European Heart Journal (2025) 46, 996–998

https://doi.org/10.1093/eurheartj/ehae847

Global Spotlights

The ‘10 commandments’ for the 2024

European Society of Cardiology guidelines

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on atrial fibrillation
1,2 3 3,
Dipak Kotecha , Michiel Rienstra , and Isabelle C. Van Gelder *
1
Department of Cardiovascular Sciences, College of Medicine and Health, University of Birmingham, Birmingham, UK; 2NIHR Birmingham Biomedical Research Centre, University Hospitals
Birmingham NHS Foundation Trust, Birmingham, UK; and 3Department of Cardiology, University of Groningen, University Medical Center Groningen, P.O. Box 30.001, 9700 RB
Groningen, The Netherlands

The 2024 European Society of Cardiology guidelines for (5) Consider oral anticoagulation in device-detected subclinical AF
the management of atrial fibrillation (AF) were developed in collab­ for patients with high stroke risk and low bleeding risk, acknow­
oration with the European Association for Cardio-Thoracic ledging the high chance of progression to clinical AF (6%–9%
Surgery by a multidisciplinary team including patient representa­ per year), and also the bleeding risk accompanying
tives.1 These ‘10 commandments’ summarize the full guideline anticoagulation.4
(Figure 1). (6) For patients with AF undergoing cardiac surgery, left atrial ap­
pendage exclusion can prevent thromboembolism as an adjunct
to anticoagulation.5
(1) Treat all patients with AF according to the AF-CARE framework (7) Catheter ablation in suitable patients with paroxysmal AF can be
to enhance patient-centred care and reduce adverse outcomes, used as a first-line rhythm control option to alleviate symptoms,
including shared decision-making with patients within a multi- reduce AF recurrence, and delay progression of AF.6,7
disciplinary team for: (8) Rhythm control in selected patients with AF can improve progno­
[C] Comorbidity and risk factor management sis: within 12 months of an AF diagnosis and a high risk of
[A] Avoid stroke and thromboembolism thromboembolism8 and with heart failure and reduced ejection
[R] Reduce symptoms by rate and rhythm control fraction either due to tachycardia or in selected patients where
[E] Evaluation and dynamic reassessment rhythm control is expected to reduce heart failure hospitalization
(2) Provide anticoagulation to patients at risk of ischaemic stroke or and mortality.1
thromboembolism, preferably a direct oral anticoagulant and use (9) Cardioversion of AF requires appropriate anticoagulation or
locally validated risk scores or the simplified CHA2DS2-VA score transoesophageal echocardiography if AF duration is longer
(same thresholds for women and men).2 than 24 h; consider safety first and the scope to wait for spontan­
(3) Do not use bleeding risk scores to decide on starting or with­ eous cardioversion.
drawing anticoagulants; instead, address all modifiable bleeding (10) Regular re-evaluation is critical, with routine heart rhythm assess­
risk factors to improve safety. ment during healthcare contact for all individuals aged ≥65 years
(4) Consider long-term oral anticoagulation in trigger-induced AF to facilitate earlier detection of AF,1 and population-based non-
(for example sepsis), according to the perceived individual risk invasive ECG screening for those with risk factors for
of stroke or thromboembolism.3 thromboembolism.9

* Corresponding author. Tel: +31 50 3611327, Email: i.c.van.gelder@umcg.nl

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Figure 1 Central patient pathways for AF-CARE from the 2024 European Society of Cardiology/European Association for Cardio-Thoracic Surgery
guideline for the management of atrial fibrillation.1 See full guideline for rhythm control pathways. AF, atrial fibrillation; AF-CARE, atrial fibrillation—[C]
comorbidity and risk factor management, [A] avoid stroke and thromboembolism, [R] reduce symptoms by rate and rhythm control, [E] evaluation and
dynamic reassessment; CCS, chronic coronary syndrome; CHA2DS2-VA, congestive heart failure, hypertension, age ≥75 years (2 points), diabetes mel­
litus, prior stroke/transient ischaemic attack/arterial thromboembolism (2 points), vascular disease, age 65–74 years; DOAC, direct oral anticoagulant;
ECG, electrocardiogram; HFrEF, heart failure with reduced ejection fraction; INR, international normalized ratio of prothrombin time; OAC, oral anti­
coagulant; OSA, obstructive sleep apnoea; PVD, peripheral vascular disease; SGLT2, sodium-glucose cotransporter-2; VKA, vitamin K antagonist. aAs
part of a comprehensive management of cardiometabolic risk factors
998 CardioPulse

Declarations 4. Sanders P, Svennberg E, Diederichsen SZ, Crijns HJGM, Lambiase PD, Boriani G, et al.
Great debate: device-detected subclinical atrial fibrillation should be treated like clinical
atrial fibrillation. Eur Heart J 2024;45:2594–603. https://doi.org/10.1093/eurheartj/
Disclosure of Interest ehae365
All authors declare no disclosure of interest for this contribution. 5. Whitlock RP, Belley-Cote EP, Paparella D, Healey JS, Brady K, Sharma M, et al. Left atrial
appendage occlusion during cardiac surgery to prevent stroke. N Engl J Med 2021;384:
2081–91. https://doi.org/10.1056/NEJMoa2101897
6. Wazni OM, Dandamudi G, Sood N, Hoyt R, Tyler J, Durrani S, et al. Cryoballoon ablation
References as initial therapy for atrial fibrillation. N Engl J Med 2021;384:316–24. https://doi.org/10.
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2024 ESC guidelines for the management of atrial fibrillation developed in collaboration 7. Andrade JG, Wells GA, Deyell MW, Bennett M, Essebag V, Champagne J, et al.
with the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J 2024; Cryoablation or drug therapy for initial treatment of atrial fibrillation. N Engl J Med
45:3314–3414. https://doi.org/10.1093/eurheartj/ehae176 2021;384:305–15. https://doi.org/10.1056/NEJMoa2029980
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Gender and contemporary risk of adverse events in atrial fibrillation. Eur Heart J 2024; therapy in patients with atrial fibrillation. N Engl J Med 2020;383:1305–16. https://doi.org/
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