ATRIAL FIBRILLATION

ESC GUIDELINES
PGI Iris Joyce Florentino
PGI Justice Norhailyn Pangarungan
 Atrial Fibrillation
- disorganized, rapid, and irregular atrial activation with loss of atrial contraction
and with an irregular ventricular rate that is determined by AV nodal
conduction

Harrison’s Principle of Internal Medicine 21st edition

Atrial Fibrillation
- supraventricular tachyarrhythmia
with uncoordinated electrical
activation and consequently
ineffective atrial contraction
- Electrocardiographic characteristics:
- Irregularly irregular R-R intervals
- Absence of distinct repeating P waves
- Irregular atrial activations
- Diagnosis: Rhythm documentation with an
electrocardiogram tracing showing AF or an episode
of atleast 30 sec
Clinical AF Atrial high-rate episode AF,
Subclinical AF
- symptomatic or asymptomatic AF that is - individuals without symptoms attributable
documented by surface ECG to AF, in whom clinical AF is not previously
detected
- Diagnosis: at least 30 seconds or entire
12-lead ECG AHRE - events fulfilling programmed or specified
criteria, detected by cardiac implantable
electronic devices, with an atrial lead allowing
automated continuous monitoring of atrial rhythm
and tracings storage
Subclinical AF - includes AHRE confirmed to be
AF, AFL or an AT, or AF episodes detected by
insertable cardiac monitor or wearable monitor
and confirmed by visually reviewed intracardiac
electrograms or ECG-recorded rhythm.
Epidemiology
Risk factors
Pathophysiology
AHRE/ /
Subclinical AF
Clinical
Features
Classifications of AF

AF pattern Definition

First diagnosed AF not diagnosed before, irrespective of duration or presence/severity of

AF-related symptoms

Paroxysmal AF terminating spontaneously or with intervention within 7 days of onset

Persistent AF that is continuously sustained beyond 7 days, including episodes

terminated by cardioversion

Long-standing persistent Continuous AF >12 months duration when decided to adopt a rhythm
control strategy

Permanent AF accepted by the patient and physician and no further attempts to

restore/maintain sinus rhythm will be taken.
Represents a therapeutic attitude of the patient and physician.
Atrial fibrillation burden
- overall time spent in AHRE/subclinical AF during specified monitoring.

Clinical AF burden - routinely determined by AF temporal pattern and intermittent

ECG monitoring, neither corresponding well to the long-term ECG monitoring.

- may influence the response to rhythm control therapy.

- >6 h AF/week —> increased mortality
Atrial cardiomyopathy
- clinical classification are based on:
- Structure
- Morphology
- Electrical function
- Mechanical function
- Diagnosis
Sensitivity and Specificity of various AF screening considering the 12L ECG
as the gold standard

Sensitivity Specificity

Pulse taking 87-97% 70-81%

Automated BP monitors 93-100% 86-92%

Single lead ECG 94-98% 76-95%

Smartphone apps 91.5-98.5% 91.4-100%

Watches 97-99% 83-94%

- The risk of AF and stroke
increase with age, justifying AF
screening in the elderly.
- Opportunistic AF screening
seems to be cost-effective in
>65 years old, and among
75-76-year-old individuals
undergoing a 2 week
intermittent ECG screening.
EHRA Symptom Scale
Score Symptoms Description

1 None AF does not cause any symptoms

2a Mild Normal daily activity not affected by symptoms related to AF

2b Moderate Normal daily activity not affected by symptoms related to AF, but
patient are troubled by symptoms

3 Severe Normal daily activity affected by symptoms related to AF

4 Disabling Normal daily activity discontinued

Integrated Management with Atrial Fibrillation
- requires a coordinated and agreed patient-individualized care pathway to deliver optimized treatment
by an interdisciplinary team.
Integrated ABC Pathway
- A: anticoagulation/avoid stroke
- B: better symptom management
- C: cardiovascular and comorbidity optimization
”A” Anticoagulation / Avoid Stroke
- AF in the absence of severe mitral stenosis or prosthetic heart valves
Stroke Prevention Therapies
Vitamin K antagonists (VKA)

- reduces stroke risk by 64% and mortality by 26%.

- The only treatment with established safety in AF patients with rheumatic mitral
valve disease and/or an artificial heart valve.
Non Vitamin K antagonists and anticoagulants
“B” Better Symptom Control
Rhythm Control Strategy
- attempts to restore and
maintain sinus rhythm
- May engage a
combination of treatment
approaches, along with
an adequate rate control,
anticoagulation therapy
and comprehensive
cardiovascular
prophylactic therapy
Joyce
“C” Cardiovascular Risk Factors and Concomitant Diseases:
Detection and Management
18 Key Messages
18 Key Messages
1. The diagnosis of AF needs to be confirmed by a conventional 12- lead ECG tracing or rhythm strip
showing AF for >_30 s.

2. Structured characterization of AF, including stroke risk, symptom severity, severity of AF burden, and AF
substrate, helps improve personalized treatment of AF patients.

3. Novel tools and technologies for screening and detection of AF such as (micro-)implants and wearables
substantially add to the diagnostic opportunities in patients at risk for AF. However, appropriate
management pathways based on such tools are still incompletely defined.

4. Integrated holistic management of AF patients is essential to improving their outcomes.

5. Patient values need to be considered in treatment decision making and incorporated into the AF
management pathways; the structured assessment of PRO measures is an important element to
document and measure treatment success
18 Key Messages
6. The ABC pathway streamlines integrated care of AF patients across healthcare levels and among different
specialties.

7. Structured, clinical, risk-score-based assessment of individual thromboembolic risk, using the

CHA2DS2-VASc score, should be performed as the first step in optimal thrombo-embolic risk management in
AF patients.

8. Patients with AF and risk factors for stroke need to be treated with OAC for stroke prevention. In
NOAC-eligible patients, NOACs are preferred over VKAs.

9. A formal structured risk-score-based bleeding risk assessment using, for example, the HAS-BLED score,
helps to identify non-modifiable and address modifiable bleeding risk factors in AF patients.

10. An elevated bleeding risk should not automatically lead to withholding OAC in patients with AF and stroke
risk. Instead, modifiable bleeding risk factors should be addressed, and high-risk patients scheduled for a more
frequent clinical review and follow-up.
18 Key Messages
11. Rate control is an integral part of AF management and is often sufficient to improve AF-related symptoms.

12. The primary indication for rhythm control using cardioversion, AADs, and/or catheter ablation is reduction in
AF-related symptoms and improvement of QoL.

13. The decision to initiate long-term AAD therapy needs to balance symptom burden, possible adverse drug
reactions, particularly drug-induced proarrhythmia or extracardiac side-effects, and patient preferences.

14. Catheter ablation is a well-established treatment for prevention of AF recurrences. When performed by
appropriately trained operators, catheter ablation is a safe and superior alternative to AADs for maintenance of
sinus rhythm and symptom improvement.

15. Major risk factors for AF recurrence should be assessed and considered in the decision making for
interventional therapy.
18 Key Messages
16. In patients with AF and normal LVEF, catheter ablation has not been shown to reduce total mortality or
stroke. In patients with AF and tachycardia-induced cardiomyopathy, catheter ablation reverses LV
dysfunction in most cases.

17. Weight loss, strict control of risk factors, and avoidance of triggers for AF are important strategies to
improve outcome of rhythm control.

18. Identification and management of risk factors and concomitant diseases is an integral part of the
treatment of AF patients.

19. In AF patients with ACS undergoing uncomplicated PCI, an early discontinuation of aspirin and switch to
dual antithrombotic therapy with OAC and a P2Y12 inhibitor should be considered.

20. Patients with AHRE should be regularly monitored for progression to clinical AF and changes in the
individual thromboembolic risk (i.e. change in CHA2DS2-VASc score). In patients with longer AHRE (especially
>24 h) and a high CHA2DS2-VASc score, it is reasonable to consider the use of OAC when a positive net
clinical benefit from OAC is anticipated in a shared, informed, treatment decision-making process.
References
Gerhard Hindricks, Tatjana Potpara, Nikolaos Dagres, Elena Arbelo, Jeroen J Bax, Carina Blomström-Lundqvist, Giuseppe
Boriani, Manuel Castella, Gheorghe-Andrei Dan, Polychronis E Dilaveris, Laurent Fauchier, Gerasimos Filippatos, Jonathan M
Kalman, Mark La Meir, Deirdre A Lane, Jean-Pierre Lebeau, Maddalena Lettino, Gregory Y H Lip, Fausto J Pinto, G Neil Thomas,
Marco Valgimigli, Isabelle C Van Gelder, Bart P Van Putte, Caroline L Watkins, ESC Scientific Document Group, 2020 ESC
Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for
Cardio-Thoracic Surgery (EACTS): The Task Force for the diagnosis and management of atrial fibrillation of the European
Society of Cardiology (ESC) Developed with the special contribution of the European Heart Rhythm Association (EHRA) of the
ESC, European Heart Journal, Volume 42, Issue 5, 1 February 2021, Pages 373–498, https://doi.org/10.1093/eurheartj/ehaa612
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