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2020 AFIB 2020 - For Web

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0% found this document useful (0 votes)

103 views166 pages

2020 AFIB 2020 - For Web

Uploaded by

Hussein Tf

We take content rights seriously. If you suspect this is your content, claim it here.

Available Formats

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2020 ESC Guidelines for the diagnosis

and management of atrial fibrillation

developed in collaboration with the
European Association for
Cardio-Thoracic Surgery (EACTS)
2020 ESC Guidelines for the diagnosis and
management of atrial fibrillation developed in
collaboration with the European Association
for Cardio-Thoracic Surgery (EACTS)
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 (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).

©ESC
1Representing the European Association for Cardio-Thoracic Surgery (EACTS)

www.escardio.org/guidelines 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation
(European Heart Journal 2020-doi/10.1093/eurheartj/ehaa612)
2
2020 ESC Guidelines for the diagnosis and
management of atrial fibrillation developed in
collaboration with the European Association
for 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 of Cardiovascular Imaging (EACVI), European Association of
Preventive Cardiology (EAPC), European Association of Percutaneous Cardiovascular Interventions (EAPCI),
European Heart 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.

Definition Wording to use

Class I Evidence and/or general agreement that a given
Is recommended
treatment or procedure is beneficial, useful,
or is indicated
effective.
Class II Conflicting evidence and/or a divergence of opinion about the
usefulness/efficacy of the given treatment or procedure.
Class IIa Weight of evidence/opinion is in favour
Should be considered
of usefulness/efficacy.
Class IIb Usefulness/efficacy is less well
May be considered
established by evidence/opinion.
Class III Evidence or general agreement that the given
treatment or procedure is not useful/effective, Is not recommended

©ESC
and in some cases may be harmful.

www.escardio.org/guidelines 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation
(European Heart Journal 2020-doi/10.1093/eurheartj/ehaa612)
ESC Levels of evidence

Level of Data derived from multiple randomized clinical trials or meta-analyses.

evidence A
Level of Data derived from a single randomized clinicaltrial or large non-
evidence B randomized studies.
Level of Consensus of opinion of the experts and/or small studies, retrospective
evidence C studies, registries.

Recommendations Class
Recommendations for diagnosis of AF
ECG documentation is required to establish the diagnosis of AF.
A standard 12-lead ECG recording or a single-lead ECG tracing of ≥30 seconds
I
showing heart rhythm with no discernible repeating P waves and irregular RR
intervals (when atrioventricular conduction is not impaired) is diagnostic of clinical AF.
Recommendations for structured characterization of AF
Structured characterization of AF, which includes clinical assessment of stroke risk,
symptom status, burden of AF, and evaluation of substrate, should be considered in all
IIa
AF patients, to streamline the assessment of AF patients at different healthcare levels,
inform treatment decision-making, and facilitate optimal management of AF patients.

Recommendations Class
Recommendations for screening to detect AF
When screening for AF it is recommended that:
 The individuals undergoing screening are informed about the significance and
treatment implications of detecting AF.
 A structured referral platform is organized for screen-positive cases for further
physician-led clinical evaluation to confirm the diagnosis of AF and provide I
optimal management of patients with confirmed AF.
 Definite diagnosis of AF in screen-positive cases is established only after the
physician reviews the single-lead ECG recording of ≥30 seconds or 12-lead ECG
and confirms that it shows AF.

Recommendations Class
Recommendations about integrated AF management
It is recommended to routinely collect PROs to measure treatment success and
I
improve patient care.
Recommendations for the prevention of thromboembolic events in AF
For a formal risk-score−based assessment of bleeding risk, the HAS-BLED score
should be considered to help address modifiable bleeding risk factors, and to
IIa
identify patients at high risk of bleeding (HAS-BLED score ≥3) for early and more
frequent clinical review and follow-up.
Stroke and bleeding risk reassessment at periodic intervals is recommended to
inform treatment decisions (e.g. initiation of OAC in patients no longer at low risk of I
stroke) and address potentially modifiable bleeding risk factors.

Recommendations Class
Recommendations for the prevention of thromboembolic events in AF (continued)
In patients with AF initially at low risk of stroke, first reassessment of stroke risk
IIa
should be made 4−6 months after the index evaluation.
Estimated bleeding risk, in the absence of absolute contraindications to OAC, should
III
not in itself guide treatment decisions to use OAC for stroke prevention.
Clinical pattern of AF (i.e. first detected, paroxysmal, persistent, long-standing
III
persistent, permanent) should not condition the indication to thromboprophylaxis.

Recommendations Class
Recommendations for cardioversion
Pharmacological cardioversion of AF is indicated only in a haemodynamically stable
I
patient, after consideration of the thromboembolic risk.
For patients with sick-sinus syndrome, atrioventricular conduction disturbances or
prolonged QTc (>500 ms), pharmacological cardioversion should not be attempted III
unless risks for proarrhythmia and bradycardia have been considered.

Recommendations Class
Recommendations for rhythm control/catheter ablation of AF
General recommendations
For the decision on AF catheter ablation, it is recommended to take into
consideration the procedural risks and the major risk factors for AF recurrence I
following the procedure and discuss them with the patient.
Repeated PVI procedures should be considered in patients with AF recurrence
IIa
provided the patient’s symptoms were improved after the initial PVI.
AF catheter ablation after antiarrhythmic drug therapy failure
AF catheter ablation for PVI should be considered for rhythm control after one
failed or intolerant to beta-blocker treatment to improve symptoms of AF IIa

©ESC
recurrences in patients with paroxysmal and persistent AF.

www.escardio.org/guidelines 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation
(European Heart Journal 2020-doi/10.1093/eurheartj/ehaa612)
What is new in the 2020 Guidelines? New recommendations (7)

Recommendations Class
Recommendations for rhythm control/catheter ablation of AF (continued)
First-line therapy
AF catheter ablation for PVI should/may be considered as first-line rhythm control
therapy to improve symptoms in selected patients with symptomatic: IIa
• Paroxysmal AF episodes, or
• Persistent AF without major risk factors for AF recurrence as an alternative to AAD
IIb
class I or III, considering patient choice, benefit, and risk.
Techniques and technologies
Use of additional ablation lesions beyond PVI (low voltage areas, lines, fragmented
IIb
activity, ectopic foci, rotors, and others) may be considered but is not well established.

Recommendations Class
Recommendations for rhythm control/catheter ablation of AF (continued)
Lifestyle modification and other strategies to improve outcomes of ablation
Strict control of risk factors and avoidance of triggers are recommended as part of
I
rhythm control strategy.
Recommendations for stroke risk management peri cardioversion
It is recommended that the importance of adherence and persistence to NOAC
I
treatment both before and after cardioversion is strongly emphasized to patients.
In patients with AF duration of >24 hours undergoing cardioversion, therapeutic
anticoagulation should be continued for at least 4 weeks even after successful
IIa
cardioversion to sinus rhythm (beyond 4 weeks, the decision about long-term OAC

©ESC
treatment is determined by the presence of stroke risk factors).

Recommendations Class
Recommendations for stroke risk management peri cardioversion (continued)
In patients with a definite duration of AF ≤24 hours and a very low stroke risk
(CHA2DS2-VASc of 0 in men or 1 in women) post-cardioversion anticoagulation for 4 IIb
weeks may be omitted.
Recommendations for stroke risk management peri catheter ablation
In AF patients with stroke risk factors not taking OAC before ablation, it is recommended
that preprocedural management of stroke risk includes initiation of anticoagulation and: I
• Preferably, therapeutic OAC for at least 3 weeks before ablation, or
• Alternatively, the use of TOE to exclude LA thrombus before ablation. IIa
For patients undergoing AF catheter ablation who have been therapeutically
anticoagulated with warfarin, dabigatran, rivaroxaban, apixaban, or edoxaban, I

©ESC
performance of the ablation procedure without OAC interruption is recommended.

Recommendations Class
Recommendations for long-term AADs
In AF patients treated with sotalol, close monitoring of QT interval, serum
I
potassium levels, CrCl, and other proarrhythmia risk factors is recommended.
In AF patients treated with flecainide for long-term rhythm control, concomitant
IIa
use of an atrioventricular nodal-blocking drug (if tolerated) should be considered.
Sotalol may be considered for long-term rhythm control in patients with normal LV
function or with ischaemic heart disease if close monitoring of QT interval, serum IIb
potassium levels, CrCl, and other proarrhythmia risk factors is provided.

Recommendations Class
Recommendations for lifestyle interventions and management of risk factors and
concomitant diseases in AF
Identification and management of risk factors and concomitant diseases is
I
recommended as an integral part of treatment in AF patients.
Modification of unhealthy lifestyle and targeted therapy of intercurrent conditions
I
is recommended to reduce AF burden and symptom severity.
Opportunistic screening for AF is recommended in hypertensive patients. I
Opportunistic screening for AF should be considered in patients with OSA. IIa

Recommendations Class
Recommendations for patients with AF and an ACS, PCI, or CCS
Recommendations for AF patients with ACS
In AF patients with ACS undergoing an uncomplicated PCI, early cessation (≤1 week) of
aspirin and continuation of dual therapy with an OAC and a P2Y 12 inhibitor (preferably
clopidogrel) for up to 12 months is recommended if the risk of stent thrombosis is low or I
if concerns about bleeding risk prevail over concerns about risk of stent thrombosis,
irrespective of the type of stent used.
Recommendations in AF patients with a CCS undergoing PCI
After uncomplicated PCI, early cessation (≤1 week) of aspirin and continuation of dual
therapy with OAC for up to 6 months and clopidogrel is recommended if the risk of stent
I
thrombosis is low or if concerns about bleeding risk prevail over concerns about risk of
stent thrombosis, irrespective of the type of stent used.

Recommendations Class
Recommendations for the management of active bleeding on OAC
Four-factor prothrombin complex concentrates should be considered in AF patients
IIa
on VKA who develop a severe bleeding complication.
Recommendations for the management of AF during pregnancy
Acute management
In pregnant women with HCM, cardioversion should be considered for persistent AF. IIa
Ibutilide or flecainide i.v. may be considered for termination of AF in stable patients
IIb
with structurally normal hearts.

Recommendations Class
Recommendations for the management of AF during pregnancy
Long-term management (oral administration of drugs)
Flecainide, propafenone, or sotalol should be considered to prevent AF if
IIa
atrioventricular nodal-blocking drugs fail.
Digoxin or verapamil should be considered for rate control if beta-blockers fail. IIa
Recommendations for postoperative AF
Long-term OAC therapy to prevent thromboembolic events should be considered in
patients at risk for stroke with postoperative AF after non-cardiac surgery,
IIa
considering the anticipated net clinical benefit of OAC and informed patient
preferences.

©ESC
Beta-blockers should not be used routinely for the prevention of postoperative AF
III
in patients undergoing non-cardiac surgery.
www.escardio.org/guidelines 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation
(European Heart Journal 2020-doi/10.1093/eurheartj/ehaa612)
What is new in the 2020 Guidelines? New recommendations (15)

Recommendations Class
Recommendations pertaining to sex-related differences in AF
Women with symptomatic paroxysmal or persistent AF should be offered timely
access to rhythm control therapies, including AF catheter ablation, when IIa
appropriate for medical reasons.
Recommendations for quality measures in AF
The introduction of tools to measure quality of care and identify opportunities for
improved treatment quality and AF patient outcome should be considered by IIa
practitioners and institutions.

Recommendations about integrated AF management

2020 Class 2016 Class
To optimize shared decision-making Placing patients in a central role in
about specific AF treatment option(s) in decision-making should be considered
consideration, it is recommended that: in order to tailor management to
• Physicians inform the patient about patient preferences and improve
advantages/limitations and adherence to long-term therapy
benefit/risks associated with
I IIa
considered treatment option(s); and
• Discuss the potential burden of the
treatment with the patient and
include the patient’s perception of
treatment burden into the treatment

©ESC
decision.

www.escardio.org/guidelines 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation
(European Heart Journal 2020-doi/10.1093/eurheartj/ehaa612)
Changes in the recommendations (2)

Recommendations for the prevention of thromboembolic events in AF

2020 Class 2016 Class
For bleeding risk assessment, a Bleeding risk scores should be
formal structured risk-score−based considered in AF patients on oral
bleeding risk assessment is anticoagulation to identify
recommended to help identify non- modifiable risk factors for major
modifiable and address modifiable bleeding.
I IIa
bleeding risk factors in all AF patients,
and to identify patients potentially at
high risk of bleeding who should be
scheduled for early and more
frequent clinical review and follow-up.

Recommendations for the prevention of thromboembolic events in AF (continued)

2020 Class 2016 Class
In patients on VKAs with low time in AF patients already on treatment
INR therapeutic range (e.g. TTR with a VKAs may be considered for
<70%), recommended options are: NOAC treatment if TTR is not well
I
• Switching to a NOAC but ensuring controlled despite good adherence,
good adherence and persistence or if patient preference without IIb
with therapy; or contraindications to NOAC (e.g.
• Efforts to improve TTR (e.g. prosthetic valve).
education/counselling and more IIa
frequent INR checks).

Recommendations for rhythm control/catheter ablation of AF

AF catheter ablation after drug therapy failure
2020 Class 2016 Class
AF catheter ablation for PVI is Catheter or surgical ablation should
recommended for rhythm control be considered in patients with
after one failed or intolerant class I or symptomatic persistent or long-
III AAD, to improve symptoms of AF standing persistent AF refractory to
recurrences in patients with: AAD therapy to improve symptoms,
I IIa
• Paroxysmal AF, or considering patient choice, benefit
• Persistent AF without major risk and risk, supported by an AF Heart
factors for AF recurrence, or Team.
• Persistent AF with major risk factors

©ESC
for AF recurrence.

www.escardio.org/guidelines 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation
(European Heart Journal 2020-doi/10.1093/eurheartj/ehaa612)
Changes in the recommendations (5)

Recommendations for rhythm control/catheter ablation of AF (continued)

First-line therapy
2020 Class 2016 Class
AF catheter ablation: AF ablation should be considered in
• Is recommended to reverse LV symptomatic patients with AF and
dysfunction in AF patients when HFrEF to improve symptoms and
I
tachycardia-induced cardiomyopathy cardiac function when
is highly probable, independent of tachycardiomyopathy is suspected. IIa
their symptom status.
• Should be considered in selected AF
patients with HFrEF to improve IIa
survival and reduce HF hospitalization.

Recommendations for rhythm control/catheter ablation of AF (continued)

Techniques and technologies
2020 Class 2016 Class
Complete electrical isolation of the Catheter ablation should target
pulmonary veins is recommended isolation of the pulmonary veins
I IIa
during all AF catheter-ablation using radiofrequency ablation or
procedures. cryothermy balloon catheters.
If patient has a history of CTI- Ablation of common atrial flutter
dependent atrial flutter or if typical should be considered to prevent
atrial flutter is induced at the time of IIb recurrent flutter as part of an AF IIa
AF ablation, delivery of a CTI lesion ablation procedure if documented or
may be considered. occurring during the AF ablation.

Recommendations for rhythm control/catheter ablation of AF (continued)

Lifestyle modification and other strategies to improve outcomes of ablation
2020 Class 2016 Class
Weight loss is recommended in obese In obese patients with AF, weight loss
patients with AF, particularly those together with management of other
I IIa
who are being evaluated to undergo risk factors should be considered to
AF ablation. reduce AF burden and symptoms.
Recommendations for stroke risk management peri cardioversion
In patients with AF undergoing Anticoagulation with heparin or a
cardioversion, NOACs are NOAC should be initiated as soon as
I IIa
recommended with at least similar possible before every cardioversion of
efficacy and safety as warfarin. AF or atrial flutter.

Recommendations for stroke risk management peri catheter ablation

2020 Class 2016 Class
After AF catheter ablation, it is All patients should receive oral
recommended that: anticoagulation for at least 8 weeks
• Systemic anticoagulation with after catheter ablation.
warfarin or a NOAC is continued for
at least 2 months post ablation, and
• Long-term continuation of systemic I IIa
anticoagulation beyond 2 months
post ablation is based on the
patient’s stroke risk profile and not
on the apparent success or failure

©ESC
of the ablation procedure.

www.escardio.org/guidelines 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation
(European Heart Journal 2020-doi/10.1093/eurheartj/ehaa612)
Changes in the recommendations (9)

Recommendations for long-term antiarrhythmic drugs

2020 Class 2016 Class
Amiodarone is recommended for Amiodarone is more effective in
long-term rhythm control in all AF preventing AF recurrences than
patients, including those with HFrEF. other AAD, but extracardiac toxic
I IIa
However, owing to its extracardiac effects are common and increase
toxicity, other AADs should be with time. For this reason, other AAD
considered first whenever possible. should be considered first.

Recommendations for lifestyle interventions and management of risk factors and

concomitant diseases in patients with AF
2020 Class 2016 Class
Attention to good BP control is Blood pressure control in
recommended in AF patients with anticoagulated patients with
hypertension to reduce AF I hypertension should be considered IIa
recurrences and risk of stroke and to reduce the risk of bleeding
bleeding.
Physical activity should be considered Moderate regular physical activity is
to help prevent AF incidence or recommended to prevent AF, while
recurrence, with the exception of IIa athletes should be counselled that I
excessive endurance exercise, which long-lasting intense sports

©ESC
may promote AF. participation can promote AF

www.escardio.org/guidelines 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation
(European Heart Journal 2020-doi/10.1093/eurheartj/ehaa612)
Changes in the recommendations (11)

Recommendations for lifestyle interventions and management of risk factors and

concomitant diseases in patients with AF (continued)
2020 Class 2016 Class
Optimal management of OSA may be OSA treatment should be optimized
considered, to reduce AF incidence, to reduce AF recurrences and
IIb IIa
AF progression, AF recurrences, and improve AF treatment results.
symptoms.

Recommendations for stroke prevention in AF patients after ICH

2020 Class 2016 Class
In AF patients at high risk of ischaemic After ICH, oral anticoagulation in
stroke, (re-)initiation of OAC, with patients with AF may be reinitiated
preference for NOACs over VKAs in after 4–8 weeks provided the cause of
NOAC-eligible patients, should be bleeding or the relevant risk factor has
considered in consultation with a been treated or controlled.
neurologist/stroke specialist after:
IIa IIb
• A trauma-related ICH
• Acute spontaneous ICH (which
includes subdural, subarachnoid, or
intracerebral haemorrhage), after
careful consideration of risks and

©ESC
benefits.

www.escardio.org/guidelines 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation
(European Heart Journal 2020-doi/10.1093/eurheartj/ehaa612)
Changes in the recommendations (13)

Recommendations for postoperative AF

2020 Class 2016 Class
Long-term OAC therapy to prevent Long-term anticoagulation should be
thromboembolic events may be considered in patients with AF after
considered in patients at risk for cardiac surgery at risk for stroke,
stroke with postoperative AF after considering individual stroke and
IIb IIa
cardiac surgery, considering the bleeding risk.
anticipated net clinical benefit of OAC
therapy and informed patient
preferences.

Definition
AF A supraventricular tachyarrhythmia with uncoordinated atrial electrical
activation and consequently ineffective atrial contraction.
Electrocardiographic characteristics of AF include:
• Irregularly irregular R-R intervals (when atrioventricular conduction is not
impaired),
• Absence of distinct repeating P waves, and
• Irregular atrial activations.
Currently used terms
Clinical AF Symptomatic or asymptomatic AF that is documented by surface ECG.
The minimum duration of an ECG tracing of AF required to establish the
diagnosis of clinical AF is at least 30 seconds, or entire 12-lead ECG.

Currently used terms (continued)

Atrial high rate Refers to individuals without symptoms attributable to AF, in whom clinical
episode AF is NOT previously detected (that is, there is no surface ECG tracing of AF).
(AHRE), AHRE − events fulfilling programmed or specified criteria for AHRE that are
subclinical AF detected by CIEDs with an atrial lead allowing automated continuous
monitoring of atrial rhythm and tracings storage. CIED-recorded AHRE need
to be visually inspected because some AHRE may be electrical
artefacts/false positives.
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.

Recommendations Class Level

ECG documentation is required to establish the diagnosis of AF.
• A standard 12-lead ECG recording or a single-lead ECG tracing of
≥30 seconds showing heart rhythm with no discernible repeating P waves I B
and irregular RR intervals (when atrioventricular conduction is not impaired)
is diagnostic of clinical AF.

©ESC
www.escardio.org/guidelines 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation
(European Heart Journal 2020-doi/10.1093/eurheartj/ehaa612)
Figure 1 Diagnosis of
AHRE/subclinical atrial
fibrillation
CIEDs with an atrial lead can monitor atrial rhythm and store
the tracings. ICM have no intra-cardiac leads but
continuously monitor cardiac electrical activity by recording
and analysing a single-lead bipolar surface ECG based on
specific algorithm.
Left-bottom image: pacemaker with a right atrial lead, and a
ventricular lead in the right ventricular apex. In addition
to pacing at either site, these leads can sense activity in the
respective cardiac chamber. The device can also detect
pre-programmed events, such as AHRE.
Right-bottom image: subcutaneous ICM: these devices have
no intra-cardiac leads and essentially record a single, bipolar,

©ESC
surface ECG with inbuilt algorithms for detection of AHRE or
©ESC AF.

a Smoking, alcohol consumption, body mass index, BP,

diabetes mellitus (type 1 or 2), and history of myocardial
infarction or heart failure. bRisk profile: optimal − all risk
factors are negative or within the normal range; borderline −

©ESC
no elevated risk factors but >1 borderline risk factor;
elevated − >1 elevated risk factor.

©ESC
©ESC

www.escardio.org/guidelines 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation
(European Heart Journal 2020-doi/10.1093/eurheartj/ehaa612)
Table 4 Classification of AF (1)

AF pattern Definition
First AF not diagnosed before, irrespective of its duration or the presence/severity of
diagnosed AF-related symptoms.
Paroxysmal AF that terminates spontaneously or with intervention within 7 days of onset.

Persistent AF that is continuously sustained beyond 7 days, including episodes that are terminated
by cardioversion (drugs or direct current cardioversion) after 7 days or more.
Long-standing Continuous AF of >12 months’ duration when decided to adopt a rhythm control strategy.
persistent
Permanent AF that is accepted by the patient and physician, and no further attempts to restore/maintain
sinus rhythm will be undertaken. Permanent AF represents a therapeutic attitude of the
patient and physician rather than an inherent pathophysiological attribute of AF, and the
term should not be used in the context of a rhythm control strategy with antiarrhythmic drug
therapy or AF ablation. Should a rhythm control strategy be adopted, the arrhythmia would

©ESC
be re-classified as ‘long-standing persistent AF’.

www.escardio.org/guidelines 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation
(European Heart Journal 2020-doi/10.1093/eurheartj/ehaa612)
Table 4 Classification of AF (2)

Terminology that should be abandoned

AF pattern Definition
Lone AF A historical descriptor. Increasing knowledge about the pathophysiology of AF shows that
in every patient a cause is present. Hence, this term is potentially confusing and should be
abandoned.
Valvular/non- Differentiates patients with moderate/severe mitral stenosis and those with mechanical
valvular AF prosthetic heart valve(s) from other patients with AF, but may be confusing and should
not be used.
Chronic AF Has variable definitions and should not be used to describe populations of AF patients.

©ESC
©ESC
©ESC

Recommendations Class Level

Structured characterization of AF, which includes clinical assessment of
stroke risk, symptom status, burden of AF, and evaluation of substrate,
should be considered in all AF patients, to streamline the assessment of AF IIa C
patients at different healthcare levels, inform treatment decision-making,
and facilitate optimal management of AF patients.

Pulse palpation, automated BP monitors, single-lead ECG devices, PPG devices, other sensors (using
seismocardiography, accelerometers, and gyroscopes, etc.) used in applications for smartphones,
wrist bands, and watches. Intermittent smartwatch detection through PPG or ECG recordings.
Smartwatches and other ‘wearables’ can passively measure pulse rate from the wrist using an optical

©ESC
sensor for PPG and alerting the consumer of a pulse irregularity (based on a specific algorithm for AF
detection analysing pulse irregularity and variability
©ESC

www.escardio.org/guidelines 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation
(European Heart Journal 2020-doi/10.1093/eurheartj/ehaa612)
Table 5 Sensitivity and specificity of various AF screening tools
considering the 12-lead ECG as the gold standard
Sensitivity Specificity
Pulse taking 87−97% 70−81%
Automated BP 93−100% 86−92%
monitors
Single lead ECG 94−98% 76−95%
Smartphone apps 91.5−98.5% 91.4−100%
Watches 97−99% 83−94%

AF SCREENING

RISKS BENEFITS
Prevention of:
•Abnormal results may cause anxiety
• Stroke/SE using OAC in patients at risk
•ECG misinterpretation results may • Subsequent onset of symptoms
lead to overdiagnosis and
Prevention/reversal of:
overtreatment
• Electrical/mechanical atrial remodelling
•ECG may detect other abnormalities • AF-related haemodynamic derangements
(true or false positives) that may • Atrial and ventricular tachycardia-induced cardiopmyopathy
lead to invasive tests and Prevention/reduction of:
treatments that have the potential • AF-related morbidity; hospitalization; mortality
for serious harm (e.g., angiography /
revascularisation with bleeding, Reduction of:
contrast-induced nephropathy and • The outcomes associated with conditions / diseases associated with AF that
allergic reactions to the contrast) are discovered and treated as a consequence of the examinations prompted by

©ESC
AF detection

Recommendations Class Level

Opportunistic screening for AF by pulse taking or ECG rhythm strip is
I B
recommended in patients ≥65 years of age.
It is recommended to interrogate pacemakers and implantable cardioverter
I B
defibrillators on a regular basis for AHRE.a

©ESC
a See sections for diagnostic criteria for AF and AHRE, and for the management of patients with AHRE.

Recommendations Class Level

When screening for AF it is recommended that:
• The individuals undergoing screening are informed about the significance
and treatment implications of detecting AF.
• A structured referral platform is organized for screen-positive cases for
further physician-led clinical evaluation to confirm the diagnosis of AF and I B
provide optimal management of patients with confirmed AF.
• Definite diagnosis of AF in screen-positive cases is established only after
physician reviews the single-lead ECG recording of ≥30 seconds or 12-lead
ECG and confirms that it shows AF.
Systematic ECG screening should be considered to detect AF in individuals
IIa B
aged ≥75 years, or those at high risk of stroke.

All AF patients Selected AF patients Structured follow-up

Ambulatory ECG monitoring:

Medical history: • Adequacy of rate control • To ensure continued optimal
• AF-related symptoms • Relate symptoms to AF recurrences management
• AF pattern Transoesophageal echocardiography: • A cardiologist / AF specialist
• Concomitant conditions • Valvular heart disease coordinates the follow-up in
• CHA2DS2-VASc score • LAA thrombus collaboration with specially
cTnT-hs, CRP, BNP/NT-ProBNP trained nurses and primary
12-lead ECG Cognitive function assessment care physicians
Thyroid and kidney function,
electrolytes and full blood Coronary CTA or ischaemia imaging:
count • Patients with suspected CAD
Brain CT and MRI:
Transthoracic • Patients with suspected stroke
echocardiography LGE-CMR of the LA:
• To help decision-making in AF

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treatment

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Table 6 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 troubled by symptoms
3 Severe Normal daily activity affected by symptoms related to AF
4 Disabling Normal daily activity discontinued

©ESC
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Figure 9
Imaging in AF

©ESC

2020 ESC Guidelines for the diagnosis and management of atrial fibrillation
(European Heart Journal 2020-doi/10.1093/eurheartj/ehaa612)
Recommendations for diagnostic evaluation of patients with AF

Recommendations Class Level

In patients with AF, it is recommended to:
• Evaluate AF-related symptoms (including fatigue, tiredness, exertional
shortness of breath, palpitations, and chest pain) and quantify the patient
symptom status using the modified EHRA symptom scale before and after I C
initiation of treatment.
• Evaluate AF-related symptoms before and after cardioversion of persistent
AF to aid rhythm control treatment decisions.

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Recommendations Class Level

To optimize shared decision-making about specific AF treatment option(s) in
consideration, it is recommended that physicians:
• Inform the patient about the advantages/limitations and benefit/risks
I C
associated with the treatment option(s) being considered; and
• Discuss the potential burden of the treatment with the patient and include
the patient’s perception of treatment burden into the treatment decision.
It is recommended to routinely collect PROs to measure treatment success
I C
and improve patient care.
Integrated management with a structured multidisciplinary approach
including healthcare professionals, patients, and their family/carers, should IIa B
be used in all AF patients to improve clinical outcomes.

Most commonly Positive Other clinical Imaging biomarkers Blood/urine

studied clinical risk studies/All risk factors biomarkers
factors (a systematic studies
review)
Stroke/TIA/systemic 15/16 Impaired renal function/CKD Echocardiography Cardiac troponin T and I
embolism Natriuretic peptides
Cystatin C
Hypertension 11/20 OSA LA dilatation
Proteinuria
Ageing (per decade) 9/13 Hypertrophic cardiomyopathy Spontaneous contrast
CrCl/eGFR
or thrombus in LA
Structural heart 9/13 Amyloidosis in degenerative CRP
Low LAA velocities
disease cerebral and heart diseases IL-6
Complex aortic plaque
GDF-15
Diabetes mellitus 9/14 Hyperlipidaemia von Willebrand factor
Vascular disease 6/17 Smoking Cerebral imaging D-dimer

CHF/LV dysfunction 7/18 Metabolic syndrome Small-vessel disease

Sex category (female) 8/22 Malignancy

CHA2DS2-VASc score
Risk factors and definitions Points Comment
awarded
C Congestive heart failure 1 Recent decompensated HF irrespective of LVEF (thus incorporating
Clinical HF, or objective HFrEF or HFpEF), or the presence (even if asymptomatic) of moderate-
evidence of moderate to severe LV systolic impairment on cardiac imaging; HCM confers a high
severe LV dysfunction, or HCM stroke risk and OAC is beneficial for stroke reduction.
H Hypertension 1 History of hypertension may result in vascular changes that predispose
or on antihypertensive therapy to stroke, and a well-controlled BP today may not be well-controlled
over time. Uncontrolled BP − the optimal BP target associated with the
lowest risk of ischaemic stroke, death, and other cardiovascular
outcomes is 120−129/<80 mmHg.
A Age 75 years or older 2 Age is a powerful driver of stroke risk, and most population cohorts
show that the risk rises from age 65 years upwards. Age-related risk is
a continuum, but for reasons of simplicity and practicality, 1 point is
given for age 65−74 years and 2 points for age ≥75 years.

CHA2DS2-VASc score
Risk factors and definitions Points Comment
awarded
D Diabetes mellitus 1 Diabetes mellitus is a well-established risk factor for stroke, and more
Treatment with oral recently stroke risk has been related to duration of diabetes mellitus
hypoglycaemic drugs and/or (the longer the duration of diabetes mellitus, the higher the risk of
insulin or fasting blood glucose thromboembolism) and presence of diabetic target organ damage,
>125 mg/dL (7 mmol/L) e.g. retinopathy. Both type 1 and type 2 diabetes mellitus confer
broadly similar thromboembolic risk in AF, although the risk may be
slightly higher in patients aged <65 years with type 2 diabetes mellitus
compared to patients with type 1 diabetes mellitus.
S Stroke 2 Previous stroke, systemic embolism, or TIA confers a particularly high
Previous stroke, TIA, or risk of ischaemic stroke, hence weighted 2 points. Although excluded
thromboembolism from RCTs, AF patients with ICH (including haemorrhagic stroke) are at
very high risk of subsequent ischaemic stroke, and recent
observational studies suggest that such patients would benefit from

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oral anticoagulation.

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Table 8 CHA2DS2-VASc score (3)

CHA2DS2-VASc score
Risk factors and definitions Points Comment
awarded
V Vascular disease 1 Vascular disease (PAD or myocardial infarction) confers a 17−22%
Angiographically significant excess risk, particularly in Asian patients. Angiographically significant
CAD, previous myocardial CAD is also an independent risk factor for ischaemic stroke among AF
infarction, PAD, or aortic patients (adjusted incidence rate ratio 1.29, 95% CI 1.08−1.53).
plaque Complex aortic plaque on the descending aorta, as an indicator of
significant vascular disease, is also a strong predictor of ischaemic
stroke.
A Age 65−74 years 1 See above. Recent data from Asia suggest that the risk of stroke may
rise from age 50−55 years upwards and that a modified CHA 2DS2-VASc
score may be used in Asian patients.
Sc Sex category (female) 1 A stroke risk modifier rather than a risk factor.
Maximum score 9

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Table 9 factors for bleeding with OAC and antiplatelet therapy
Non-modifiable Potentially modifiable Modifiable Biomarkers
Age >65 years Extreme frailty ц Hypertension/elevate SBP GDF-15
Previous major bleeding excessive risk of Concomitant Cystatin C
Severe renal impairment (on fallsa antiplatelet/NSAID / CKD-EPI
dialysis or renal transplant) Anaemia Excessive alcohol intake cTnT-hs
Severe hepatic dysfunction Reduced platelet Non-adherence to OAC Von Willebrand
(cirrhosis) count or function Hazardous hobbies / factor (+ other
Malignancy Renal impairment occupations coagulation
Genetic factors (e.g., CYP 2C9 with CrCl <60 mL/min Bridging therapy with markers)
polymorphisms) VKA management heparin
Previous stroke, small-vessel strategyb INR control (target 2.0–
disease, etc. 3.0), target TTR >70%c
Diabetes mellitus Appropriate choice of OAC
Cognitive impairment/dementia and correct dosingd

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a Walking aids; appropriate footwear; home review to remove trip hazards; neurological assessment where appropriate. bIncreased INR monitoring, dedicated OAC
clinicals, self-monitoring/self-management, educational/behavioural interventions. cFor patients receiving VKA treatment. dDose adaptation based on patient’s age, body
weight, and serum creatinine level.

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Table 10 Clinical risk factors in the HAS-BLED score (1)
Risk factors and definitions Points
awarded
H Uncontrolled hypertension 1
Systolic BP >160 mmHg
A Abnormal renal and/or hepatic function 1 point
Dialysis, transplant, serum creatinine >200 µmol/L, cirrhosis, for each
bilirubin > 2 upper limit of normal, AST/ALT/ALP >3  upper limit
of normal
S Stroke 1
Previous ischaemic or haemorrhagica stroke
B Bleeding history or predisposition 1
Previous major haemorrhage or anaemia or severe thrombocytopenia

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a Haemorrhagic stroke would also score 1 point under the ‘B’ criterion.

Risk factors and definitions Points

awarded
L Labile INRb 1
TTR <60% in patient receiving VKA
E Elderly 1
Aged >65 years or extreme frailty
D Drugs or excessive alcohol drinking 1 point
Concomitant use of antiplatelet or non-steroidal anti-inflammatory for each
drugs; and/or excessivec alcohol per week
Maximum score 9
bOnly relevant if patient receiving a VKA.
cAlcohol excess or abuse refers to a high intake (e.g. >14 units per week), where the clinician assesses there would be an impact on h ealth or bleeding risk.

Dabigatran Rivaroxaban Apixaban Edoxaban

Standard dose 150 mg b.i.d. 20 mg o.d. 5 mg b.i.d. 60 mg o.d.
Lower dose 110 mg b.i.d.
Reduced dose 15 mg o.d. 2.5 mg b.i.d. 30 mg o.d.
Dose- Dabigatran CrCl 15−49 mL/min At least 2 of 3 If any of the following:
reduction 110 mg b.i.d. in criteria: • CrCl 15−50 mL/min,
criteria patients with: • Age ≥80 years, • Body weight ≤60 kg,
• Age ≥80 years • Body weight • Concomitant use of
• Concomitant ≤60 kg, or dronedarone,
use of • Serum creatinine ciclosporin,
verapamil, or ≥1.5 mg/dL erythromycin, or
• Increased (133 μmol/L) ketoconazole
bleeding risk

©ESC
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Table 12 Antithrombotic therapy after left atrial appendage
occlusion
Device/patient Aspirin OAC Clopidogrel Comments
Watchman 75−325 mg/day Start warfarin after Start 75 mg/day when Some centres do not
/low bleeding risk indefinitely procedure (target INR 2−3) OAC stopped, continue withhold OAC at the time
until 45 days or continue until 6 months after the of procedure (no data to
until adequate LAA sealing procedure support/deny this
is confirmeda by TOE. approach)
NOAC is a possible
alternative
Watchman 75−325 mg/day None 75 mg/day for 1−6 Clopidogrel often given for
/high bleeding indefinitely months while ensuring shorter time in very
risk adequate LAA sealinga high-risk situations

ACP/Amulet 75−325 mg/day None 75 mg/day for 1−6 Clopidogrel may replace
indefinitely months while ensuring long-term aspirin if better
adequate LAA sealinga tolerated

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Note: Load aspirin or clopidogrel before procedure if untreated. Heparin with activated clotting time >250 seconds before or immediately after trans-septal punctures for all
patients, followed by low-molecular-weight heparin when warfarin needed.
a Less than 5 mm leak.

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a If
a VKA being considered, calculate SAMe-
TT2R2 score: if score 0–2, may consider VKA
treatment (e.g. warfarin) or NOAC; if score >2,
should arrange regular review/frequent INR
checks/ counselling for VKA users to help good
anticoagulation control, or reconsider the use
of NOAC instead; TTR ideally >70%.

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©ESC

Recommendations Class Level

For stroke prevention in AF patients who are eligible for OAC, NOACs are
recommended in preference to VKAs (excluding patients with mechanical I A
heart valves or moderate-to-severe mitral stenosis).
For stroke risk assessment, a risk-factor−based approach is recommended,
using the CHA2DS2-VASc clinical stroke risk score to initially identify patients
I A
at ‘low stroke risk’ (CHA2DS2-VASc score = 0 in men, or 1 in women) who
should not be offered antithrombotic therapy.
OAC is recommended for stroke prevention in AF patients with CHA 2DS2-
I A
VASc score ≥2 in men or ≥3 in women.

Recommendations Class Level

OAC should be considered for stroke prevention in AF patients with a CHA2DS2-VASc
score of 1 in men or 2 in women. Treatment should be individualized based on net IIa B
clinical benefit and consideration of patient values and preferences.
For bleeding risk assessment, a formal structured risk-score−based bleeding risk
assessment is recommended to help identify non-modifiable and address
modifiable bleeding risk factors in all AF patients, and to identify patients I B
potentially at high risk of bleeding who should be scheduled for early and more
frequent clinical review and follow-up.
For a formal risk-score−based assessment of bleeding risk, the HAS-BLED score
should be considered to help address modifiable bleeding risk factors, and to IIa B
identify patients at high risk of bleeding (HAS-BLED score ≥3) for early and more

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frequent clinical review and follow-up.

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Recommendations for the prevention of thromboembolic
events in AF (3)
Recommendations Class Level
Stroke and bleeding risk reassessment at periodic intervals is recommended
to inform treatment decisions (e.g. initiation of OAC in patients no longer at I B
low risk of stroke) and address potentially modifiable bleeding risk factors.a
In patients with AF initially at low risk of stroke, first reassessment of stroke
IIa B
risk should be made at 4−6 months after the index evaluation.
If a VKA is used, a target INR of 2.0−3.0 is recommended, with individual
I B
TTR ≥70%.
a Including uncontrolled BP; labile INRs (in a patient taking VKA); alcohol excess; concomitant use of NSAIDs or aspirin in an anticoagulated patient; bleeding tendency or
predisposition (e.g. treat gastric ulcer, optimize renal or liver function etc.).

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Recommendations for the prevention of thromboembolic
events in AF (4)
Recommendations Class Level
In patients on VKAs with low time in INR therapeutic range (e.g. TTR <70%),
recommended options are:
I B
• Switching to a NOAC but ensuring good adherence and persistence with
therapy; or
• Efforts to improve TTR (e.g. education/counselling and more frequent INR
IIa B
checks).
Antiplatelet therapy alone (monotherapy or aspirin in combination with
III A
clopidogrel) is not recommended for stroke prevention in AF.
Estimated bleeding risk, in the absence of absolute contraindications to OAC,
III A
should not in itself guide treatment decisions to use OAC for stroke prevention.
Clinical pattern of AF (i.e. first detected, paroxysmal, persistent, long-standing persistent,
III B

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permanent) should not condition the indication to thromboprophylaxis.

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Recommendations for the prevention of thromboembolic
events in AF (5)
Recommendations for occlusion or exclusion of the LAA Class Level
LAA occlusion may be considered for stroke prevention in patients with AF
and contraindications for long-term anticoagulant treatment (e.g. intracranial IIb B
bleeding without a reversible cause).
Surgical occlusion or exclusion of the LAA may be considered for stroke
IIb C
prevention in patients with AF undergoing cardiac surgery.

©ESC
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Table 13 Drugs for rate control in AFa (1)
Intravenous administration Usual oral maintenance dose Contraindicated
Beta-blockersb
Metoprolol tartrate 2.5−5 mg i.v. bolus; up to 4 doses 25−100 mg b.i.d. In case of asthma use
Metoprolol XL N/A 50−400 mg o.d. beta-1-blockers
(succinate) Contraindicated in acute
HF and history of severe
Bisoprolol N/A 1.25−20 mg o.d. bronchospasm
Atenololc N/A 25−100 mg o.d.

Esmolol 500 µg/kg i.v. bolus over 1 min, N/A

followed by 50−300 µg/kg/min
Landiolol 100 µg/kg i.v. bolus over 1 min, N/A
followed by 10−40 µg/kg/min; in
patients with cardiac dysfunction:
1-10 µg/kg/min
Nebivolol N/A 2.5−10 mg o.d.

Carvedilol N/A 3.125−50 mg b.i.d.

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a All ratecontrol drugs are contraindicated in Wolff−Parkinson−White syndrome, also i.v. amiodarone. bOther beta-blockers are available but not recommended as
specific rate control therapy in AF and therefore not mentioned here (e.g. propranolol and labetalol). cNo data on atenolol; should not be used in HFrEF.

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Table 13 Drugs for rate control in AFa (2)
Intravenous administration Usual oral maintenance dose Contraindicated
Non-dihydropyridine calcium channel antagonists
Verapamil 2.5−10 mg i.v. bolus 40 mg b.i.d. to 480 mg Contraindicated in HFrEF
over 5 min (extended release) o.d. Adapt doses in hepatic and
Diltiazem 0.25 mg/kg i.v. bolus over 5 min, then 60 mg t.i.d. to 360 mg renal impairment
5−15 mg/h (extended release) o.d.
Digitalis glycosides
Digoxin 0.5 mg i.v. bolus (0.75−1.5 mg over 0.0625−0.25 mg o.d. High plasma levels
24 hours in divided doses) associated with increased
mortality
Check renal function
before starting and adapt
dose in CKD patients
Digitoxin 0.4−0.6 mg 0.05−0.1 mg o.d. High plasma levels
associated with increased

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mortality
a All rate control drugs are contraindicated in Wolff−Parkinson−White syndrome, also i.v. amiodarone.

Intravenous administration Usual oral maintenance dose Contraindicated

Other
Amiodarone 300 mg i.v. diluted in 250 mL 200 mg o.d. after loading In case of thyroid disease,
5% dextrose over 30−60 min 3200 mg daily over 4 weeks, only if no other options
(preferably via central venous then 200 mg dailyd(reduce
cannula), followed by 900−1200 mg other rate controlling drugs
i.v. over 24 hours diluted in 500−1000 according to heart rate)
mL via a central venous cannula
a All rate control drugs are contraindicated in Wolff−Parkinson−White syndrome, also i.v. amiodarone.
d Loading regimen may vary; i.v. dosage should be considered when calculating total load.

©ESC
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a Clinical reassessment should be
focused on evaluation of resting
heart rate, AF/AFL-related
symptoms & quality of life. In case
suboptimal rate control (resting
heart rate >110 bpm), worsening of
symptoms or quality of life
consider 2nd line &, if necessary,
3rd line treatment options. bCareful
institution of beta-blocker and

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NDCC, 24-hour Holter to check for
bradycardia.

Recommendations Class Level

Beta-blockers, diltiazem, or verapamil are recommended as first-choice drugs
I B
to control heart rate in AF patients with LVEF ≥40%.
Beta-blockers and/or digoxin are recommended to control heart rate in AF
I B
patients with LVEF <40%.
Combination therapy comprising different rate controlling drugsa should be
IIa B
considered if a single drug does not achieve the target heart rate.
A resting heart rate of <110 bpm (i.e. lenient rate control) should be
IIa B
considered as the initial heart rate target for rate control therapy.
a Combining beta-blocker with verapamil or diltiazem should be performed with careful monitoring of heart rate by 24-h ECG to check for bradycardia.

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Recommendations for ventricular rate control in patients
with AF (2)
Recommendations Class Level
Atrioventricular node ablation should be considered to control heart rate in
patients unresponsive or intolerant to intensive rate and rhythm control
IIa B
therapy, and not eligible for rhythm control by LA ablation, accepting that
these patients will become pacemaker dependent.
In patients with haemodynamic instability or severely depressed LVEF,
IIb B
intravenous amiodarone may be considered for acute control of heart rate.

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symptoms is not due to unconscious adaptation to
reduced physical and/or mental capacity.
©ESC

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Recommendations for rhythm control

Recommendations Class Level

Rhythm control therapy is recommended for symptom and QoL
I A
improvement in symptomatic patients with AF.

©ESC
time needed to achieve therapeutic anticoagulant
effect.
©ESC

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Table 14 Antiarrhythmic drugs used for restoration of sinus
rhythm (1)
Antiarrhythmic drugs for restoration of sinus rhythm (pharmacological cardioversion)
Drug Administration Initial dose Further dosing Acute success rate Contraindications/
route For For and expected time to Precautions/
cardioversion cardioversion sinus rhythm comments
Flecainidea Oralb 200−300 mg - Overall: 59−78% • Should not be used in
i.v. 2 mg/kg over (51% at 3 h, ischaemic heart disease
10 min 72% at 8 h) and/or significant structural
Propafenonea Oralb 450−600 mg - Oral: 45−55% at 3 h, heart disease
i.v. 1.5−2 mg/kg 69−78% at 8 h; • May induce hypotension, AFL
over 10 min i.v.: 43−89% with 1:1 conduction (in
Up to 6 h 3.5−5.0% of patients)
• Flecainide may induce mild
QRS complex widening
• Do NOT use for
pharmacological
cardioversion of AFL

©ESC
a Most frequently used for cardioversion of AF, available in most countries. bMay be self-administered by selected outpatients as a ‘pill-in-the-pocket’ treatment
strategy. For more details regarding pharmacokinetic or pharmacodynamic properties refer to EHRA AADs–clinical use and clinical decision making: a consensus
document.

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Table 14 Antiarrhythmic drugs used for restoration of sinus
rhythm (2)
Antiarrhythmic drugs for restoration of sinus rhythm (pharmacological cardioversion)
Drug Administration Initial dose Further dosing Acute success rate Contraindications/
route For For and expected time to Precautions/
cardioversion cardioversion sinus rhythm comments
Vernakalantc i.v. 3 mg/kg over 2 mg/kg over <1 h (50% conversion • Should not be used in
10 min 10 min within 10 min) patients with arterial
(10−15 min hypotension (SBP
after the initial <100 mmHg), recent ACS
dose) (within 1 month), NYHA III or
IV HF, prolonged QT, or
severe aortic stenosis
• May cause arterial
hypotension, QT
prolongation, QRS widening,
or non-sustained ventricular
tachycardia

©ESC
cNotavailable in some countries. For more details regarding pharmacokinetic or pharmacodynamic properties refer to EHRA AADs –clinical use and clinical decision
making: a consensus document.

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Table 14 Antiarrhythmic drugs used for restoration of sinus
rhythm (3)
Antiarrhythmic drugs for restoration of sinus rhythm (pharmacological cardioversion)
Drug Administration Initial dose Further dosing Acute success rate Contraindications/
route For For and expected time to Precautions/
cardioversion cardioversion sinus rhythm comments
Amiodaronea i.v. 5−7 mg/kg 50 mg/h 44% • May cause phlebitis (use a
over 1−2 h (maximum 8−12 h to several large peripheral vein, avoid
1.2 g for 24 h) days i.v. administration >24 hours
and use preferably
volumetric pump)
• May cause hypotension,
bradycardia/atrioventricular
block, QT prolongation
• Only if no other options in
patients with
hyperthyroidism (risk of
thyrotoxicosis)

©ESC
a Most
frequently used for cardioversion of AF, available in most countries. For more details regarding pharmacokinetic or pharmacodynamic properties refer to EHRA
AADs–clinical use and clinical decision making: a consensus document.

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Table 14 Antiarrhythmic drugs used for restoration of sinus
rhythm (4)
Antiarrhythmic drugs for restoration of sinus rhythm (pharmacological cardioversion)
Drug Administration Initial dose Further dosing Acute success rate Contraindications/
route For For and expected time to Precautions/
cardioversion cardioversion sinus rhythm comments
Ibutilidec i.v. 1 mg over 1 mg over 31−51% (AF) • Effective for conversion of
10 min 10 min 63−73% (AFL) AFL
0.01 mg/kg if (10−20 min ≈1 h • Should not be used in
body weight after the initial patients with prolonged QT,
<60 kg dose) severe LVH, or low LVEF
• Should be used in the setting
of a cardiac care unit as it
may cause QT prolongation,
polymorphic ventricular
tachycardia (torsades de
pointes)
• ECG monitoring for at least 4
hours after administration to

©ESC
detect a proarrhythmic event
cNot available in some countries.
For more details regarding pharmacokinetic or pharmacodynamic properties refer to EHRA AADs–clinical use and clinical decision making: a consensus document.

Goals
Early recognition of AF recurrence by ECG recording after cardioversion
Evaluation of the efficacy of rhythm control by symptom assessment
Monitoring of risk for proarrhythmia by regular control of PR, QRS, and QTc intervals
Evaluation of balance between symptoms and side-effects of therapy considering QoL and
symptoms
Evaluation of AF-related morbidities and AAD-related side-effects on concomitant
cardiovascular conditions and LV function
Optimization of conditions for maintenance of sinus rhythm including cardiovascular risk
management (BP control, HF treatment, increasing cardiorespiratory fitness, and other
measures.

Recommendations Class Level

For pharmacological cardioversion of new-onset AF, i.v. vernakalant (excluding
patients with recent ACS or severe HF) or flecainide or propafenone (excluding I A
patients with severe structural heart disease) is recommended.
Intravenous amiodarone is recommended for cardioversion of AF in patients
with HF or structural heart disease, if delayed cardioversion is consistent with I A
clinical situation.
Cardioversion of AF (either electrical or pharmacological) is recommended in
I B
symptomatic patients with persistent AF as part of rhythm control therapy.
Pharmacological cardioversion of AF is indicated only in a haemodynamically
I B
stable patient, after consideration of the thromboembolic risk.

©ESC
Note: For cardioversion in various specific conditions and AF populations see section 11.

Recommendations Class Level

Pretreatment with amiodarone, flecainide, ibutilide, or propafenone should
IIa B
be considered to facilitate the success of electrical cardioversion.
In selected patients with infrequent and recent-onset AF and no significant
structural or ischaemic heart disease, a single self-administered oral dose of
flecainide or propafenone (‘pill in the pocket’ approach) should be IIa B
considered for patient-led cardioversion, but only following efficacy and
safety assessment.
For patients with sick-sinus syndrome, atrioventricular conduction
disturbances or prolonged QTc (>500 ms), pharmacological cardioversion
III C
should not be attempted unless risks for proarrhythmia and bradycardia have
been considered.

©ESC

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a Significantly enlarged bIn
LA volume, advanced age, long AF duration, renal dysfunction, and other cardiovascular risk factors. rare individual circumstances,
catheter ablation may be carefully considered as first -line therapy. Recommended to reverse LV dysfunction when tachycardiomyopathy is highly probable.dTo
c

improve survival and reduce hospitalization.

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Table 16 Procedure-related complications in catheter ablation and
thoracoscopic ablation of AF (1)
Complication severity Complication type Complication rate
Catheter ablation Thoracoscopic ablation
Life-threatening Periprocedural death <0.1% <0.1%
complications Oesophageal perforation/fistula <0.5% N/A
Periprocedural thromboembolic <1.0% <1.5%
event
Cardiac tamponade ≈1% <1.0%
Severe complications Pulmonary vein stenosis <1.0% N/A
Persistent phrenic nerve palsy <1.0% N/A
Vascular complications 2-4% N/A
Conversion to sternotomy N/A <1.7%

©ESC
Pneumothorax N/A <6.5%
NA = not available.

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Table 16 Procedure-related complications in catheter ablation
and thoracoscopic ablation of AF (2)
Complication severity Complication type Complication rate
Catheter ablation Thoracoscopic ablation
Moderate or minor Various 1−2% 1−3%
complications
Complications of Asymptomatic cerebral 5−15% N/A
unknown significance embolism
NA = not available.

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Figure 18 Contribution of
AF risk factors to the
development of an
abnormal substrate
translating into poorer
outcomes with rhythm
control strategies

Several AF risk factors may contribute to the development

of LA substrates and thus affect the outcome of AF
catheter ablation, predisposing to a higher recurrence

©ESC
rate. Aggressive control of modifiable risk factors may
reduce recurrence rate
©ESC

Key issues
Recognition and management of complications
• Patients must be fully informed about the clinical signs and symptoms of rare but potentially
dangerous ablation-related complications that may occur after hospital discharge (e.g. atrio-
oesophageal fistula, pulmonary vein stenosis).
Follow-up monitoring:
• Useful to assess procedural success and correlate symptom status with rhythm. Recurrences beyond
the first month post-ablation are generally predictive of late recurrences, but recurrent symptoms may
be due to ectopic beats or other non-sustained arrhythmia; conversely the presence of asymptomatic
AF after ablation is well described.
• Monitoring may be performed with intermittent ECG, Holter, Patch recordings, external or implanted
loop recorder, or smart phone monitor (although the latter has not been validated for such use).
Patients should be first reviewed at a minimum of 3 months and annually thereafter.

Key issues
Management of antiarrhythmic medication and treatment of AF recurrences
a. Continuing AAD treatment for 6 weeks to 3 months may reduce early AF recurrences,
rehospitalizations and cardioversions during this period. Clinical practice regarding routine AAD
treatment after ablation varies and there is no convincing evidence that such treatment is routinely
needed.
b. Subsequently, AADs may be weaned, ceased, or continued according to symptoms and rhythm status.
Recent findings suggest that in AAD-treated patients remaining free of AF at the end of the blanking
period, AAD continuation beyond the blanking period reduces arrhythmia recurrences.
Management of anticoagulation therapy
a. In general, OAC therapy is continued for 2 months following ablation in all patients. Beyond this time,
a decision to continue OAC is determined primarily by the presence of CHA2DS2-VASc stroke risk

©ESC
factors rather than the rhythm status (see section 10.2.2.6).

Recommendations Class Level

General recommendations
For the decision on AF catheter ablation, it is recommended to take into
consideration the procedural risks and the major risk factors for AF I B
recurrence following the procedure and discuss them with the patient.
Repeated PVI procedures should be considered in patients with AF recurrence
IIa B
provided the patient’s symptoms were improved after the initial PVI.

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Recommendations for rhythm control/catheter ablation
of AF (2)
Recommendations Class Level
AF catheter ablation after failure of drug therapy
AF catheter ablation for PVI is recommended for rhythm control after one
failed or intolerant class I or III AAD, to improve symptoms of AF recurrences
in patients with
• Paroxysmal AF, or I A
• Persistent AF without major risk factors for AF recurrence, or A
• Persistent AF with major risk factors for AF recurrence B
AF catheter ablation for PVI should be considered for rhythm control after
one failed or intolerant to beta-blocker treatment to improve symptoms of IIa B
AF recurrences in patients with paroxysmal and persistent AF.

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Recommendations for rhythm control/catheter ablation
of AF (3)
Recommendations Class Level
First-line therapy
AF catheter ablation for PVI should/may be considered as first-line rhythm
control therapy to improve symptoms in selected patients with symptomatic:
• Paroxysmal AF episodes, or IIa B
• Persistent AF without major risk factors for AF recurrence. IIb C
as an alternative to AAD class I or III, considering patient choice, benefit,
and risk.

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Recommendations for rhythm control/catheter ablation
of AF (4)
Recommendations Class Level
First-line therapy (continued)
AF catheter ablation:
• Is recommended to reverse LV dysfunction in AF patients when
tachycardia-induced cardiomyopathy is highly probable, independent of I B
their symptom status.
• Should be considered in selected AF patients with HF with reduced LVEF to
IIa B
improve survival and reduce HF hospitalization.
AF catheter ablation for PVI should be considered as a strategy to avoid
pacemaker implantation in patients with AF-related bradycardia or
IIa C
symptomatic pre-automaticity pause after AF conversion considering the

©ESC
clinical situation.

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Recommendations for rhythm control/catheter ablation
of AF (5)
Recommendations Class Level
Techniques and technologies
Complete electrical isolation of the pulmonary veins is recommended during
I A
all AF catheter-ablation procedures.
If patient has history of CTI-dependent AFL or if typical AFL is induced at the
IIb B
time of AF ablation, delivery of a CTI lesion may be considered.
Use of additional ablation lesions beyond PVI (low voltage areas, lines,
fragmented activity, ectopic foci, rotors, and others) may be considered but IIb B
is not well established.

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Recommendations for rhythm control/catheter ablation
of AF (6)
Recommendations Class Level
Lifestyle modification and other strategies to improve outcomes of ablation
Weight loss is recommended in obese patients with AF, particularly those
I B
who are being evaluated to undergo AF ablation.
Strict control of risk factors and avoidance of triggers are recommended as
I B
part of a rhythm control strategy.

Recommendations Class Level

Concomitant AF ablation should be considered in patients undergoing cardiac
surgery, balancing the benefits of freedom from atrial arrhythmias and the risk
IIa A
factors for recurrence (left atrial dilatation, years in AF, age, renal dysfunction, and
other cardiovascular risk factors).
Thoracoscopic − including hybrid surgical ablation − procedures should be
considered in patients who have symptomatic paroxysmal or persistent AF
refractory to AAD therapy and have failed percutaneous AF ablation, or with
IIa B
evident risk factors for catheter ablation failure, to maintain long-term sinus
rhythm. The decision must be supported by an experienced team of
electrophysiologists and surgeons.
Thoracoscopic − including hybrid surgical ablation − procedures may be considered
in patients with persistent AF with risk factors for recurrence, who remain
IIb C

©ESC
symptomatic during AF despite at least one failed AAD and who prefer further
rhythm control therapy.
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Recommendations for stroke risk management
pericardioversion (1)
Recommendations Class Level
In patients with AF undergoing cardioversion, NOACs are recommended with
I A
at least similar efficacy and safety as warfarin.
For cardioversion of AF/AFL, effective anticoagulation is recommended for a
I B
minimum of 3 weeks before cardioversion.
TOE is recommended to exclude cardiac thrombus as an alternative to 3-
I B
week preprocedural anticoagulation when early cardioversion is planned.
In patients at risk of stroke, it is recommended that oral anticoagulant
therapy is continued long-term after cardioversion according to the long-
term anticoagulation recommendations, irrespective of the method of I B
cardioversion, the apparent maintenance of sinus rhythm, or characterization
of AF as a ‘first-diagnosed episode”.

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Recommendations for stroke risk management
pericardioversion (2)
Recommendations Class Level
When thrombus is identified on TOE, effective anticoagulation is
I B
recommended for at least 3 weeks before cardioversion of AF.
It is recommended that the importance of adherence and persistence to
NOAC treatment both before and after cardioversion is strongly emphasized I C
to patients.
Effective anticoagulation should be initiated as soon as possible before every
IIa B
cardioversion of AF or AFL.
Early cardioversion can be performed without TOE in patients with an AF
IIa B
duration of <48 hours.

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Recommendations for stroke risk management
pericardioversion (3)
Recommendations Class Level
In patients with AF duration of >24 hours undergoing cardioversion,
therapeutic anticoagulation should be continued for at least 4 weeks, even
after successful cardioversion to sinus rhythm (beyond 4 weeks, the decision IIa B
about long-term OAC treatment is determined by the presence of stroke risk
factors).
When thrombus is identified on TOE, a repeat TOE to ensure thrombus
IIa C
resolution should be considered before cardioversion.
In patients with a definite duration of AF ≤24 hours and a very low stroke risk
(CHA2DS2-VASc of 0 in men or 1 in women) post-cardioversion IIb C
anticoagulation for 4 weeks may be omitted.

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for stroke risk
Recommendations for risk management peri catheter
catheter
ablation (1)
Recommendations Class Level
Level
before ablation, it is
In AF patients with stroke risk factors not taking OAC before
recommended that preprocedural management of stroke risk includes
II CC
initiation of anticoagulation and:
• Preferably, therapeutic OAC for at least 3 weeks before ablation, or
or
• Alternatively, the use of TOE to exclude LA thrombus before ablation. IIa CC
For patients undergoing AF catheter ablation who have been therapeutically
anticoagulated with warfarin, dabigatran, rivaroxaban, apixaban, or
II A
A
edoxaban, performance of the ablation procedure without OAC interruption
is recommended.

©ESC
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2020 ESC Guidelines for the
the diagnosis
diagnosis and
and management
management of
of atrial
atrial fibrillation
fibrillation
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(European Heart Journal; 2020)
Recommendations for stroke risk management peri catheter
ablation (2)
Recommendations Class Level
After AF catheter ablation, it is recommended that:
• Systemic anticoagulation with warfarin or a NOAC is continued for at least
2 months post ablation, and
I C
• Long-term continuation of systemic anticoagulation beyond 2 months post
ablation is based on the patient’s stroke risk profile and not on the
apparent success or failure of the ablation procedure.

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Recommendations for postoperative anticoagulation after
AF surgery
Recommendations Class Level
Long-term OAC is recommended in patients after AF surgery and appendage
closure, based on the patient’s thromboembolic risk assessed with the I C
CHA2DS2-VASc score.

Principles
AAD therapy aims to reduce AF-related symptoms
Efficacy of AADs to maintain sinus rhythm is modest
Clinically successful AAD therapy may reduce rather than eliminate AF recurrences
If one AAD ‘fails’, a clinically acceptable response may be achieved by another drug
Drug-induced proarrhythmia or extracardiac side-effects are frequent
Safety rather than efficacy considerations should primarily guide the choice of AAD

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Table 19 Rules to initiate antiarrhythmic drugs for long-term
rhythm control in AF (1)
Consideration Criteria
Indication for AAD • Is the patient symptomatic?
• Are AF symptoms severe enough (EHRA class) to justify AAD use?
• Are there associated conditions predicting poor tolerance of AF episodes?
When to start AAD • Usually not for the first episode, but it may enhance efficacy of
cardioversion
How to choose • Minimize proarrhythmic risk and organ toxicity
among AADs Evaluate for:
• basal ECG abnormalities (QRS duration, PR, QTc) and possible
interference with AAD
• impact on LV function
• important pharmacokinetic and pharmacodynamic interactions
(i.e. antithrombotic drugs)

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Table 19 Rules to initiate antiarrhythmic drugs for long-term
rhythm control in AF (2)
Consideration Criteria
How to minimize • Evaluate ECG after the treatment, as indicated in these Guidelines
proarrhythmic risk • Evaluate periodically for organ toxicity (amiodarone)
• Long-term Holter monitoring and exercise test in selected cases
• Avoid AAD combinations
How to verify • Estimate AF burden under therapy (ask patient for noting episodes)
efficacy • If the patient is already on AAD and it was effective but was stopped
because of intolerance, choose preferably from the same class
Adjuvant • In patients with atrioventricular conduction abnormalities and/or sinus
interventions and node dysfunction, pacemaker implantation should be considered if AAD
hybrid therapy therapy is deemed necessary
• Short-term AAD therapy could prevent early recurrences after AF ablation

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Table 20 AADs used for long-term maintenance of sinus rhythm
in AF patients (1)
Drug Administration Dose Contraindications/precautions/comments
route
Amiodarone Oral 3 200 mg • The most effective AAD
daily over • RCTs showed lower AF recurrence compared
4 weeks, with sotalol and dronedarone
then • Also reduces ventricular rate (for 10−12 bpm),
200 mg safe in patients with HF
daily • Concomitant use with other QT-prolonging
drugs with caution
• Concomitant use with VKAs or digitalis (their
dose should be reduced)
• Increased risk of myopathy when used with
statins
• Requires regular surveillance for liver, lung, and
thyroid toxicity

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Table 20 AADs used for long-term maintenance of sinus rhythm
in AF patients (2)
Drug Administration Dose Contraindications/precautions/comments
route
Amiodarone Oral 3 200 mg • Has atrioventricular nodal-slowing properties,
(continued) daily over but should not be used as first intention for rate
4 weeks, control
then • QT prolongation is common but rarely
200 mg associated with torsades de pointes (<0.5%)
daily • Torsades de pointes occurs infrequently during
treatment with amiodarone (the proarrhythmia
caution requires QT-interval and TU-wave
monitoring)
• Should be discontinued in case of excessive QT
prolongation (>500 ms)
• ECG at baseline, after 4 weeks

Drug Administration Dose Contraindications/precautions/comments

route
Amiodarone Oral 3 200 mg • Contraindicated in manifest hyperthyroidism
(continued) daily over • Numerous and frequent extracardiac side-
4 weeks, effects may warrant discontinuation of
then amiodarone, thus making it a second-line
200 mg treatment when other choices are possible
daily

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Table 20 AADs used for long-term maintenance of sinus rhythm
in AF patients (4)
Drug Administration Dose Contraindications/precautions/comments
route
Flecainide Oral 100−200 mg • Effective in preventing recurrence of AF
Flecainide b.i.d., or • Should not be used in patients with CrCl
slow release 200 mg <35 mL/min/1.73 m2 and significant liver
once daily disease
(flecainide • Both are contraindicated in patients with
slow ischaemic heart disease or reduced LVEF
release) • Should be discontinued in case of QRS widening
>25% above baseline and patients with left
bundle-branch block or any other conduction
block >120 ms
• Caution when sinoatrial/atrioventricular
conduction disturbances present
• CYP2D6 inhibitors increase concentrationb

©ESC
b Caution is needed when using any AAD in patients with conduction-system disease (e.g. sinoatrial or atrioventricular node disease).

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Table 20 AADs used for long-term maintenance of sinus rhythm
in AF patients (5)
Drug Administration Dose Contraindications/precautions/comments
route
Flecainide Oral 100−200 mg • May increase AFL cycle length, thus promoting
Flecainide b.i.d., or 1:1 atrioventricular conduction and increasing
slow release 200 mg once ventricular rate. This risk can be reduced by
(continued) daily concomitant administration of an
(flecainide atrioventricular nodal-blocking drug such as a
slow release) beta-blocker or non-dihydropyridine calcium-
channel blocker
• In patients properly screened for propensity to
proarrhythmias, both flecainide and
propafenone are associated with a low
proarrhythmic risk
• ECG at baseline, after 1−2 weeks

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Table 20 AADs used for long-term maintenance of sinus rhythm
in AF patients (6)
Drug Administration Dose Contraindications/precautions/comments
route
Propafenone Oral 150−300 mg • Should not be used in patients with significant
Propafenone three times renal or liver disease, ischaemic heart disease,
slow release daily, or reduced LV systolic function, or asthma
225−425 mg • Should be discontinued in case of QRS widening
b.i.d. >25% above baseline and in patients left
(propafenone bundle-branch block and any other conduction
slow release) block >120 ms
• Caution when sinoatrial/atrioventricular
conduction disturbances present
• Increases concentration of
warfarin/acenocoumarin and digoxin when
used in combinationb

©ESC
bCaution is needed when using any AAD in patients with conduction-system disease (e.g. sinoatrial or atrioventricular node disease).

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Table 20 AADs used for long-term maintenance of sinus rhythm
in AF patients (7)
Drug Administration Dose Contraindications/precautions/comments
route
Propafenone Oral 150−300 mg • May increase AFL cycle length, thus promoting
Propafenone three times 1:1 atrioventricular conduction and increasing
slow release daily, or ventricular rate
(continued) 225−425 mg • ECG at baseline and after 1−2 weeks
b.i.d.
(propafenone
slow release)

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Table 20 AADs used for long-term maintenance of sinus rhythm
in AF patients (8)
Drug Administration Dose Contraindications/precautions/comments
route
Dronedarone Oral 400 mg b.i.d. • Less effective than amiodarone in rhythm
control but has very few extracardiac side-
effects
• Reduces cardiovascular hospitalizations and
death in patients with paroxysmal or persistent
AF or AFL and cardiovascular comorbidity
• Associated with increased mortality in patients
with recent decompensated HF or permanent
AF
• Dronedarone has the most solid safety data
and may thus be a preferable first choice,
however not indicated in patients with HF and

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Table 20 AADs used for long-term maintenance of sinus rhythm
in AF patients (9)
Drug Administration Dose Contraindications/precautions/comments
route
Dronedarone Oral 400 mg b.i.d. • Should not be used in NYHA class III or IV or
(continued) unstable HF, in combination with QT-prolonging
drugs or with strong CYP3A4 inhibitors (e.g.
verapamil, diltiazem) and in patients with CrCl
<30 mL/min
• Concomitant use with dabigatran is
contraindicated
• Combination with digoxin may significantly
increase digoxin serum concentration
• When used with digitalis or beta-blockers their
doses should be reduced
• Should be discontinued in case of excessive QT

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Table 20 AADs used for long-term maintenance of sinus rhythm
in AF patients (10)
Drug Administration Dose Contraindications/precautions/comments
route
Dronedarone Oral 400 mg b.i.d. • A modest increase in serum creatinine is
(continued) common and reflects drug-induced reduction in
CrCl rather than a decline in renal function
• Has atrioventricular nodal-slowing properties
• ECG at baseline and after 4 weeks

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Table 20 AADs used for long-term maintenance of sinus rhythm
in AF patients (11)
Drug Administration Dose Contraindications/precautions/comments
route
Sotalol Oral 80−160 mg • Only class III effects if dosing >160 mg daily
(d,l racemic b.i.d. • Considering its safety and efficacy and potential
mixture) drug alternatives, sotalol should be used with a
caution
• Should not be used in patients with HFrEF,
significant LVH, prolonged QT, asthma,
hypokalaemia, or CrCl <30 mL/min
• Dose-related torsades de pointes may occur in
>2% of patients
• Should be discontinued in case of excessive QT
prolongation (>500 ms or >60 ms increase)

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Table 20 AADs used for long-term maintenance of sinus rhythm
in AF patients (12)
Drug Administration Dose Contraindications/precautions/comments
route
Sotalol Oral 80−160 mg • The potassium channel-blocking effect
(d,l racemic b.i.d. increases with increasing dose and,
mixture) consequently, the risk of ventricular
(continued) proarrhythmia (torsades de pointes) increases
• Observational data and a recent meta-analysis
revealed a correlation with an increased
all-cause mortality, whereas a nationwide
registry analysis and two RCTs found no
evidence for increased safety concerns with
sotalol
• ECG at baseline, after 1 day and after
1−2 weeks

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Table 20 AADs used for long-term maintenance of sinus rhythm
in AF patients (13)
Drug Administration Dose Contraindications/precautions/comments
route
Disopyramide Oral 100−400 mg • Associated with significantly increased
two or t.i.d. mortality, and rarely used for rhythm control in
(maximum AF. Should not be used in patients with a
800 mg/24 h) structural heart disease. Rarely used for rhythm
control in AF patients, due to increased
mortality and frequent intolerance to side-
effects
• May be useful in ‘vagal’ AF occurring in athletes
or during sleep
• Reduces LV outflow obstruction and symptoms
in patients with HCM

©ESC
©ESC

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Table 21 Non-antiarrhythmic drugs with antiarrhythmic
properties (upstream therapy) (1)
Drugs Comment
ACEi, Activated renin-angiotensin-aldosterone system is up-regulated in AF. ACEi and ARBs showed
ARBs encouraging results in preventing AF in preclinical studies.
As suggested by retrospective analyses and studies where AF was a prespecified secondary
endpoint, ACEi/ARBs could prevent new-onset AF in patients with LV dysfunction, LVH, or
hypertension.
As initial treatment, ACEi and ARBs seem to be superior to other antihypertensive regimens, but
ARBs did not reduce AF burden in patients without structural heart disease. Despite several
positive small-scale prospective studies and retrospective analyses, larger RCTs have shown
controversial results and failed to confirm the role of ACEi or ARBs in secondary (post-
cardioversion) prevention of AF. The multifactorial pathways for AF promotion and study design
could explain these negative results and should not discourage the use of ACEi or ARB to AAD in
patients with structural heart disease.

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Table 21 Non-antiarrhythmic drugs with antiarrhythmic
properties (upstream therapy) (2)
Drugs Comment
MRAs Aldosterone is implicated in inducibility and perpetuation of AF. Evidence from RCTs showed
that MRAs reduced new-onset atrial arrhythmias in patients with HFrEF in parallel with
improvement of other cardiovascular outcomes.
Recently, the positive impact of MRAs was also shown in patients with HFpEF irrespective of
baseline AF status. Regarding other renin-angiotensin-aldosterone system inhibitors, the role of
MRAs as upstream therapy in rhythm control strategy for patients with HF and AF has not been
clarified. As AF is a marker of HF severity, the beneficial antiarrhythmic effect could be driven
indirectly, through improvement of HF. A recent meta-analysis showed that MRAs significantly
reduced new-onset AF and recurrent AF, but not postoperative AF.
Beta- Several small studies suggested a lower AF recurrence rate with beta-blockers, with a
blockers comparable efficacy with sotalol. However, most evidence pleads against a significant role of
beta-blockers in preventing AF. The observed beneficial effect could also result from
transformation of clinically manifested AF to silent AF, because of the rate control with beta-

©ESC
blockers.

Recommendations Class Level

Flecainide or propafenone is recommended for long-term rhythm control in AF
patients with normal LV function and without structural heart disease, including I A
significant LVH and myocardial ischaemia.
Dronedarone is recommended for long-term rhythm control in AF patients with:
• Normal or mildly impaired (but stable) LV function, or I A
• HFpEF, ischaemic, or VHD.
Amiodarone is recommended for long-term rhythm control in all AF patients,
including those with HFrEF. However, owing to its extracardiac toxicity, other AADs I A
should be considered first whenever possible.
In AF patients treated with sotalol, close monitoring of QT interval, serum
I B
potassium levels, CrCl, and other proarrhythmia risk factors is recommended.

Recommendations Class Level

In AF patients treated with flecainide for long-term rhythm control, concomitant
IIa C
use of an atrioventricular nodal-blocking drug (if tolerated) should be considered.
Sotalol may be considered for long-term rhythm control in patients with normal LV
function or with ischaemic heart disease if close monitoring of QT interval, serum IIb A
potassium levels, CrCl, and other proarrhythmia risk factors is provided.
AAD therapy is not recommended in patients with permanent AF under rate
control and in patients with advanced conduction disturbances unless III C
antibradycardia pacing is provided.

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Recommendations for lifestyle interventions and management
of risk factors and concomitant diseases in patients with AF (1)
Recommendations Class Level
Identification and management of risk factors and concomitant diseases is
I B
recommended as an integral part of treatment in AF patients.
Modification of unhealthy lifestyle and targeted therapy of intercurrent
I B
conditions is recommended to reduce AF burden and symptom severity.
Opportunistic screening for AF is recommended in hypertensive patients. I B
Attention to good BP control is recommended in AF patients with
I B
hypertension to reduce AF recurrences and risk of stroke and bleeding.
In obese patients with AF, weight loss together with management of other
risk factors should be considered to reduce AF incidence, AF progression, AF IIa B
recurrences, and symptoms.

©ESC
www.escardio.org/guidelines 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation
(European Heart Journal 2020-doi/10.1093/eurheartj/ehaa612)
Recommendations for lifestyle interventions and management
of risk factors and concomitant diseases in patients with AF (2)
Recommendations Class Level
Advice and management to avoid alcohol excess should be considered for AF
IIa B
prevention and in AF patients considered for OAC therapy
Physical activity should be considered to help prevent AF incidence or
recurrence, with the exception of excessive endurance exercise, which may IIa C
promote AF.
Opportunistic screening for AF should be considered in patients with OSA. IIa C
Optimal management of OSA may be considered, to reduce AF incidence, AF
IIb C
progression, AF recurrences, and symptoms.

©ESC
www.escardio.org/guidelines 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation
(European Heart Journal 2020-doi/10.1093/eurheartj/ehaa612)
Recommendations for management of AF with haemodynamic
instability
Recommendations Class Level
Emergency electrical cardioversion is recommended in AF patients with acute
I B
or worsening haemodynamic instability.
In AF patients with haemodynamic instability, amiodarone may be considered
IIb B
for acute control of heart rate.

©ESC
www.escardio.org/guidelines 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation
(European Heart Journal 2020-doi/10.1093/eurheartj/ehaa612)
Figure 20 (1) Post-procedural management of patients with AF and ACS/PCI (full-
outlined arrows represent a default strategy; graded/dashed arrows show treatment
modifications depending on individual patient’s ischaemic and bleeding risks)

©ESC
©ESC

www.escardio.org/guidelines 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation
(European Heart Journal 2020-doi/10.1093/eurheartj/ehaa612)
Figure 20 (2) Post-procedural management of patients with AF and ACS/PCI (full-
outlined arrows represent a default strategy; graded/dashed arrows show treatment
modifications depending on individual patient’s ischaemic and bleeding risks)

©ESC
©ESC

©ESC
www.escardio.org/guidelines 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation
(European Heart Journal 2020-doi/10.1093/eurheartj/ehaa612)
Recommendations for patients with AF and an ACS, PCI,
or CCS (3)
Recommendations Class Level
Recommendations for AF patients with ACS
In AF patients with ACS undergoing an uncomplicated PCI, early cessation (≤1
week) of aspirin and continuation of dual therapy with an OAC and a P2Y 12
inhibitor (preferably clopidogrel) for up to 12 months is recommended if the I A
risk of stent thrombosisb is low or if concerns about bleeding riskc prevail over
concerns about risk of stent thrombosisb, irrespective of the type of stent used.
Triple therapy with aspirin, clopidogrel, and an OACd for longer than 1 week
after an ACS should be considered when risk of stent thrombosisb outweighs
the bleeding risk,c with the total duration (≤1 month) decided according to IIa C
assessment of these risks, and the treatment plan should be clearly specified
at hospital discharge.
bRisk of stent thrombosis encompasses: (i) risk of thrombosis occurring and (ii) risk of death should stent thrombosis occur, both of which relate to anatomical, procedural, and clinical characteristics. Risk factors for CCS
patients include stenting of left main stem or last remaining patent artery; suboptimal stent deployment; stent length >60 mm ; diabetes mellitus; CKD; bifurcation with two stents implanted; treatment of chronic total
occlusion; and previous stent thrombosis on adequate antithrombotic therapy. CBleeding risk in AF patients may be assessed using the HAS-BLED score, which draws attention to modifiable bleeding risk factors; those at

©ESC
high risk (score ≥3) can have more frequent or early review and follow-up. Bleeding risk is highly dynamic and does not remain static, and relying on modifiable bleeding risk factors alone is an inferior strategy to
evaluate bleeding risk. dWhen dabigatran is used in triple therapy, dabigatran 110 mg b.i.d may be used instead of 150 mg b.i.d, but the evidence is insufficient .

www.escardio.org/guidelines 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation
(European Heart Journal 2020-doi/10.1093/eurheartj/ehaa612)
Recommendations for patients with AF and an ACS, PCI,
or CCS (4)
Recommendations Class Level
Recommendations in AF patients with a CCS undergoing PCI
After uncomplicated PCI, early cessation (≤1 week) of aspirin and continuation
of dual therapy with OAC for up to 6 months and clopidogrel is recommended
if the risk of stent thrombosisb is low or if concerns about bleeding riskc prevail I A
over concerns about risk of stent thrombosis,b irrespective of the type of stent
used.
Triple therapy with aspirin, clopidogrel, and an OACd for longer than 1 week
should be considered when risk of stent thrombosisb outweighs the bleeding
risk,c with the total duration (≤1 month) decided according to assessment of IIa C
these risks, and the treatment plan should be clearly specified at hospital
discharge.
bRisk ofstent thrombosis encompasses: (i) risk of thrombosis occurring and (ii) risk of death should stent thrombosis occur, both of which relate to anatomical, procedural, and clinical characteristics. Risk factors for CCS
patients include stenting of left main stem or last remaining patent artery; suboptimal stent deployment; stent length >60 mm ; diabetes mellitus; CKD; bifurcation with two stents implanted; treatment of chronic total

©ESC
occlusion; and previous stent thrombosis on adequate antithrombotic therapy.c Bleeding risk in AF patients may be assessed using the HAS-BLED, which draws attention to modifiable bleeding risk factors; those at high risk
(score ≥3) can have more frequent or early review and follow-up. Bleeding risk is highly dynamic and does not remain static, and relying on modifiable bleeding risk factors alone is an inferior strategy to evaluate bleeding
risk.dWhen dabigatran is used in triple therapy, dabigatran 110 mg b.i.d may be used instead of 150 mg b.i.d, but the evidence is insufficient.

www.escardio.org/guidelines 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation
(European Heart Journal 2020-doi/10.1093/eurheartj/ehaa612)
Recommendations for the search for AF in patients with
cryptogenic stroke
Recommendations Class Level
In patients with acute ischaemic stroke or TIA and without previously
known AF, monitoring for AF is recommended using a short-term ECG
I B
recording for at least the first 24 hours, followed by continuous ECG
monitoring for at least 72 hours whenever possible.
In selecteda stroke patients without previously known AF, additional ECG
monitoring using long-term non-invasive ECG monitors or insertable IIa B
cardiac monitors should be considered, to detect AF.
a Not
all stroke patients would benefit from prolonged ECG monitoring; those deemed at risk of developing AF (e.g. elderly, with ca rdiovascular risk factors or
comorbidities, indices of LA remodelling, high C2HEST score, etc.) or those with cryptogenic stroke and stroke characteristics suggestive of an embolic stroke should be
scheduled for prolonged ECG monitoring.

©ESC
www.escardio.org/guidelines 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation
(European Heart Journal 2020-doi/10.1093/eurheartj/ehaa612)
Figure 21
(Re-) initiation of
anticoagulation
post-intracranial
bleeding
A pooled analysis of individual patient data
from cohort studies (n=20 322 patients; 38
cohorts; >35 225 patient-years) showed
that although cerebral microbleeds can
inform regarding the risk for ICH in patients
with recent ischaemic stroke/TIA treated
with antithrombotic therapy, the absolute
risk of ischaemic stroke is substantially
higher than that of ICH, regardless of the
presence, burden, or location of cerebral

www.escardio.org/guidelines 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation
(European Heart Journal 2020-doi/10.1093/eurheartj/ehaa612)
Recommendations for secondary stroke prevention in
AF patients after acute ischaemic stroke
Recommendations Class Level
In AF patients with an ischaemic stroke or TIA, long-term secondary
prevention of stroke using OAC is recommended if there is no strict
I A
contraindication to OAC use, with a preference for NOACs over VKAs in
NOAC-eligible patients.
In AF patients presenting with acute ischaemic stroke, very early
anticoagulation (<48 hours) using UFH, LMWH, or VKAs is not III B
recommended.

©ESC
www.escardio.org/guidelines 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation
(European Heart Journal 2020-doi/10.1093/eurheartj/ehaa612)
Recommendations for stroke prevention in AF patients after
intracranial haemorrhage
Recommendations Class Level
In AF patients at high risk of ischaemic stroke, (re-)initiation of OAC, with
preference for NOACs over VKAs in NOAC-eligible patients, should be
considered in consultation with a neurologist/stroke specialist after:
• A trauma-related ICH IIa C
• Acute spontaneous ICH (which includes subdural, subarachnoid, or
intracerebral haemorrhage), after careful consideration of risks and
benefits.a
a Amore favourable net benefit is likely with deep ICH or without neuroimaging evidence of cerebral amyloid angiopathy or microb leeds.

©ESC
Management of active bleeding in patients receiving anticoagulation (institutions should have an agreed procedure in place).

www.escardio.org/guidelines 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation
(European Heart Journal 2020-doi/10.1093/eurheartj/ehaa612)
Recommendations for the management of active bleeding
on OAC
Recommendations Class Level
In an AF patient with severe active bleeding, it is recommended to:
• Interrupt OAC until the cause of bleeding is identified and active bleeding is
resolved; and I C
• Promptly perform specific diagnostic and treatment interventions to
identify and manage the cause(s) and source(s) of bleeding.
Four-factor prothrombin complex concentrates should be considered in AF
IIa C
patients on VKA who develop a severe bleeding complication.

©ESC
www.escardio.org/guidelines 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation
(European Heart Journal 2020-doi/10.1093/eurheartj/ehaa612)
Recommendations for patients with valvular heart disease
and AF
Recommendations Class Level
NOACs are contraindicated in patients with a prosthetic mechanical valve. III B
Use of NOACs is not recommended in patients with AF and moderate-to-
III C
severe mitral stenosis.

©ESC
www.escardio.org/guidelines 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation
(European Heart Journal 2020-doi/10.1093/eurheartj/ehaa612)
Recommendations for the management of AF in patients with
congenital heart disease (1)
Recommendations Class Level
• Oral anticoagulation should be considered in all adult patients with
intracardiac repair, cyanosis, Fontan palliation, or systemic right ventricle and
a history of AF, atrial flutter, or intra-atrial re-entrant tachycardia.
IIa C
• In patients with AF and other congenital heart diseases, anticoagulation
should be considered in the presence of one or more non-sex stroke risk
factor(s).
Surgery for AF should be considered in patients:
• Who need surgical closure of an atrial septal defect and who have a history of
symptomatic atrial arrhythmia (atrial ablation should be considered at the time
of surgical closure). IIa C
• Cox maze surgery should be considered in patients with symptomatic AF and an
indication for corrective repair of congenital heart defects. The surgery should

www.escardio.org/guidelines 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation
(European Heart Journal 2020-doi/10.1093/eurheartj/ehaa612)
Recommendations for the management of AF in patients with
congenital heart disease (2)
Recommendations Class Level
AF catheter ablation of atrial arrhythmias associated with congenital heart
IIb C
defects may be considered when performed in experienced centres.
In patients with congenital heart disease, TOE may be considered together
IIb C
with 3-week anticoagulation therapy before cardioversion.

©ESC
www.escardio.org/guidelines 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation
(European Heart Journal 2020-doi/10.1093/eurheartj/ehaa612)
Recommendations for the management of AF during
Pregnancy (1)
Recommendations Class Level
Acute management
Immediate electrical cardioversiona is recommended in case of
I C
haemodynamic instability or pre-excited AF.
In pregnant women with HCM, cardioversiona should be considered for
IIa C
persistent AF.
Ibutilide or flecainide i.v. may be considered for termination of AF in stable
IIb C
patients with structurally normal hearts.
a Cardioversion of AF should generally be preceded by anticoagulation

©ESC
www.escardio.org/guidelines 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation
(European Heart Journal 2020-doi/10.1093/eurheartj/ehaa612)
Recommendations for the management of AF during
Pregnancy (2)
Recommendations Class Level
Long-term management (oral administration of drugs)
Therapeutic anticoagulation with heparin or VKA according to the stage of
I C
pregnancy is recommended for patients with AF.
Beta-selective blockers are recommended for rate control in AF.b I C
Flecainidec, propafenone,c or sotalold should be considered to prevent AF if
IIa C
atrioventricular nodal-blocking drugsd fail.
Digoxine or verapamile should be considered for rate control if beta-blockers
IIa C
fail.
bAtenolol have been associated with higher rates of foetal growth retardation and is not recommended.cFlecainide and propafenone should be combined with
atrioventricular nodal-blocking drugs, but structural heart disease, reduced LV function, and bundle branch block should be excluded. dClass III drugs should not be used in
prolonged QTc. e Atrioventricular nodal-blocking drugs should not be used in patients with pre-excitation on resting ECG or pre-excited AF.
Note that the former A to Xcategories of drugs – the classification system for counselling of pregnant women requiring drug the rapy – was replaced by the Pregnancy and

©ESC
Lactation Labelling Rule, which provides a descriptive risk summary and detailed information on animal and clinical data, by the US FDA in June 2015.

Recommendations Class Level

It is recommended to counsel professional athletes that long-lasting intense
sports participation may promote AF, while moderate physical activity is I B
recommended to prevent AF.

©ESC
©ESC
©ESC

Recommendations Class Level

Perioperative amiodarone or beta-blocker therapy is recommended for the
I A
prevention of postoperative AF after cardiac surgery.
Long-term OAC therapy to prevent thromboembolic events should be
considered in patients at risk for stroke with postoperative AF after non-cardiac
IIa B
surgery, considering the anticipated net clinical benefit of OAC therapy and
informed patient preferences.
Long-term OAC therapy to prevent thromboembolic events may be considered
in patients at risk for stroke with postoperative AF after cardiac surgery,
IIb B
considering the anticipated net clinical benefit of OAC therapy and informed
patient preferences.
Beta-blockers should not be used routinely for the prevention of postoperative
III B

Recommendations Class Level

It is recommended that women and men with AF are equally offered
diagnostic assessment and therapies to prevent stroke and other AF-related I A
complications.
Women with symptomatic paroxysmal or persistent AF should be offered
timely access to rhythm control therapies, including AF catheter ablation, IIa B
when appropriate for medical reasons.

©ESC
www.escardio.org/guidelines 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation
(European Heart Journal 2020-doi/10.1093/eurheartj/ehaa612)
Table 22 Summary of quality indicators for the diagnosis and
management of AF (1)
Domain: Patient assessment (at baseline and follow-up)
Main quality indicator: CHA2DS2-VASc cardioembolic risk assessment.
Main quality indicator: bleeding risk assessment using a validated method such as the HAS-BLED score.
Numerator: number of AF patients who have their respective score documented at the time of
diagnosis and at every follow-up appointment.
Denominator: number of AF patients.
Domain: Anticoagulation
Main quality indicator: inappropriate prescription of anticoagulation to patients with a CHA2DS2-
VASc score of 0 for men and 1 for women.
Numerator: number of AF patients with CHA2DS2-VASc score of 0 for men and 1 for women, who are
inappropriately prescribed anticoagulation.
Denominator: number of AF patients with CHA2DS2-VASc score of 0 for men and 1 for women who

www.escardio.org/guidelines 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation
(European Heart Journal 2020-doi/10.1093/eurheartj/ehaa612)
Table 22 Summary of quality indicators for the diagnosis and
management of AF (2)
Domain: Anticoagulation (continued)
Main quality indicator: proportion of patients with a CHA2DS2-VASc score of ≥1 for men and ≥2 for
women who are prescribed anticoagulation.
Numerator: number of AF patients with CHA2DS2-VASc score of ≥1 for men and ≥2 for women who
are prescribed anticoagulation.
Denominator: number of AF patients with CHA2DS2-VASc score of ≥1 for men and ≥2 for women
who are eligible for anticoagulation with no contraindication or refusal.
Domain: rate control
Main quality indicator: inappropriate prescription of AADsa to patients with permanent AF (i.e.
where no attempt to restore sinus rhythm is planned).
Numerator: number of patients with permanent AF who are prescribed one or more AADsa for
rhythm control.
Denominator: number of patients with permanent AF.

www.escardio.org/guidelines 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation
(European Heart Journal 2020-doi/10.1093/eurheartj/ehaa612)
Table 22 Summary of quality indicators for the diagnosis and
management of AF (3)
Domain: rhythm control
Main quality indicator: inappropriate prescription of class IC AADs to patients with structural heart
disease.
Numerator: number of AF patients with structural heart disease who are inappropriately prescribed
class IC AADs.
Denominator: number of AF patients with structural heart disease.
Main quality indicator: proportion of patients with symptomatic paroxysmal or persistent AF who
are offered AF catheter ablation after failure of/intolerance to one class I or class III AAD.
Numerator: number of patients with paroxysmal or persistent AF who are offered catheter ablation
after the failure of, or intolerance to, at least one class I or class III AAD.
Denominator: number of patients with paroxysmal or persistent AF with no contraindications
(or refusal) to catheter ablation who remain symptomatic on, or intolerant to at least one class I or

www.escardio.org/guidelines 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation
(European Heart Journal 2020-doi/10.1093/eurheartj/ehaa612)
Table 22 Summary of quality indicators for the diagnosis and
management of AF (4)
Domain: risk factor management
Main quality indicator: proportion of patients who have their modifiable risk factors identified.
Numerator: number of AF patients who have their modifiable risk factors (e.g. BP, obesity, OSA,
alcohol excess, lack of exercise, poor glycaemic control and smoking) identified
Denominator: number of AF patients.
Domain: outcomes
Main quality indicator: ischaemic stroke or TIA.
Main quality indicator: life-threatening or major bleeding events.b
Numerator: number of AF patients who have a documented ischaemic or bleeding event
Denominator: number of AF patients or number of patients prescribed an OAC, respectively.

bUsing the definitions of the International Society of Thrombosis and Haemostasis.

©ESC
www.escardio.org/guidelines 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation
(European Heart Journal 2020-doi/10.1093/eurheartj/ehaa612)
Recommendations for quality measures in patients
with AF
Recommendations Class Level
The introduction of tools to measure quality of care and identify
opportunities for improved treatment quality and AF patient outcome should IIa B
be considered by practitioners and institutions.

©ESC
www.escardio.org/guidelines 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation
(European Heart Journal 2020-doi/10.1093/eurheartj/ehaa612)
Figure 24 Progression of atrial high-rate episode burden
(left panel) and stroke rates according to AHRE daily burden
and CHA2DS2-VASc score (right panel)

©ESC
©ESC
a The
higher the burden at diagnosis, the greater the incidence of progression in the next 6 months and thereafter. bStroke rates above the threshold for OAC are
shown in red.

a Highly selected

patients (e.g. with

previous stroke and/or
age ≥75 years, or ≥3
CHA2DS2-VASc risk
factors, and additional
non-CHA2DS2-VASc
stroke factors such as
CKD, elevated blood
biomarkers,
spontaneous echo
contrast in dilated LA,
etc); selected patients
(e.g. with previous
stroke and/or age
≥75 years, or ≥3

Recommendations Class Level

In patients with AHRE/subclinical AF detected by CIED or insertable cardiac
monitor, it is recommended to conduct:
• Complete cardiovascular evaluation with ECG recording, clinical risk
factors/comorbidity evaluation, and thromboembolic risk assessment using
the CHA2DS2-VASc score. I B
• Continued patient follow-up and monitoring (preferably with the support of
remote monitoring) to detect progression to clinical AF, monitor the
AHRE/subclinical AF burden (especially transition to ≥24 hours), and detect
changes in underlying clinical conditions.

©ESC
©ESC

www.escardio.org/guidelines 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation
(European Heart Journal 2020-doi/10.1093/eurheartj/ehaa612)
Central Illustration Management of AF (2)

©ESC
©ESC

www.escardio.org/guidelines 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation
(European Heart Journal 2020-doi/10.1093/eurheartj/ehaa612)
www.escardio.org/guidelines

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©ESC
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www.escardio.org/guidelines 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation
(European Heart Journal 2020-doi/10.1093/eurheartj/ehaa612)
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©ESC
www.escardio.org/guidelines 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation
(European Heart Journal 2020-doi/10.1093/eurheartj/ehaa612)

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2020 AFIB 2020 - For Web

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2020 AFIB 2020 - For Web

Uploaded by

2020 ESC Guidelines for the diagnosis

and management of atrial fibrillation

Definition Wording to use

Level of Data derived from multiple randomized clinical trials or meta-analyses.

Recommendations about integrated AF management

Recommendations for the prevention of thromboembolic events in AF

Recommendations for the prevention of thromboembolic events in AF (continued)

Recommendations for rhythm control/catheter ablation of AF

Recommendations for rhythm control/catheter ablation of AF (continued)

Recommendations for rhythm control/catheter ablation of AF (continued)

Recommendations for rhythm control/catheter ablation of AF (continued)

Recommendations for stroke risk management peri catheter ablation

Recommendations for long-term antiarrhythmic drugs

Recommendations for lifestyle interventions and management of risk factors and

Recommendations for lifestyle interventions and management of risk factors and

Recommendations for stroke prevention in AF patients after ICH

Recommendations for postoperative AF

Currently used terms (continued)

Recommendations Class Level

a Smoking, alcohol consumption, body mass index, BP,

Terminology that should be abandoned

Recommendations Class Level

Recommendations Class Level

Recommendations Class Level

All AF patients Selected AF patients Structured follow-up

Ambulatory ECG monitoring:

Score Symptoms Description

Recommendations Class Level

Recommendations Class Level

Most commonly Positive Other clinical Imaging biomarkers Blood/urine

CHF/LV dysfunction 7/18 Metabolic syndrome Small-vessel disease

Risk factors and definitions Points

Dabigatran Rivaroxaban Apixaban Edoxaban

Recommendations Class Level

Recommendations Class Level

Esmolol 500 µg/kg i.v. bolus over 1 min, N/A

Carvedilol N/A 3.125−50 mg b.i.d.

Intravenous administration Usual oral maintenance dose Contraindicated

Recommendations Class Level

Recommendations Class Level

Recommendations Class Level

Recommendations Class Level

improve survival and reduce hospitalization.

Several AF risk factors may contribute to the development

Recommendations Class Level

Recommendations Class Level

Drug Administration Dose Contraindications/precautions/comments

Recommendations Class Level

Recommendations Class Level

Recommendations Class Level

Recommendations Class Level

Recommendations Class Level

bUsing the definitions of the International Society of Thrombosis and Haemostasis.

patients (e.g. with

Recommendations Class Level

Full Text Guidelines

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