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Atrial fibrillation

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Updated 2024 ESC guidelines for the diagnosis and management of atrial fibrillation.

Background

Overview

Definition
AF is a cardiac arrhythmia characterized by a diffuse and abnormal pattern of electrical activity in the atria of the heart. AF is classified as valvular or nonvalvular based on the presence or absence of valvular heart disease, specifically MS, or a prosthetic heart valve.
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Pathophysiology
The development of AF is related to structural and electrophysiological abnormalities resulting from comorbid conditions (including hypertension, diabetes mellitus, obesity, obstructive sleep apnea, myocardial infarction, HF), genetics, sex, and other factors.
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Epidemiology
The prevalence of AF in the US ranges is estimated at 700-775 cases per 100,000 persons.
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Disease course
In patients with AF, rapid and irregular atrial contractions lead to tachyarrhythmias, which lead to symptoms of palpitations, dyspnea, and an increased risk of HF; as well as stasis of blood in the LAA, which increases the risk of stroke and systemic embolism.
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Prognosis and risk of recurrence
AF is estimated to cause 15% of all strokes and is associated with a 5-fold increased risk of stroke and a 2-fold risk for all-cause mortality, respectively.
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Guidelines

Key sources

The following summarized guidelines for the evaluation and management of atrial fibrillation are prepared by our editorial team based on guidelines from the American Academy of Family Physicians (AAFP 2024,2017), the American Heart Association (AHA/HRS/ACC/ACCP 2024), the Canadian Cardiovascular Society (CCS/CAIC 2024), the European Society of Cardiology (ESC/EACTS 2024,2021), the Kidney Disease: Improving Global Outcomes Foundation (KDIGO 2024), the Society ...
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Screening and diagnosis

Indications for screening, general population
As per EACTS/ESC 2024 guidelines:
Obtain routine heart rhythm assessment during healthcare contact in all individuals aged ≥ 65 years for earlier detection of AF.
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Consider obtaining population-based screening for AF using a prolonged noninvasive ECG-based approach in individuals aged ≥ 75 years, or ≥ 65 years with additional CHA2DS2-VA risk factors to ensure earlier detection of AF.
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  • Indications for screening (stroke)

  • Indications for screening (previous atrial arrhythmias)

  • Indications for screening (cardiac implantable electronic devices)

  • Confirmatory testing

Classification and risk stratification

Stroke risk assessment
As per ACC/ACCP/AHA/HRS 2024 guidelines:
Assess the annual risk of thromboembolic events using a validated clinical risk score, such as the CHA2DS2-VASc score, in patients with AF.
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Take into consideration factors that might modify the risk of stroke to help inform the decision in patients with AF at intermediate annual risk of thromboembolic events (based on risk scores, such as equivalent to CHA2DS2-VASc score of 1 in males or 2 in females) remaining uncertain about the benefit of anticoagulation.
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  • Bleeding risk assessment

Diagnostic investigations

Evaluation of palpitations: as per AAFP 2024 guidelines, obtain a 12-lead ECG as part of the initial evaluation of patients with palpitations to screen for structural and ischemic heart disease, conduction disorders, and arrhythmias. Recognize that ambulatory ECG monitoring for 2 weeks has the highest diagnostic yield-to-cost ratio in the evaluation of palpitations of unknown etiology.
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  • Initial evaluation

  • Evaluation for hypertension

  • Evaluation for ischemia

  • Evaluation for sleep apnea

Medical management

General principles: as per ACC/ACCP/AHA/HRS 2024 guidelines, provide comprehensive care addressing guideline-directed lifestyle risk factor modification, AF symptoms, risk of stroke, and other associated medical conditions to reduce AF burden, progression, or consequences.
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  • Management of intercurrent conditions (general principles)

  • Management of intercurrent conditions (HF)

  • Management of intercurrent conditions (diabetes mellitus)

  • Management of intercurrent conditions (obstructive sleep apnea)

  • Management of secondary causes

  • Rate control (acute control, targets)

  • Rate control (acute control, choice of agents)

  • Rate control (long-term control, beta-blockers and CCBs)

  • Rate control (long-term control, digoxin)

  • Rate control (long-term control, amiodarone and dronedarone)

  • Rate control (long-term control, targets)

  • Rhythm control (general indications)

  • Rhythm control (pharmacological cardioversion, indications)

  • Rhythm control (pharmacological cardioversion, choice of agent)

  • Rhythm control (pharmacological cardioversion, pill-in-the-pocket)

  • Rhythm control (electrical cardioversion)

  • Rhythm control (maintenance therapy)

  • Anticoagulant therapy (general indications)

  • Anticoagulant therapy (DOACs)

  • Anticoagulant therapy (VKAs)

  • Anticoagulant therapy (peri-cardioversion)

  • Anticoagulant therapy (peri-catheter ablation)

  • Antiplatelet therapy

  • Management of bleeding (general principles)

  • Management of bleeding (direct thrombin inhibitors)

  • Management of bleeding (direct factor Xa inhibitors)

  • Management of bleeding (VKAs)

  • Management of bleeding (resumption of anticoagulation)

  • Management of hypertension (rate control)

  • Management of hypertension (anticoagulation)

  • Management of hypertension (antihypertensive therapy)

Nonpharmacologic interventions

Weight loss: as per ACC/ACCP/AHA/HRS 2024 guidelines, advise weight loss with an ideal target of at least 10% weight loss to reduce AF symptoms, burden, recurrence, and progression to persistent AF in patients with overweight or obesity (with BMI > 27 kg/m²).
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  • Physical activity

  • Smoking cessation

  • Alcohol restriction

  • Caffeine restriction

Therapeutic procedures

Catheter ablation, indications: as per ACC/ACCP/AHA/HRS 2024 guidelines, consider performing catheter ablation to improve symptoms in patients with symptomatic AF if antiarrhythmic drugs have been ineffective, contraindicated, not tolerated, or not preferred, and continued rhythm control is desired.
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  • Catheter ablation (technical considerations)

  • Catheter ablation (post-ablation antiarrhythmics)

  • Catheter ablation (post-ablation anticoagulation)

  • Atrioventricular nodal ablation (indications)

  • Atrioventricular nodal ablation (pacemaker placement)

Perioperative care

Pre-procedural anticoagulation interruption: as per ACC/ACCP/AHA/HRS 2024 guidelines, interrupt oral anticoagulation without bridging anticoagulation in patients with AF, excluding patients with recent stroke or TIA or a mechanical valve, receiving oral anticoagulation with either warfarin
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or a DOAC scheduled to undergo an invasive procedure or surgery.
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  • Pre-procedural anticoagulation bridging

  • Post-procedural resumption of anticoagulation

Surgical interventions

LAA closure, indications: as per ACC/ACCP/AHA/HRS 2024 guidelines, consider performing percutaneous LAA occlusion in patients with AF, a moderate-to-high risk of stroke (CHA2DS2-VASc score ≥ 2), and contraindications to long-term oral anticoagulation due to a nonreversible cause.
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  • LAA closure (perioperative imaging)

  • LAA closure (technical considerations)

  • LAA closure (management of complications)

  • LAA closure (postoperative anticoagulation)

  • Surgical ablation

Specific circumstances

Athletes, physical activity: as per CCS/CHRS 2020 guidelines, consider offering a period of decreased exercise intensity (detraining) as a possible management strategy in patients engaged in high-intensity, long-duration endurance activity, taking into account their values and preferences.
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  • Athletes (catheter ablation)

  • Young patients (evaluation)

  • Young patients (catheter ablation)

  • Elderly patients

  • Pregnant patients (rate control)

  • Pregnant patients (cardioversion)

  • Pregnant patients (maintenance therapy)

  • Pregnant patients (anticoagulation)

  • Patients with obesity

  • Critically ill patients

  • Patients with subclinical AF (evaluation)

  • Patients with subclinical AF (anticoagulation)

  • Patients with postoperative AF (prevention)

  • Patients with postoperative AF (rate and rhythm control)

  • Patients with postoperative AF (anticoagulation)

  • Patients with postoperative AF (monitoring)

  • Patients with atrial flutter (catheter ablation)

  • Patients with atrial flutter (anticoagulation)

  • Patients with WPW and pre-excitation syndromes (rate control)

  • Patients with WPW and pre-excitation syndromes (cardioversion)

  • Patients with WPW and pre-excitation syndromes (catheter ablation)

  • Patients with chronic liver disease

  • Patients with CKD

  • Patients with AIS

  • Patients with embolic stroke of unknown source

  • Patients with ICH

  • Patients with CAD

  • Patients with ACS

  • Patients with PAD

  • Patients with valvular heart disease

  • Patients with CHD (general principles of management)

  • Patients with CHD (anticoagulation)

  • Patients with CHD (catheter ablation)

  • Patients with CHD (surgery)

  • Patients with HCM

  • Patients with HF (evaluation)

  • Patients with HF (rate control)

  • Patients with HF (catheter ablation)

  • Patients with HF (atrioventricular nodal ablation and pacing)

  • Patients with pulmonary disease

  • Patients with hyperthyroidism

  • Patients with cancer

Patient education

General counseling: as per EACTS/ESC 2024 guidelines, provide education to patients, family members, caregivers, and healthcare professionals to optimize shared decision-making and facilitate open discussion of both the benefits and risks associated with each treatment option.
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Preventative measures

Primary prevention: as per ACC/ACCP/AHA/HRS 2024 guidelines, offer comprehensive guideline-directed lifestyle risk factor modification for AF, targeting obesity, physical inactivity, unhealthy alcohol consumption, smoking, diabetes, and hypertension in patients at increased risk of AF.
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Follow-up and surveillance

Clinical follow-up: as per CCS/CHRS 2020 guidelines, assess patient-reported AF-related symptoms and QoL with validated instruments as part of the longitudinal management of patients with AF.
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  • ECG monitoring

  • Assessment of treatment response

Quality improvement

Quality of care: as per EACTS/ESC 2024 guidelines, consider evaluating quality of care and identifying opportunities for improved treatment of AF by practitioners and institutions to improve patient experiences.
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