.18 Atrial fibrillation in professional athletes . . . . . . . . . . . . . . . . . . . .11.19 Postoperative atrial fibrillation . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11.19.1 Prevention of postoperative AF . . . . . . . . . . . . . . . . . . . . . . . .11.19.2 Prevention of thrombo-embolic events . . . . . . . . . . . . . . . .12 Prevention of atrial fibrillation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12.1 Primary prevention of atrial fibrillation . . . . . . . . . . . . . . . . . . . . . . .12.2 Secondary prevention of atrial fibrillation . . . . . . . . . . . . . . . . . . . .13 Sex-related differences in atrial fibrillation . . . . . . . . . . . . . . . . . . . . . . . .14 Implementation of the atrial fibrillation guidelines . . . . . . . . . . . . . . . . .15 Quality measures and clinical performance indicatorsin the management of atrial fibrillation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16 Epidemiology, clinical implications, and management of atrialhigh-rate episodes/subclinical atrial fibrillation . . . . . . . . . . . . . . . . . . . . . . .17 Atrial fibrillation and other atrial tachyarrhythmias (atrial flutterand atrial tachycardias) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18 Key messages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19 Gaps in evidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20 ‘What to do’ and ‘what not to do’ messages from theGuidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21 Supplementary data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22 Appendix . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .ESC 78787981858586List of recommendationsNew recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9Changes in the recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11Recommendations for diagnosis of AF . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14Recommendations for structured characterization of AF . . . . . . . . . . . . 19Recommendations for screening to detect AF . . . . . . . . . . . . . . . . . . . . . . . 23Recommendations for diagnostic evaluation of patients with AF . . . . . 25Recommendations about integrated AF management . . . . . . . . . . . . . . . 29Recommendations for the prevention of thrombo-embolicevents in AF . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36Recommendations for ventricular rate control in patients with AF . . . 40Recommendations for rhythm control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42Recommendations for cardioversion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45Recommendations for rhythm control/catheter ablation of AF . . . . . . . 49Recommendations for surgical ablation of AF . . . . . . . . . . . . . . . . . . . . . . . 50Recommendations for stroke risk management peri-cardioversion . . . 51Recommendations for stroke risk management peri-catheter ablation . . . . 52Recommendations for postoperative anticoagulation afterAF surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52Recommendations for long-term antiarrhythmic drugs . . . . . . . . . . . . . . 58Recommendations for lifestyle interventions and management ofrisk factors and concomitant diseases in patients with AF . . . . . . . . . . . . 60. Recommendations for management of AF with haemodynamic. instability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60. Recommendations for patients with AF and an ACS, PCI, or CCS . . . . 63. Recommendations for the search for AF in patients with. cryptogenic stroke . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65. Recommendations for secondary stroke prevention in AF. patients after acute ischaemic stroke . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65. Recommendations for stroke prevention in AF patients after intracranial. haemorrhage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65. Recommendations for the management of active bleeding on OAC . . . . . 68. Recommendations for patients with valvular heart disease and AF . . . . 68. Recommendations for the management of AF in patients with. congenital heart disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71. Recommendations for the management of AF during pregnancy . . . . . 72. Recommendations for sports activity in patients with AF . . . . . . . . . . . . 72. Recommendations for postoperative AF . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74. Recommendations pertaining to sex-related differences in AF . . . . . . . 75. Recommendations for quality measures in patients with AF . . . . . . . . . . 75. Recommendations for management of patients with AHRE . . . . . . . . . . 78. List of tables. Table 1 Classes of recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7. Table 2 Levels of evidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7. Table 3 Definition of atrial fibrillation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13. Table 4 Classification of AF . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18. Table 5 Sensitivity and specificity of various AF screening tools. considering the 12-lead ECG as the gold standard . . . . . . . . . . . . . . . . . . . 22. Table 6 EHRA symptom scale . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24. Table 7 Stroke risk factors in patients with AF . . . . . . . . . . . . . . . . . . . . . . . 30. Table 8 CHA2DS2-VASc score . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31. Table 9 Risk factors for bleeding with OAC and antiplatelet. therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31. Table 10 Clinical risk factors in the HAS-BLED score . . . . . . . . . . . . . . . . 32. Table 11 Dose selection criteria for NOACs . . . . . . . . . . . . . . . . . . . . . . . . 33. Table 12 Antithrombotic therapy after left atrial appendage. occlusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34. Table 13 Drugs for rate control in AF . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39. Table 14 Antiarrhythmic drugs used for restoration of sinus rhythm . . . 44. Table 15 Goals of follow-up after cardioversion of AF . . . . . . . . . . . . . . . 45. Table 16 Procedure-related complications in catheter ablation and. thoracoscopic ablation of AF . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47. Table 17 Key issues in follow-up after AF catheter ablation . . . . . . . . . . 48. Table 18 Principles of antiarrhythmic drug therapy . . . . . . . . . . . . . . . . . . 53. Table 19 Rules to initiate antiarrhythmic drugs for long-term. rhythm control in AF . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53. Table 20 AADs used for long-term maintenance of sinus. rhythm in AF patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54. Table 21 Non-antiarrhythmic drugs with antiarrhythmic. properties (upstream therapy) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57. Table 22 Summary of quality indicators for the diagnosis. and management of AF . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76. List of figures. Figure 1 Diagnosis of AHRE/subclinical AF . . . . . . . . . . . . . . . . . . . . . . . . . . 14
5ESC GuidelinesFigure 2 Epidemiology of AF: prevalence; and lifetime risk andprojected rise in the incidence and prevalence . . . . . . . . . . . . . . . . . . . . . . 15Figure 3 Summary of risk factors for incident AF . . . . . . . . . . . . . . . . . . . . . 16Figure 4 Clinical presentation of AF and AF-related outcomes . . . . . . . 17Figure 5 4S-AF scheme as an example of structuredcharacterization of
Associations: Association for Acute CardioVascular Care (ACVC), Association of Cardiovascular Nursing & Allied Professions (ACNAP), European Association of Cardiovascular Imaging (EACVI), European Association of Preventive Cardiology (EAPC), European Association of Percutaneous Cardiovascular Interventions (EAPCI), European
