ESC POCKET GUIDELINES Committe for Practice Guidelines To improve the quality of clinical practice and patient care in Europe SOCIETY OF CARDIOLOGY® EUROPEAN SOCIETY OF CARDIOLOGY LES TEMPLIERS - 2035 ROUTE DES COLLES C3 80179 BIOT i (06903 SOPHIA ANTIPOLIS CEDEX, FRANCE PHONE: +33 (0}4 92 94 76 00 GUIDELINES FOR THE MANAGEMENT FAX: 433 (0}4 92 94 76 01 ‘OF ATRIAL FIBRILLATION Esmail: quidelines@escardio.org ! 1 1 J 1 EUROPEAN 1 1 I I Oe Re Toi Ree Re Ture| Caine el ophion othe epee nieve aes | retrospective sud reste 3 PeRele mere lured 2016 ESC Guidelines for the Management of Atrial Fibrilation’ Enared ErpnSeh rn (50 chairperson: malt pchctbham ace mal sn emi ch “Task Force Members: hak Ketch (UK) Anders Aon (Sweden Dan Ase (Norway Burtars Cat! (UX) anal Carel Prc (Sp Hint Cop Dine (Gera Hen He Jevoan Hens (The Netra, Gerhard drt (Garanyh Aone 8. Mn (Greece Jos lire veces) Bopsn Aanan Popes Roman Ulich St (hehe Bre Vn Pte The Netra, Paragon Vs (rat) ‘Othor ESC encties having partlepated in the development of this document: 0! Cuore Ia (ACM. Eropen Here Rayon Verne Ds, CathSo Table of Contents ESC Table of Clases of recommendations & Lev f evidence |. Epidemiology and impact for patients 2. Diagnosis and imely detection of ari britation 3. Chssfeation of aril brilation 44 Detection and management of risk factors and concomitant cardonascuar diseases Heare ure 5. Incgrated managerene of pacints with aril flriltion 6. Stroke prevention therapy nara rilaton pasens Lefesral appendage occlusion an exclusion Secondary stroke prevention and anécoagultion fer an ineacerebra bleed landing in ancoaguted patents with tri britation Combination therapy with oalancaaglants and acpaelets 7. Rate coneral therapy instr bilavon 8. Rhythm contol therapy in tril brilstion [cute restoration of srus rhythm Long-term ancirriythmic drug therapy Choice of rhydn con flowing reacmenc lure ‘scallion surgery The Atrial Flrlation Heart Team 8 Specie sation: Fralland elder’ patients Inherited eardlomyopathes,chamelopathis, nd accessory pathy Spores nd atrial fibration Pregnancy Postoperative aval brilion ‘Aral archi in grown-up paints with congenital heart disease Management of trl fatter 10, Patient imevement duction an seliranagement Page Pages Page 4 Pages Page? aged Page I Page 3 Page 9 Page 9 Page 22 Page 4 Page 27 Page 32 Page Page 3S Page Page 45 Page 46 Page 48 Page 48 Page 48 Page 49 Page SO Page St Page St Page 3 Page 53 Pood ‘clase! ‘cass Coneting evidence and/or 3 =e Aivergence of opinion about the Se Usefulness/efeacy ofthe gen a “traatment or proceaure, ce ena se Serer|. Epidemiology and impact for patients Atrial bration (AF) isthe mos corimon sustsned cardiac arrhythmia, with one tn four mee-age adults in developed countries expected to dvelop AF By 2030, 14-17 milion AF patients are artiipated in the European Union, with 120 000-215 000 newly diagnosed pasens per yar ‘AF i independently stead with an increased rik of daath and high evel of ‘morbidity such as hear flr and seoke, 5 wl as frequent hospitalisation and reduced quality off (Tel). “Table 3 Cardiovascular morbidity and morelty ass. that prolonged ECG monitoring enhances the detection of undiagnosed AF Prolonged ECG monitoring sors reasonable inal survivors ofan ischaemic stroke without an exiting dagnoss of AF and in elderly populations. implanted devices should be interrogated on 2 regular basis fr AHRE (trial high rate episodes, and pateres wich AHRE should undergo svoke rsh assesment and ECG moritring (Fawe |). | Figure | Management of AHRE detected by an implanted device. Dest reed moro epi exon moray dwt scen Tas egy fro congas wing ah ere Ske CHADS.VASe score [iow 20-04 ofa avcer are die OAE A gong rb of pers T iho re dared wa let, ces jee | eitatns | 10-40% ofA ers arp ery yar Tayote [niyo ned cor | Sranhrcoeas Let verwiodar | Let verter dysfunction i found in 20-30% of aAF pens AF Splanceon nd | cusesoragranterVdjnczon in may A patents wie ore Irarfae” |e cng preserved Y feton epi gaan AE | come ene | Cape deine a ares deraa cn cele nin | sdvaciar | ardempedA pats Brn wherein re more eves nen inAF tenth nats wehoue 2. Diagnosis and timely detection of atrial fibrillation The diagnosis of AF reques rhythm documencation using an eectrocardagram (EC), showing irequar RR itera and no esineP waves. Many AF patients have both symptomatic and asymptomatic episodes of A. There i good evidence I I I Tol pe tay ECE damn eg resting ECG I Fan ES ec Naaeoplen I I I Seok rk Rew doves eeograns fara) ein ater A Conic ptee ecarie (epsvalersh) cl pen prterence cary runs apenas ean seroivetaana em | I 3| Opporeunisicscrening for AF isracommended by puise taking eee reer rene AF pattern Definition ex nt] tsb tien dager repese Beart ff |2tesapineye aieusttyerr se fe anyunsatuiptsis omen enoeteans Su anlar | sheer bens ava Wienciomitee oa farsa hoes Boomerang ry ct eerie ctr ueea eee rear I | ceermatarcrencr ts Spee alan plore emer bres ain a EBVO cine | Attain fener cig ick Gas, | extemal mnt rin edeemorabe mete aicanacamersenaen IRE rte er nosey cone ree [Soe sr er Tegan | Conner yar oha Tea a oR reste cael [ein ters ated EG nanan eer Inne ECG mortor a rg loop recorder sou be Consdere to dozen sleet lion, ‘Strat EC scetong maybe conned 0 daaet AF pater g¢4°75 yrs, those gh strobe ermarenvAP | A ti cepted yh a ind yaa) Hen ye ora meron ry efnson nt pred pte wth met ‘8 Spd thm corel rae be doen be amo be reid ager pert. | ae 3. Classification of atrial fibrillation [AF aly progresses from short, infequent paronysmal episodes to longer and more Fequene stacks, culminating n persistent AF (Table 4) Although the patern of AF maybe the same, the mechanisms underpioing AFvary substatily between pavers (eb 5). AF symptoms shouldbe described using the modified EHRA score (Tee ‘Recommendation on use ofthe modified EHRA symptom scale Recommendation ni ‘Use the modified EHRA yom ale recommended ie tll prace nd esarch iso quay Areas motos ! Se TTT Coed [A secondary | AF npr wes WV ap oF tosrcurl” | dasole dren ng aning heart dase | hypertension with Vader ther ruc here sie The ort OFAF in ese pers cormon ‘xe ofhospaon ands ed ees Inreaed aa presre amd w smear remodeling gre wth oraen ofthe spac ad Pretraf por eine FalAF [Paces wich ep stralrne | Loaleed ema naw cs a roguentsoreepscdes ot |oigatng fom te umenary fpronaral a feaon Okan |v neste AF Fahy ymporateouge ens | AF eto ona or ow ress wth depute aril wars | ire coda to be part (ecaseAPyauileaopy andor ftir ype ofA sealed dere WAR BaheeacAF | An airs of coon gee ih ear ome Cueniy der Te rence ofrecer may 0 ‘eee extant tame,en sane ee ese TS) ood Posoperve |New onet fAF (ily se | Act ectrenflanracon ai oF termining) emer (aly |e sro gh ppc fardacsurpyin pcen who | toner changes ant ‘reese ytimbee surgery |vlume ovens posaby eran, linia presentation Possible pathophysiolagy | End ope cry PAE” | wiha prec state [Aft paces [AF pi with rd nai, | Leal present) and —] frchind|akerrel ae srerymdin | soume Caprese lace | Tensor |some oes terval aise, | aes of al evbrgemen prommese eral reading [Anais |Unaly poeple wo —_| eran gh aaa ator edmensyeFeig_| eure Monognc|AFinptenswaharerted | Thearehnagescrmecanine | 4, Detection and management of risk factors and concomitant cardiovascular diseases Many eardiovatculirdeenses and concomitant conditions increase the rick of developing AF, recurrent AF, nd AF-szocnted complications. These concomitant conditions add to the AF risk conveyed by patent factors such as alder age, obesity, smoking, excess alcohol consumption and frequent vigorous exercise Identifcation of rs factors. tele prevention and treacment Is an ipertane component of preventing AF and is save burden Heart failure Many AF patients develop heart ilure with or without reduced election fraction, ‘The diagnosis of hare fue with reduce ejection fraction (HFrEF) can be made wth any carciae imaging modslty Oiagnosof hee nue wth preserves jection fraction (HFpEF) inthe context af AF is more challenging. as AF and HpEF boch present wich similar symptoms and elevated natriuretic peptide leva Management of AF and HFpEF shoul focus on contelof id balance and ‘concomitant condos seh as hypertension and ischaemia, rrr ea Ca ced Se ee | ara ere = vee | Saat oe Se | mis atres 4 2b "Normal daly activiy discontinued a ft fctoryntiaincerg [rope brain de re rege” eens Fare 2 summaries he appronho pens wh new dagosed AF adhere int n ouput fare : es Figure? Iniial management af newly dlagnosed concomitant hear allure and AF. ‘Management of patents presenting acutely with AF and heart allure Prose emienpeie i ngdriacaerslapaesnntvarthOther cardiovascular conditions such as hypertension, valla heart dense, abetes metus, obesiy, pulmonary dsease, or chron kidney dase often coexist in AF patients. They shouldbe rested vo reduce cardiovascular is, and ‘he are relevare to inform AF management options. eee 1G Class | Lever yr he sarge shoul be canara pvr mal repion preserved reson. and new net AF even the absence of symptoms garter when ae raps ett, acre mil sean dca atony | Hl | oes Recommendation Ty aba yrons wt AF, wait le tystor with managanene other rk tar shui be considered to reduce AF burden Sedoympcems, ee es Recommendations Correction efhyasaenia sb ado shoud be conadered at nil marageman for pars whe cevlop AF cing an sete pumerary nes or exacranton of cron puloary dee Inarogiten fo az sgnof bruce seep apnoea shoul oniere inal AF pert J Otstucte see gross renin soul be opted ta reduce AF recurences aa mrove AF trent eu, Recommendations Tha asesumeat okey fino by rum Gate or rentinecnranc seconded AF pens to ect | kine diese and to suppore crc das of A heap. ‘NAF pant treated wth oral wcomuation shoul be ‘onsiered for ata yarn uneton elation to detect | roe cone 5. Integrated management of patients with atrial fibrillation Most pavenes access the healthcare sytem intially through pharmacs, community beth workers or primary care physicians. The Intl assessment of tients presenting with newly diagnosed AF should address five major domi haemodynamic sabliy, the presence of precipitating factor or underying conditions, stroke risk and acogulon, rate contol, and the ned for rhython control therapy Figur 3). Several agnosie procedures are needed ca define the bese AF management. Review by an AF service is usualy eeconimended, nlaing urgne referral in some patients (Tole 7). An iteratad, structured approach to AF care, as appled sucesly co exher domains of medline, wil faite onsite, guideline adherent AF management fora patents, with te potential to Improve outcomes, AF management comprises theapes wih prognostic Impact (anticoagulation and treatment af exriovascla contin) and therapies predominantly proving symptomatic benef (rate control, rhythm conval Enparirg the expected benefts co each palene atthe start of AF management wil proven: unfunded expectations and has the potent to opemize quality ef ite Figure 3 Acute and chronie management of AF patients, desired ‘cardiovascular outcomes, and patient benefits | ra bore it yon | Yenc ce a | ea range aL sep ——Se Se sere ESTEE Ce ee ot ae ee Haeredramiinabl Unconolabe ra ‘Symponaic daria vo rae reditnfrae carec ge rg lf ver ron Tans kouonc ack oka nmendations for an integrated approach to care Recommendations - os a negate appronch wih aracared epson teseand | owe shold be corsdered inal pens wth A, ing sngrona using adherence ao Feds hrplaaon nd ens. Plcing pans na cena rola the decnon making ovabe | conser overt lor management pan prlerences 6. Stroke prevention therapy in atrial fibrillation patients (Oral anticoagulant (OAC) therapy can prevent the majority of Schaeml strokes In AF paens and can along life. We recommend estinsting stoke risk AF patients based on the CHALDS.-VASe ris score (Table 6). ln general, paients Without dincal stroke risk factrs do not need OAC, while patents with a CCHA,DS,VAS¢ sore of2 or morein men, and 3 more n women wil have lear bone (gure 4) Many pationes with one cncal rik factor (e. CHADS. YASe ‘score af | for men, and 2for waren, wl lio Bene ram OAC, blncing the lower absolute rs f stroke, eeding risk and patient preference a eS eT] eee CeCe Congestive hear are Seneympecs of erie o bee eden ord ane ecto on Hyperion Rest Hood presse > 14050 mn an alent oo oecto o crent chyperesve teste Trarsthorse ehoriog apy recomended inal AF patents Wiser apetion ae ngerm EG montoring sold be onidered inlets pater toasess heaceausyofrteconralinsmpemse | i Fates and relat sympcons with AF opsodes 2 iz Stepnictaeaseataenem ie eyeaee = eT Deiee ation +i DSBs flags works ot A po eg ail elo ern hol pcp anes Previous stroke, transient ischaemic attack, or thromboembolism a 6 ctv eid Sah Galo revien te = a | fall cardiovascular evaluation indiuding an accurate history, Previous myocardial ifrcton peripheral artery disease, or sore plaque i ores en enone —v_ 5 sasonh creer pos Belem — *Figure 4 Stroke prevention in AF. | sricontion indeed a cect catons Corecireverile Deed recs (Tk occadg eves ray be \ cain \ es a far OAC fle) wy ra etn AA“ al pms NOAC cot Kt is, eco cmp keer eg Seer r= pr). bes rane oh Stem hy ede 9 pes mal a an Several Bleeding risk scores have bean developed, an risk factors for bleeding frequertly overp with thote for stroke. high bleeding risk score shoud seneraly not resuke in withhoiing OAC. Rather bleeing rk fctos shouldbe ented and treatable factors shouldbe corrected (Tale 9 Anticoagulated patients based on bleeding rik scores Pena Hypertension (spell when ste ood pressures >16 mi able IN or ine in therapeutic ange E03 n patents on unin Kanga edicionpredsposng oles, ich tangata droge anor anny drag = [cee soho 8 rinks ee) Imre eal neaan=™ [Redced ptt count o neta ed ‘Age ( 65 yar) 5 yen) = Sa paces ie eT a eer iBeth nanan Kanon ra antcoapdas (NOACE apbban abit, - elena, rrarocbar) aed earn K ogi are elecve annals : Terao prenon Ak neigh AF parts a NOMC recommenda : aie] preference to ination with viaminK antagonists. NOACS should not be used in a jelsele (82 [sz]. Fav wth moderate ral sures or mechanical ear aes The eaelPile les [fa/s |s FNORC va have been conducted wt rey selected doses nding Cen Bey |iseie leo (85 ‘rules for dose reduction in patients with kidney disease (Table 10). $s ae 1S 5 Artpales fr eephpith or dere) we ober wardens iu i andre retraced force preven n AF pats | : i ithe ara appendage (LAA) ocusion maybe considered In those with cls 3 lefzl i : contra-indications to anticoagulation, and surgical LAA exclusion can be » \Es849] sl, [32 : faired somber oie pry or ors wll drone Bale teatHedied (fs moceire Flelalg |ealgeelasiee lei c a2/3]2 [feta cladis lie ‘Recommendations for prediction of stroke and bleeding r ea "le eg egal" ales 82 & be FER Sls |E5 Recommendations om sala i The CHADSASe ware eanmeded rool ik . - - pecan tase ma |. |. lng | ale. [¢ ge 3 5 a2 |.3 ft linge res sh a oat AF paso reLlsie (2 (te |ee/8 lie ee ey neki tc tr end yelele le [ES ladies (it Blaartar’ ah agian wopedn and Newrialpre= ye £5 FS 3 bape eretcpot coun lerstlaed atetrea Hee Sieg | sis: |e sodeand tng kn A oat 4 = |= arta CHADSOASE = ang Par ve poo AR EH f G ic A ei lak gi i 8 8 i i y 7 i Glh leet . 4g |islits i as sh : |Recommendations Clase [Lever Oniancephin iex7apectimbamcens Recommendations ronmmat fora mal poo ith CAADSASescore [a NOACs gta. tgs cain avira week ater nore ae |rsonneded nar wth mecca hes fae fs Tort nccapiaion benpyo peeve (am |slorrateewosoere msc nl entoee tenant eet pee whe CHADS AS core ‘im eer OOS Capt Nar Men pe oan fae oo oor more ae ‘NGM esta Kemgent on eerie OAC ute bon TR vane nde Onlandagdain aengy pot ivonbonisin taal — fala toqeicho saan nape an oer etree Smiacianiespaeenmscraswascsort| | la fa candereg nde ancteaand peepee, [a [ee enone ‘rl aeardon dha rors ener shod bs | ST Coideetin tone At porn CDS MScsre 2, | I | considering ined chr tia patent preferences. De Recommendations | iain K nego therapy (NR 20-30 or ihe Teeonmandd fr tke presen AF parts with E 5 noderata e-oar rr eno or ecu hear wae. When raleceagitin fr ntiedins pane wh AF wo sil fr aNORE pntindidpran edontan.or tartan R :NOAC ie reconinandedingrelrereetos Varia Kanagoast.—| Wen pats are raid with amin Kaetgont, ine in therapeu ange (TTR) sould be kepe ash a pose an sey manors {AF patensakeady on rasianewtha amin Kanagonit may fo te carideed for NOAC wexmant TTR nt wel cond spigot adherence or part preference wou cons inseaions to NOAC (eg prostate va) EB Combine foal antianguares and ptt Whar Increase blecing akan shld be 201d in AF patets 5 without raha nation for pele nhiton inal or ale AF pases witout dor] woke rakor snsengli or rtp therpy ent rxommence or ch Aptis monotherapy it ot reconmerded for sake proverson Epis reardes of rue ri Ae surg accion or excaion oT eUAK ks ‘ecomiatded to continue srcoaguason nati patets with A for seroua preveon ak ednon my be cord for ack prewribn npadens won AF an cortisone or longterm ancngle, extmert fg those nhs previous He rete led witout Sujal occlrion a eacaion othe LAA iy be considered or sole proven pairs win AF undergoing ede srry. Supa acs er cn oh LAR mb constr toe everson npr undereg eran Farge. Secondary stroke prevention and anticoagulation after an intracerebral bleed The most importanc ris factors for stoke n AF patients are advanced ag and previous stroke or TIA, andthe hes rik of recurrant stroke is nthe exy phase afer a stroke. The tation of OAC in AF patient after an ace stroke ‘or TIA and after exclusion of inracerabal haemorrhage need to bslncesroke and insacranial Bleeding rk (gue 5). A multidcipinary decison algrim foc intaing or resuming OAC in AF patients wth an ftraranal bleed fs given infgue 6 3Figure Initiation or continuation of anticoagulation in AF pationts| after a stroke or THA. Tis sppraich tase on onsersusoprion rater han prospective a Figure 6 initiation or resumption of anticoagulation in AF patients after an intracranial bleed. Ths prc stared o cor epson ‘ease dnl pte eon 93 mltiecpinryparw srr re ‘reer ok pseu carlegse nererag andrea). ‘Patient with AF suring trom an intracranial bleed on OAC acuta event establish Intensity of arcogulaton (Heng ow ch) | Wadarte rake) (Serena (ss 215) (QaHSS 216) pe ers See coco surg erenson Neate coed rgey remertapewemfooner Newroopayensabe ery per Usconted paren Fakes orartag amformvon'y | | eandormecr CFertalac dys | | CTeor PRlae gy sea cnr orn nap Mt age er rgrg NSS “Raa cam lenses aan (sepsis ep Ne a Skah OAC -erempinoeIA= wae ec : + “Contra-_ (consider farther information te allow formed judgement Indeation ———. indication || Fecors poring Factors suportig wetolang of OAC: ‘einaton of ORC: Bedrgocured an sdequly|| Slag ocd on A GodNOAC orimaearga || “srnsetng of onene ‘reer inerupeon or || Taurate or enalecase dering oun ere Wl canted Wperaraon| Unesceted ypericn || Bulent em Cor teed Nocti ie meter Severe nrc tad ‘esr Fede rb eg >'0) || Sug rane of bd Custer eedcamette || hereon Tenoed or reed stench rons hse ‘osurimcped or cle Necdter div anc: || Hig rare ce ‘Serpe ® ‘Patient or next of kin choice informed by malscipinary team avi Telats or resume OAG, choosing an agent with fw ntracranial bleeding sk alter 4-8 weeks (D6). or tear AA i peg NOA onc gic cpl Onc ert msapie P= porararar ee Aa a Fy 7SSS = eee ed Recommendations soaglzon with aprn 6 LMWH sneer an ahaa rake ot recommend AF part Tr ptr who fer a TA or stroke whe on anicengutin, sdrerenes tothe shold be assed and opti in paents who era madert-tosvreichawric la wie | ‘Shonen ction shoul be erp or Sys sed on amcdcipnay serine of ee roe nd beeing ise | [iA patents wha aller a woke spr shale conser for rowan of econdiry soa wi teint or euro of Peloton ees Spee iota wi PA neracormended INR above Tetra gr PTT i owe orl NOAC ar recommend ener wih previous S20 ‘fer Tor roe, combination hrapy of OAC a ay Endl nt rconmended [After nerscranl hemorrhage. ol adenagon apes ‘nth AF maybe remaeed er 4-8 weeks provded the case of Desig th lene rik actor hs ben ete or controle ‘ino ou nectar gto NOR =n Kango ecu Bleeding in anticoagulated patients with atrial brillation Minimizing trexable Being rik actors (Tobe 9) seems paramount co reduce the blaeing rate on OAC, This neludes | Gonerlng iced presse according to current hypertension guldeines. 2. Asses pir bling evensn patients in whom the source of bldg has been identfid and corracted, OAC canbe reiined 3. Achieving thigh TTR on VKA cor chactng the apaoprate NOAC dosage hte ncn rls, considering real unecn, age, and weight 4. Avoiding aleobol excess. 2 5. Reducing fll; however, OAC should enly be withheld from pasens with severe uncontraled fs (eg eplpsy or aévnced multisystem atrophy with tsclorrds flor n selected patients with dementia where compliance and scherence cannot be ensred by 2 aria 6, When interruption of OAC is required, briing with heparin doesnot seem to be beneficial, except in pater with mechanical heart vals Even on optimal management bleeds can occur and health care professions should be prepared co manage ther. A scheme to manage Seeding events in patients on OAC shown in Fire 7 [Figure 7 Management of active bleeding in patients receiving | anticoagulation. Insition sous Have an ered poser ples Ce ‘drape oot tn Tradl ‘aae(ee puree) Vann (log a[Recommendations Blood pressure conta nasa ned pats wih hypercaon hol be conaceos to rece the rik of sen ‘When ibs ed ede dove (110 gece) my beconadredm pars >7S year to rede he ek olen Inpaets ach of gona len, a VKA or anetee NOAC prepara shold be prefered ovr dabiuran [Sdn wie ay Fraroxabar 20mg once cay. edoraban eo mgonce cay. ‘Ascend resenant oso Heal ec shoud be aradered nae panes consdred foc OMG, Genetic esting belore che ttn of VKA therapy lac. recommardee Raraton of OAC aera Beadrg err shoud be canard nll pee byamuliipiary AF ea, coer, een ameonguer anc role preetion erento Improved minagenent of tors at conrbuze a esting ad In AF pans wih sere are Dd vo recone rerapt OAC therapy the use of sed rsa stdin NONE nwo a gine HC ‘Combination therapy with oral anticoagulants and antiplatelets Co-prscription of OAC with ancpaelet therapy, in pariuarwiple therapy, increases the absolute rik of rajor haemorrhage. OAC monotherapy, and not combination therapy withanepnteles, is recommenced in AF ples with seable CCAD. Inpatients treated for ACS (Figure 8 andin those recelvinga coronary stent (Figure 9), shoreserm tpe combination therapy oF OAC, clopidogrel, ad aspirin seems warranted a Figure 8 Antithrombotic therapy after an ACS in AF patients requiring anticoagulation, ‘AF patient in need of OAC after an ACS Tine from ACS a4 1 mony je | | teeters) Iaomhe elon onc Magee trys Ml Copp 75 mp ly cs cera =a Sir O8C nl aegis (errant wei = prance rare la dine pag crate room et ‘Sicha Sark Cree toe code pete t I I I I I I I t I t U I tIntervention in AF patients requlring anticoagulation. ramen ote onc ME pin 75-00 mg Wh Cepget5gcy ssn eat cA sc ee ere kayo nage) P= posteccemey emn ‘Salgryamtsc tune coqairvnyoal p \Sicgengenaprne [Sates Sn tstcysy cnn Ea Figure 9 Antithrombotic therapy after elective percutaneous Recommendations eee] ‘Aer deco eororar song hr oberon arey asec [ll AF pers aio sae, cantnason gla whan, Speed ora ald be creel or eth oper recrencororae ad ert scam eens | Man ACS wht ngraion AF pnt kof rte cembraon rp apy hase, apo anda [salanicoagare odie condrestor |-Srandopremne | Mm | teen cororaryand erica oe ‘arn AS wort mpieon NAF fats kt sea, a treatment wth an oral aneoapane np pda stud be comiere for upto 2 moths a prean recrerecororary and caesar es. s The duran of embton tharos pec pl therapy shad be epi priog bang the tiated of recurrent cron vet ab eee Dial ergy with ry orl aicngln pls epee 75 mela maybe considered as an aarantve crit ripe hry wh spn nlc ats Class | Level 7. Rate control therapy in AF ‘ewe (Figure 10) oF longer (Figure {(} rate contol can be achieved with beta-bocers, digoxin, ee calcium chanel Blockers ditiazem and verapamil, or combination therapy (Tbe 10). The optimal hear race target in A patents is unclear but evidence suggests that lenient rate contro (heart rate | Pes yoo ryarda me amin |AV Hed Wil ow veri te Vives [ot Ogre | Osyesconenion tsrpm Mion [2h Pepienowe || 1S Dae Wipes el ier wi ome in [ earaton OS prlergion i, ont [45000 Asians wth HD aor pre carter dose Tea |W [meow |Imeaer | OT ralomonpobmorre Tomn | IOninaher | verecubr experts vntrgtor | primes 4% opens Wi sow Tom | verre e Jolin pais wth QT frorpon pore see Wier ow eon facia Rama [V|Swabzonr [2ogkeowr | Hyprion on suined| Tome | Omar | yerradt aromas OT nd vaingtor | ORS prongs iS | Arn pens wl SBP OD rrmgreer (30 )ACS, rk Chas Wand are {are Tinsral oegson | orc QT 0m l ower nee, ‘lac diese nnens Comper mn u Long-term ehythm control Long-term use of AAD should consider thar: I. Thealm of reatmantis to reduce AF-elated symptoms 2. Efieacy of AAD to maintain sinus rhythm ismodest, 3. Cliealy sucess! AAD may reduce rather than eine the recxrence ofAF 4 fone AAD “alsa clinically acceptable response may be achieved with another gent 5, Druginduced proarehythmis or oxra-ardiac side-effects ae frequent 6 Sofetyrather than efficacy considerations should primary guide the choce oA AAD. “To reduce the risk of side effects,» shorter duration of AAD soems desirable for example after cardioversion of abltlon.Lenger-cerm use should carefully ‘consider the sfety profle of each AAD and paenecharactaristis (gue 3) Carell analysis of ECG changes ring the ination of AAD (PR, QRS and QT ince) can identity patients a ik of devgindoced proarehythnia (Tete. [AAD should not be used in patients with exiting QT prolongation, or chose with siniieane sinatra or atrioventricular node dysfunction wh do nor have 1 impanted pacemaker. Catheter ablation is ndcated to improve AF symptoms in psents who have symptomatic recurrences of AF on AAD, or 25 an alternative to AAD in Sslectd patients with symptomatic paroxysmal AF, performed in experienced centres by adequately rained cams. Ta minimize periprocedural completions (Tobie 12), patente should undergo AF ablation on continuous OAC. Patents with recurrences of AF on several AD andr aftr catheter ablation should be cussed nan AF Heart Team, Management of concomitant cardiovascular conditions can als reduce symptom burden in AF and factitate maingenance of snus rhyhm, including wight ‘eduction, bloodpressure control. hearefaluretrestmentand moderate exercise. "ACE ihibicors, ARBs and bats-lackers reduce rew-onset AF Inpatients with structural heart iscse %Figure 13 tniliation of rhythm control therapy inaymptomate patients. Titiation of long term rhythm control therapy to Improve symptoms in AF ec pen ndgerdomens te pried in lee a, Riythn contrl therapy indented or ymptom irreverent in pater with A ‘Class | Level Managenert of ardovasar rekon wd woitnes AF igre pursed npr on hyn col hap | eae micas of si yer ‘Whe caption of AF aocted wit anodyeani rab, the che betwee electra and prmaclopa rdlewerson shoul gest psone and pycanpeternces erie earsirerson fF iracormenda nae wh sata emodyrantabty ose ester tp. Crdoverson of AF (her electra or parmieolopea) "ang pratene A ear rhythm conta ther Pretraacnetwithamiodrone, ec, utd, ropaenane toute consiered to enhance succes of eer ‘roenion nd prevent rearen A Te pars wid ohstory of ache severe ase fein, propsonoe or vrai ae recommend or piornscslapal edoveson of new-onset AE opts wir no hioryofichaeic or ctrl Rear ens, [bald shou he cariared for paraclogal eonverson of AE in aeecradpcens wth recenconsx AF and no agian sca orsemnemie heart desea arg or or of fern ot prpsenne epithe pier approx shouldbe consered {or patertied rdomrsion folowing lt sere Te pnts with chee ndorstucural ere de, moron rcormened for erioverson of ARecommendations | Verlaan maybe conieed aan aerate to amiorone for prormacloge dO msupon Boies Ippon CCl $9 gi. eerie eerste decor eirsclatipan | z aChoice of rhythm control fllowing treatment failure Patient preferences, local acess to therapy and muliscltnary approsch ae important consderations to inform the choke of ehythm control therapy after tn iil therapy fare (Figure), Early recurrences of AF or arial tachycardias after ablation (eecurrng within 8 weoks) canbe treated with cardioversion. [Figure 18 choice of rythm contra appronehes following ‘treatment fallure. Selection of further rhythm control therapy after ‘therapy failure to Improve symptoms of AF Faire oh Falah Aronearone eer “ecnie sbinion propafenone or) eases ea ee GG ez a0 ayn ug hPa per an aera dea re te pone ea igs pre race gcd A seg roa ren gy sey werd rng Har a ‘Atrial bilaion surgery “The deciion fora surgical approach should be discussed within an AF Heart Tear, ‘ade and inform patent choice. Concoritane AF surgery results i pear freedom from AF compareé to no surgery, without a detectable dference in other outcomes (Figure 15) Ape from an inerease In pacemaker implantation, perioperative completions are not sgitcancy increased aed AF surgery. tand- Alone maze surgery canbe performed using 2 minmaly invasive thoracoscop Sppreach, which smo effective that epentcateterabation for maining sms Ft but wth higher rate of completions (Tal 15) As wigheathete ablation, ntoaguation for troke prevention sould be conned indefinitely in pains at hig riko stroke, even after apparently sucessful surgeal ablation of A. Figure 15 Surgical rhythm control in patients undergoing cardiac surgery. ‘AF patient undergoing open heart surgery (eg: CABG, valve surgery) iy convo erapy esa to improve Abreted smpuams Yes (Patient choie informed by AF Heart Team fea Seer san Gs ge Ap pea ‘are eb Pn pon bs npg pede | Setar ede ode sok ce ete OOP ery Sea s eeConnector tats [Pacer epenaccn [Antccnuion for stroke poventon shouldbe contd Drang fr pastor indfny aer apparent sccesl ctheter or sri abiton| Sey AF parte athigh rit soi, Recommendations [ Apatens shoud rece orl swecaeglaon fr a aa | wes ste eather 8) 2 surges aC) sbiston This Task Force propotes tat decsions involving AF surgery or extensive AF ablation, but ao reversal to 4. rate control strategy in severely symptomatic tients should be based on advice from an AF Heart Team. An AF Heart {Team shoul const ofa cardlogit With experts in AAD, a incerventonal ectrophysologstand cards surgeon wih experience in sgl AF ablation, Such AF Heart Teams should be esabshed to provide optimal advice and Ukimacely co improve rhythm outcomes for paints in need of advanced and complex rhyhm conto) nerventions. eee eed ‘Catheter abison fsppeomacc ronal A inronrended to improve AF syngas inp wn av symptomatic Featrenes of Aron anny at ergy erodaront retire feaede propaeone, sta) and who pele cher hh carr ray when prormed by 32 Sntrophyslags who ht ees propre ring and performing the procera an exgeriiced cee, bln onmon sal Sater shol be conser to prevent ecuren tar a arf on AE sbitionprocedie#prevasiy documend or orig ding the AF aan, [Caecr bio of shoul be conaeret seine ore prevent rere AF nd ingroe symposia atts ‘hppa pry AF ara alersse to aearhycii bag hay consign cee bee ik % Wen cht alton cf AF lined criminal snocoaguen wha VKA a6 or NOAC (ls) shoes rare iy be pode. martin late secenguen, Catheter aon sau args scan fhe pulnonsyvene ung nifremioney sion er eyothemytaloan eters [AF ablton shold be cnsdered msrp ans wi AF seen faure wen eczed geet ratio por symptons| | and cardac rion when cyerdoryopathy is supeced [AF sion shou e considered a raegy oO pcnaar imolunatonnpstensweh AF ented bade ‘Ctetr orga abtion shouldbe corer np wih samp erento lnnpandng eres AF relctry 1 AAD therapy oimrove symptoms, considering patent che eof andi supported an AF Hoare Tem ins naive srery wh epardal porary vn oon shoul consderedn patents withsypeonatc AF when ‘atheteraiton hs fled, Decors on och pecs hobs supported by an AF Hen Tes Mae srry, peti via marly vate apereah, prior yan adquntelainedopaator nan experiencers ous a comiered yan AF Heart Ter as weston option or fara wih mpm reac prsten AF postion Me srry preferably Dural shod be conoed hone undergong crac surgery compre symptoms bua to AF barge aes rk on proesureand he era oh ey control therapy. Cereritar awa rua or pulmonary van don nay be consderednaemperatis AF pert undergoing erie mre. 79. Specific situations Fra and elderly’ patients Elderly AF patients ae at higher risk of stroke and ths moraikaly co benef from ‘OAC than younger pints. Avible rate and rhythm contr incrventons, including pacemakers and catheter ablaon, should be used without discriminating by age. Invidual patents at older age may present with mulpl comorbid whieh may int quay of fe more than AF-related symptoms. Impairment of Fenal and hepa function and multiple simulaneous medications make drug Inceactions and adverse drug reactions more ly ucgrated AF management tnd carell adaptation of drug dosing seam reasonable to reduce complications of [AF therapy in fal pats. Inherited cardiomyopathies, channelopathies, and accessory pathways “Trestment ofthe underying cardiac condition fan important contribution te AF management n pavents with AF and Inhereed eardomyapatis, including the inherted arrtythmogenic diseases. In WPW patients wih AF nd evidence ofan cessor pthay, catheter ablation ofthe gachway is recommended to reduce the risk of sudden death, AF ig the mast common arrhyehma in pacens with Hot associated witha high stoke rand the ned fr OAC, New-onset AF in {young otherwise healthy individuals shoul rigger a careful earch for iherced ondkons, ching cine! history. fmly history, ECG phenotype cardiac imaging and argeted gonctic testing eee ed Recommendations Cathe abion ofthe scezory paths io WY pans vwthAF and rpicondoction ve he cesory pany is ‘Reomendod to prevent sodden cree deh Cab ablation of the acetory pathway ie recormended thon dey in WPW pacers whosuriv sudden cardiac death, Asya prs with vere pre-exiaton and AF sould be ovate fr ncesory ther alton ser re coursing. ong ra aseouguon to reer soko recommended in HeM poets deep AR ee) Recommendations Restoration of si ryehm by elec or pharmacological ardoversion a ingrote spams receded HEM | pints wih sympeomalnov-cnset AF Jintsemedramialy sable HCM pens wih AF venti] | coral ui ten locas slssemerpa recommends “Treen fk auto ter absrction bul be coneredin Af pats wth HCM to inprove symptoms [Ariedirene hod conde wo ahve im conealand ronan si pin HOM ptr won rere srmgror A Taga esting shod be corsered gan wth AF and [eee Tnipcetctmeredcrtemepcneser scp et | secs ory fry horyordrocrdogaate pcame. al Aas, Hered de HOW =a Sports and atrial fibrillation The management of athletes with AF i siniar to general AF management, but bodily contact and potential trauma shoul be considered to decide on OAC. Bexa-bockers are not well colerated and at tines prohibited, and digo, verapamil, and diazem are often not potent enough to slow heart rate during exertional AF. Catheter ablation for AF should be considered and if ug pilin the-pockes AAD, pains should be advises to refrain rom spats unt the AAD a ben cliinaced. Recommendations for physical activity n patients with AF cert regular pysal vii recommended open AE ‘wl ber hole count hat ngs mare mere spor parca a promote AE A aban shuld be considered wo preven recut Ae siete a @[Recommendations for physical activity inpatients with AF (continued) Recommendations The versed ate whe xrcang with AF should be elated Inver able (oy spp nor by mooring) and traced ‘i onl shouldbe seated ernest of pl-n-th-pcke Cs Tanaris preted ean or sport as reat AF part an rt raves ofthe asrehyehm: hve ee Pregnancy Prep women with AF should be managed a hghisk pregnancies in close colaborason wich eardologees,obstetrcans nd neoratologists.Aicoagans teed tobe selected considering potential rsks tothe foetus. For rate contr beta-blockers andor lgoxin are peered an carry 2 US FDA pregnancy salty Caungory fC (beefs may outweigh isk) except for acnoll ategry poise trigence fF) Al rate conerelagens are present in breast mi although eves of tetalockers digoxin ad verapamil are usualy too low tobe considered harmful For rythm contro leainide and socal can be used Electrical cardioversion is eect in cases of haemodynamic ins, but requires fetal monitoring Recommendations dur Recommendations Eacrialcaroveson can be prtorned wl 355 ope andi rcanranded i pains mo ae emodjamicly ante do AF and wherever teri of | casing A cone ph for he mater rth fon, ‘eosin racer preg pans with AFSC ve. Tomiie eng riskand inane leg oveagused pe recomended dary the ise reso per andthe 2-4 wank blr elie Vea Karagoris Sr hopin can be edn enanngpets cl he prgrncy [NOACS shoul beavoied in preeany adn women planing pregnancy. pregnancy Postoperative atrial fibrillation ‘A scommonsfter surgeryand cated withan inreased length ofhospeal say tnd bgher rates of compilations, Postoperative AF is associated wich increased froke risk OAC use i astocated with reduced longterm mortaty in these pants, albeie without controlled tras In haemodyramicaly unstable patents, ‘occa or pharmacalogal cardioversion is recommended, Amiodarone oF eralalnt are affective in restoring snus rhythm in symptomaceepavens. In symptotatc patents and in those with aceepeablesympeams, ate contol oF deferred cardioversion preceded by anccoaglation is reasonable appreach, Ss Recommendations _— Fervoperae cra bets locker tarapy is econmendedor he eran of postopera AF tr cardiac gy Restoran of ru yim by eleriel arsverson ot cary rs recommended postoperative AF ith arodyaicnaly. Longer anicoaplason sod be considered poe ith Arter cade srary ari for rok, comeing inal ished bleding ri pecartytnic ves shold be conaleedorrpamne postopera A er cardi orgy an tarp estore Sen [Pest opesinesiedirone hood coniered prophet rape prevent A ae ode rey Aaynptona postoperative AF shady Be manage wih Teena eran be cared er rdoneson of portaprtr An pan wiht eee hea re Pps, Sesser pecs re tar) w‘Aerial arrhythmias in grown-up patients with congenital heart disease ‘aural arhythmias often occur ite afer surgical reaiin grown-up patients with Congenital heart disease (GUCH) and ae associated with Increased morbidity nd mortal. Managemen largely based on observational daca and expert Recommendations Class | LeveP perl ae delect Sos toad conadered ore Be uth [a head lie to dneish be canes far Rar an con | |inpadens who seed pal ose fan tal septal éeectand [| ik ave tory o symone ral arya, AF atten Should be consderod std ine of urge cose ‘Cox mae srry shoud ondered pars wih ypc ‘andar endaton or cece reat of cogent ear cs [Nish surge sad be done experienced os. ‘Management of atrial utter ‘Anticoagulation shou be ued in pavens with trial fate nthe sme way a A, Rate control and cardioversion canbe attempted similar to A, but medeatons may bees effec in arial fuer. Abistion ofthe cavorcusi isthmus forthe ependene right aval fuer is recommended for recurrent atrial fer, Recommendations For pers witha futon ativombo hope recorevndedaccorig to tha save rek prof wad fo AF ‘Over stra rig of al uttr ul cones an sitamatve io eetrial arcoversion depending onloel albiy snd eperinc. Managemen of yal serial Rata wih ston ol he enor cp iss recommended fr patents fig arctic ug, chro os rs ne treat conierig per preerees. ‘Clase [Lave ‘nl anconpnon souldbe once inal nu Ls wh franc ep cjnn onan palason osama ree ncahsry oA lar or er ral eet eyerda halt cone et dase ae i A Toop shoud be conaderedfCHA.DS.WASC sare Caer abo ral ares sine wth congenital here fetes ray bcos hn prlorned i parece’ cates: inti wh corgetl art dss, rnscetophnge ocasiogphy maybe consared together with onek aneeagulton tern bore carsoveson I Sar tin CAMDEN = Cope He Bin ei ro ro Teas B Vaal ater has been doce beloe AF tion sbcon ofthe caver mus nl bs considered pr of he AF lion rede 10. Patient involvement, education and self-management Eedeation Isa prerequisite for informed, volved patents. This incudes taored patient eduction focusing on the dleeze, symptom recognition, therapy. ‘modifable risk factors for AF, and se-nanagement actives (Tab 5ed pont tg peo’Notes NEW State-Of-The-Art Tools To Improve The Care Of Your Atrial Fibrillation Patients [| Revolutionise your elinieal decision-making Download the ESC Pocket Guidelines App to access the 2016 ESC Clinica Practice Guidlines on Ab and excing new tools from CATCHME. ff ‘ost Atrial Fbritiation How to access app and tools: Semen ESC Pocket Guidelines? in Apple Store, ESC Google Play or Amazon | Doviload the FREE aes = Sees FSC Pocket Guidelines App Select the AFib Guidelines ‘Click on the Overall Treatment Manager from CATCH ME BEE. wwmescardio.org/CATCHMEEUROPEAN SOCIETY OF CaroioLocr= Carcology No patois ake Gin yb rates op res forthe marageest je vas ace tm ne ESC 2016 Gu fa dation ropes Hes Sars 2016 0 109/euen/era Tverd net peta pace by the European Sac ns We Ste wwvwescardio.org/guidelines sy of Crags st 1 1 1 1 10.2016 The Fisopean Scie of 1 1 1 setter ciate ome igs Reseweds Sonos ee TCL Supporting Your Clinical Det In Line With Best Practice Guidelines The ESC Pocket Guidlines App gves you acess to the 2016 Cina Practice Guidelines on Atrial Firion, ‘The app incides the first version of a state-of-the-art Overall Treatment Manager, developed by CATCH ME ‘This tool will help you personalize prevention and management of AFIb patients and implement best clinical practice, even when you are under pressure eo make a rapid decision. Download the ESC Pocket Guidelines App to: 1 hecets the latest ESC Practice Guidelines on AF in a suciner and easy to red format 1 Use interactive lnc! toks including + Pathways of care ad risk score caeuators, such s the CHA,DS,-VASC +The novel Overall Treatment Manger that provides a treatment package cor pathway, based on the clini! condtions or your individual patient ata» frst ina series of tools rom CATCH ME ‘Watch out for updated CATCH ME tls inthe AF section of your spp and che sew CATCH ME patient app that wil further support your iterated approach ‘to Afb care- expected launch December 2016 CATCH ME‘ funded bythe Eropean Uns Harn 2020 rete inca progr Under gran gram N"633196 epllmeatchme ie ‘eATCH ME