AF management - 2024 ESC Guidelines

The 2024 ESC Guidelines for AF management succinctly outlined some of the changes in AF management in the last few years. The CARE multidisciplinary approach to AF management is briefly outlined below.

CARE stands for

  • Comorbidity and risk factor management

  • Avoid stroke and thromboembolism

  • Reduce symptoms by rate and rhythm control

  • Evaluation and dynamic reassessment

(C) Comorbidity and risk factor management

  • Hypertension - antihypertensives

  • Diabetes - effective glycaemic control

  • Heart failure

    • Diuretics for congestion

    • HFrEF medical Rx

    • SGLT2 inhibitors

  • Overweight or obese - aim for 10% weight loss

  • Obstructive sleep apnoea

  • Exercise capacity - tailored exercise programme

  • Alcohol - reduce to <=3 drinks per week

(A) Avoid stroke and thromboembolism

  • Risk of thromboembolism

    • start oral anticoagulation

    • Temporal pattern of AF not relevant to anticoagulation decision making

    • Antiplatelet is not an alternative

  • Risk score - CHAD2D2VA

    • OAC if CHAD2D2VA = 2 (class I)

    • OAC if CHAD2D2VA = 1 (class IIa)

  • Choice of anticoagulant

    • DOAC unless mitral stenosis, or mechanical valve

  • Assess bleeding risk

    • manage all modifiable bleeding risk factors

    • do not use risk scores to withhold anticoagulation

  • Prevent bleeding

    • do not combine antiplatelet and OAC for stroke prevention

    • avoid antiplatelets beyond 12 months in OAC treated CCS/PVD

(R) Reduce symptoms by rate and rhythm control

  • pathways different for

    • first diagnosed AF

    • paroxysmal AF

    • persistent AF

    • permanent AF

  • options include

    • rate control drugs

    • cardioversion

    • antiarrhythmics

    • catheter ablation; surgical ablation

    • pace and ablate

(E) Evaluation and dynamic reassessment

  • re-evaluate when AF episodes or non-AF admissions

  • regular re-evaluation 6 months after presentation, then at least annually

AF ablation indication has been changing, but these patient groups benefit most

  • paroxysmal atrial fibriatllation

  • high symptom burden

  • refractory to antiarrhythmics

  • smaller left atrial dimensions

  • AF with LV impairment

  • younger patients

Contraindication

  • severe pulmonary disease

  • endstage renal disease

  • endstage lung disease

  • contraindication to oral anticoagulant

  • left expectancy <1y

  • cognitive impairment

Note that these patients are mostly excluded from trials, hence indicating some controversy around efficacy

  • asymptomatic permanent AF

  • long standing persistent AF

  • severe valvular heart disease

  • severely dilated left atrium

  • very severe LV systolic impairment

  • recent MI or severe coronary artery disease

  • prior LA ablation or cardiac surgery