ESC lanceert nieuwe richtlijnen AF management

The updated European Society of Cardiology (ESC) guidelines for the management of patients with atrial fibrillation (AF) have been published, with a large part devoted to prevention of embolism.
 

"There has been much research into stroke prevention, which has influenced this guideline," say writers A John Camm (St George's University of London, UK) and colleagues.
 

They stress that AF accounts for about one in every five strokes, and that strokes caused by AF are often particularly severe.

So assessing the need for antithrombotic treatment is vital, and the guidelines, which appear in the European Heart Journal, advise a risk factor-based approach, rather than "artificial division into high-, moderate-, or low-risk categories."
 

Camm et al recommend initial use of the CHADS2 risk score, which assesses stroke risk in AF patients on the basis of five key risk factors: congestive heart failure, hypertension, age, diabetes, and previous stroke.
 

Patients aged 75 years or more should receive oral anticoagulation irrespective of whether they have other risk factors, while relevant non-major risk factors, namely, age 64-74 years, female gender, and the presence of vascular disease should also be considered in younger patients.
 

The guidelines stress the need for assessing bleeding risk in patients starting oral anticoagulation therapy, and states that use of the HAS-BLED risk score for this purpose "would seem reasonable." This recently derived score incorporates hypertension, abnormal renal/liver function, stroke, bleeding history or predisposition, labile International Normalized Ratio, age >65 years, and drugs/alcohol.
 

Camm and team provide antithrombotic treatment advice for subgroups of patients including those undergoing surgery or percutaneous coronary intervention, those with recent stroke, and those undergoing cardioversion.
 

For acute AF management, the guidelines recommend rate control for most patients and lists the drugs with proven efficacy. Direct current cardioversion is reserved for patients who are severely compromised by their symptoms.

Initial long-term therapy should be anticoagulation plus rate control. However, although data are lacking the guideline writers suggest that "it is likely that a window of opportunity to maintain sinus rhythm exists early in the course of management of a patient with AF."
 

In the long term, rhythm and rate control appear to produce similar outcomes, so the decision to use rhythm therapy can be tailored to individual patients. Again, the guidelines discuss relevant drugs for these purposes.

"Catheter ablation should be reserved for patients with AF which remains symptomatic despite optimal medical therapy, including rate and rhythm control," note Camm et al.
 

Finally, the guidelines detail possible upstream therapies that may prevent myocardial remodeling and, thus, deter the development or progression of AF. They also provide management recommendations for subgroups of patients including athletes, pregnant women, and patients with heart failure, valvular heart disease, hyperthyroidism, and pulmonary disease.