2012 focused update of the

ESC Guidelines
for the management of atrial fibrillation

European Heart Journal 2012

European Heart Rhythm Association (EHRA);
Endorsed by the European Association for Cardio-Thoracic Surgery (EACTS)

www.escardio.org/guidelines

European Heart Journal (2012) 33, 2719–2747

www.escardio.org/guidelines

European Heart Journal (2010) 31, 2369-2429

Definition
● Cardiac arrhythmia with the following characteristics:
(1) ECG shows ‘absolutely’ irregular RR intervals
(arrhythmia absoluta)
(2) No distinct P waves on the surface ECG
(3) The atrial cycle length (when visible), i.e. the interval
between two atrial activations, is usually variable and
<200 ms (>300 bpm)

www.escardio.org/guidelines

European Heart Journal (2010) 31, 2369-2429

2369-2429 .org/guidelines European Heart Journal (2010) 31.Clinical Events (outcomes) affected by AF www.escardio.

or encouraging progression of AF www. 2369-2429 .org/guidelines European Heart Journal (2010) 31.Conditions predisposing to.escardio.

org/guidelines European Heart Journal (2010) 31.escardio. 2369-2429 .Natural time course of AF AF = atrial fibrillation www.

Types of Atrial Fibrillation www.org/guidelines European Heart Journal (2010) 31. 2369-2429 .escardio.

EHRA score of AF. EHRA = European Heart Rhythm Association www. 2369-2429 .org/guidelines European Heart Journal (2010) 31.related symptoms AF = atrial fibrillation.escardio.

2369-2429 .escardio.General Management of the AF Patient www.org/guidelines European Heart Journal (2010) 31.

PUFA = polyunsaturated fatty acid.The management cascade for patients with AF ACEI = angiotensin-converting enzyme inhibitor.org/guidelines European Heart Journal (2010) 31. 2369-2429 . ARB = angiotensin receptor blocker. www. TE = thrombo-embolism. AF = atrial fibrillation.escardio.

TIA = transient ischaemic attack.escardio. www.org/guidelines European Heart Journal (2010) 31. EF = ejection fraction (as documented by echocardiography. LV = left ventricular. cardiac magnetic resonance imaging. radionuclide ventriculography. etc. 2369-2429 .Risk factors for stroke and thrombo-embolism in non-valvular AF AF= atrial fibrillation. cardiac catheterization.).

2369-2429 .Risk factor-based point-based scoring system . peripheral artery disease. aortic plaque.CHA2DS2-VASc *Prior myocardial infarction. www. Actual rates of stroke in contemporary cohorts may vary from these estimates.org/guidelines European Heart Journal (2010) 31.escardio.

Adjusted stroke rate according to CHA2DS2-VASc score www. 2369-2429 .escardio.org/guidelines European Heart Journal (2010) 31.

OAC = oral anticoagulant. www.escardio.Use of oral anticoagulation for stroke prevention in AF AF = atrial fibrillation. TIA = transient ischaemic attack. 2369-2429 .org/guidelines European Heart Journal (2010) 31.

CHA2DS2-VASc = cardiac failure.0 (target 2.0–3. such as a vitamin K antagonist (VKA) adjusted to an intensity range of INR 2. age 65–74 and sex category (female). INR = international normalized ratio.5).Approach to thromboprophylaxis in AF AF = atrial fibrillation. OAC = oral anticoagulation. 2369-2429 . www. age ≥ 75 (doubled).org/guidelines European Heart Journal (2010) 31. diabetes.escardio. stroke (doubled)vascular disease. hypertension.

INR = international normalized ratio.org/guidelines European Heart Journal (2010) 31.escardio. 2369-2429 .The HAS-BLED bleeding risk score *Hypertension is defined as systolic blood pressure > 160 mmHg. www.

www. 2369-2429 European Heart Journal (2012) 33.org/guidelines European Heart Journal (2010) 31. 2719–2747 .escardio.

www.org/guidelines European Heart Journal (2010) 31. 2719–2747 . 2369-2429 European Heart Journal (2012) 33.escardio.

2369-2429 European Heart Journal (2012) 33.escardio. 2719–2747 .www.org/guidelines European Heart Journal (2010) 31.

2369-2429 European Heart Journal (2012) 33.Summary of the clinical trials involving novel anticoagulants vs. warfarin for stroke prevention in non-valvular AF www.escardio.org/guidelines European Heart Journal (2010) 31. 2719–2747 .

Choice of Anticoagulant www.escardio.org/guidelines European Heart Journal (2010) 31. 2369-2429 European Heart Journal (2012) 33. 2719–2747 .

www. 2369-2429 European Heart Journal (2012) 33. 2719–2747 .org/guidelines European Heart Journal (2010) 31.escardio.

www. 2369-2429 European Heart Journal (2012) 33. 2719–2747 .escardio.org/guidelines European Heart Journal (2010) 31.

2719–2747 .org/guidelines European Heart Journal (2010) 31.escardio. 2369-2429 European Heart Journal (2012) 33.www.

2369-2429 . DCC = direct current cardioversion. NYHA. New York Heart Association.escardio. QRS = QRS duration. = per os.org/guidelines European Heart Journal (2010) 31. QT = QT interval.o. p.Drugs and doses for pharmacological conversion of (recent-onset) AF ACS = acute coronary syndrome. N/A = not applicable. AF = atrial fibrillation.v. www. = intravenous. T-U = abnormal repolarization (T-U) waves. i.

Pharmacological cardioversion of
AF

Class of recommendation. bLevel of evidence.
AF = atrial fibrillation; LoE = level of evidence; i.v. = intravenous.
a

www.escardio.org/guidelines

European Heart Journal (2010) 31, 2369-2429

www.escardio.org/guidelines

European Heart Journal (2010) 31, 2369-2429
European Heart Journal (2012) 33, 2719–2747

DC cardioversion for AF

Class of recommendation. bLevel of evidence.
AF = atrial fibrillation; DCC = direct current cardioversion.
a

www.escardio.org/guidelines

European Heart Journal (2010) 31, 2369-2429

org/guidelines European Heart Journal (2010) 31.Choice of rate and rhythm control strategies www.escardio. 2369-2429 .

2369-2429 . bLevel of evidence.org/guidelines European Heart Journal (2010) 31.escardio.Rate and rhythm control of AF Class of recommendation. AF = atrial fibrillation. a www. EHRA = European Heart Rhythm Association.

escardio.org/guidelines European Heart Journal (2010) 31. 2369-2429 .Rate control of atrial fibrillation The choice of drugs depends on life style and underlying disease www.

org/guidelines European Heart Journal (2010) 31. N/A = not applicable. 2369-2429 . ‡Only in patients with non-permanent atrial fibrillation.Drugs for rate control ER = extended release formulations. www.escardio.

2369-2429 .v. = intravenous. AF = atrial fibrillation. a www. bLevel of evidence.org/guidelines European Heart Journal (2010) 31. i.escardio.Acute rate control in AF Class of recommendation.

Long-term rate control in AF Class of recommendation. 2369-2429 .org/guidelines European Heart Journal (2010) 31. bmp = beats per minute. LV = left ventricular.escardio. AF = atrial fibrillation. a www. NYHA = New York Heart Association. bLevel of evidence.

a www. NYHA = New York Heart Association. LV = left ventricular. 2369-2429 . AF = atrial fibrillation.escardio.org/guidelines European Heart Journal (2010) 31. bLevel of evidence. bmp = beats per minute.Long-term rate control in AF Class of recommendation.

www. 2719–2747 .org/guidelines European Heart Journal (2010) 31. 2369-2429 European Heart Journal (2012) 33.escardio.

2369-2429 European Heart Journal (2012) 33.org/guidelines European Heart Journal (2010) 31.escardio.www. 2719–2747 .

escardio. 2369-2429 European Heart Journal (2012) 33.org/guidelines European Heart Journal (2010) 31.www. 2719–2747 .

a www. AF = atrial fibrillation. LVEF = left ventricular ejection fraction.escardio.org/guidelines European Heart Journal (2010) 31. NYHA = New York Heart Association. bLevel of evidence.AV node ablation in AF patients Class of recommendation. AV = atrioventricular. LV = left ventricular. CRT = cardiac resynchronization therapy. 2369-2429 .

AF = atrial fibrillation. LVEF = left ventricular ejection fraction.org/guidelines European Heart Journal (2010) 31. NYHA = New York Heart Association. AV = atrioventricular. 2369-2429 .escardio. CRT = cardiac resynchronization therapy. LV = left ventricular. a www. bLevel of evidence.AV node ablation in AF patients Class of recommendation.

bLevel of evidence. CRT = cardiac resynchronization therapy.org/guidelines European Heart Journal (2010) 31. a www. NYHA = New York Heart Association.escardio. LV = left ventricular. 2369-2429 .Choice of pacemakers after AV node ablation Class of recommendation. AV = atrioventricular. AF = atrial fibrillation. LVEF = left ventricular ejection fraction.

3. 6. 4. Efficacy of antiarrhythmic drugs to maintain sinus rhythm is modest. Drug-induced proarrhythmia or extra-cardiac side-effects are frequent. Treatment is motivated by attempts to reduce AF-related symptoms. 2. 2369-2429 . If one antiarrhythmic drug ‘fails’ a clinically acceptable response may be achieved with another agent.Principles of antiarrhythmic drug therapy to maintain sinus rhythm 1. www. 5. Safety rather than efficacy considerations should primarily guide the choice of antiarrhythmic agent.escardio. Clinically successful antiarrhythmic drug therapy may reduce rather than eliminate recurrence of AF.org/guidelines European Heart Journal (2010) 31.

LV = left ventricular.org/guidelines European Heart Journal (2010) 31.escardio. ECG = electrocardiogram. 2369-2429 . bpm = beats per minute. NYHA = New York Heart Association. CYP = cytochrome P. AV = atrioventricular.Suggested doses and main caveats for commonly used antiarrhythmic drugs AF = atrial fibrillation. www.

www.escardio. bpm = beats per minute.org/guidelines European Heart Journal (2010) 31. 2369-2429 . ECG = electrocardiogram. NYHA = New York Heart Association.Suggested doses and main caveats for commonly used antiarrhythmic drugs (Contd) AF = atrial fibrillation. LV = left ventricular. CYP = cytochrome P. AV = atrioventricular.

Suggested doses and main caveats for commonly used antiarrhythmic drugs (Contd) AF = atrial fibrillation. ECG = electrocardiogram. bpm = beats per minute. NYHA = New York Heart Association. AV = atrioventricular.org/guidelines European Heart Journal (2010) 31. 2369-2429 .escardio. LV = left ventricular. CYP = cytochrome P. www.

2719–2747 .escardio.www.org/guidelines European Heart Journal (2010) 31. 2369-2429 European Heart Journal (2012) 33.

2369-2429 . HT = hypertension. ARB = angiotensin receptor blocker. CAD = coronary artery disease. CHF = congestive heart failure. www. unstable = cardiac decompensation within the prior 4 weeks. NYHA = New York Heart Association. LVH = left ventricular hypertrophy.escardio.org/guidelines European Heart Journal (2010) 31. Antiarrhythmic agents are listed in alphabetical order within each treatment box.Choice of antiarrhythmic drug according to underlying pathology ACEI = angiotensin-converting enzyme inhibitor. ? = evidence for ‘upstream’ therapy for prevention of atrial remodelling still remains controversial.

escardio. a www. AV = atrioventricular. 2369-2429 . NYHA = New York Heart Association. LoE = level of evidence. bLevel of evidence. AF = atrial fibrillation.org/guidelines European Heart Journal (2010) 31.Choice of an antiarrhythmic drug for AF control Class of recommendation.

a www.escardio. bLevel of evidence. LoE = level of evidence. NYHA = New York Heart Association. 2369-2429 . AV = atrioventricular. AF = atrial fibrillation.org/guidelines European Heart Journal (2010) 31.Choice of an antiarrhythmic drug for AF control Class of recommendation.

Level of evidence. AF = atrial fibrillation. NYHA = New York Heart Association.escardio. a b www.Choice of an antiarrhythmic drug for AF control Class of recommendation.org/guidelines European Heart Journal (2010) 31. AV = atrioventricular. LoE = level of evidence. 2369-2429 .

CHF = congestive heart failure. LVH = left ventricular hypertrophy.escardio. 2369-2429 . CAD = coronary artery disease. *usually PVI is appropriate. † www. PVI = pulmonary vein isolation. NYHA = New York Heart Association.Choice between ablation and antiarrhythmic drug therapy for patients with and without structural heart disease More extensive LA ablation may be needed. Antiarrhythmic agents are listed in alphabetical order within each treatment box. HT = hypertension. AF = atrial fibrillation.org/guidelines European Heart Journal (2010) 31.

i. 2369-2429 . LMWH = low molecular weight heparin. UFH = unfractionated heparin. AF = atrial fibrillation. bLevel of evidence. OAC = oral anticoagulant.v.Left atrial catheter ablation Class of recommendation.escardio. = intravenous.org/guidelines European Heart Journal (2010) 31. a www.

OAC = oral anticoagulant. LMWH = low molecular weight heparin. AF = atrial fibrillation. UFH = unfractionated heparin. Level of evidence.org/guidelines European Heart Journal (2010) 31. = intravenous.v.escardio. 2369-2429 .Left atrial catheter ablation Class of recommendation. i. a b www.

AF = atrial fibrillation.org/guidelines European Heart Journal (2010) 31. Level of evidence. a b www. 2369-2429 .Surgical ablation of AF Class of recommendation.escardio.

org/guidelines European Heart Journal (2010) 31.Primary prevention of AF with “upstream” therapy Class of recommendation. ACEI = angiotensin-converting enzyme inhibitor. a b www.escardio. 2369-2429 . Level of evidence. AF = atrial fibrillation. ARB = angiotensin receptor blocker.

Secondary prevention of AF with “upstream” therapy Class of recommendation. ACEI = angiotensin-converting enzyme inhibitor. b Level of evidence. a www.escardio. 2369-2429 . AF = atrial fibrillation.org/guidelines European Heart Journal (2010) 31. ARB = angiotensin receptor blocker.

2369-2429 . Endorsed by the European Association for Cardio-Thoracic Surgery (EACTS) www.European Heart Rhythm Association (EHRA).escardio.org/guidelines European Heart Journal (2010) 31.

org/guidelines European Heart Journal (2010) 31.www.escardio. 2369-2429 .

AF = atrial fibrillation. b Level of evidence. AP = accessory pathway.Rate control during AF with heart failure Class of recommendation. 2369-2429 .escardio.org/guidelines European Heart Journal (2010) 31. LVEF = left ventricular ejection fraction. a www.

escardio. LVEF = left ventricular ejection fraction. CRT = cardiac resynchronization therapy.Rate control during AF with heart failure Class of recommendation. a b www. 2369-2429 . AF = atrial fibrillation. AV = atrioventricular.org/guidelines European Heart Journal (2010) 31. Level of evidence. NYHA = New York Heart Association.

DCC = direct current cardioversion. 2369-2429 . a www.org/guidelines European Heart Journal (2010) 31.escardio.Rhythm control of AF in heart failure Class of recommendation. NYHA = New York Heart Association. AF = atrial fibrillation. bLevel of evidence.

a www.Atrial Fibrillation in athletes Class of recommendation.org/guidelines European Heart Journal (2010) 31. 2369-2429 .escardio. AF = atrial fibrillation. bLevel of evidence.

LA = left atrial. bLevel of evidence. AF = atrial fibrillation.Atrial Fibrillation in valvular heart disease Class of recommendation. LV = left ventricular.escardio. INR = international normalized ratio. 2369-2429 . a www.org/guidelines European Heart Journal (2010) 31.

org/guidelines European Heart Journal (2010) 31.Atrial Fibrillation in acute coronary syndromes Class of recommendation. ACS = acute coronary syndrome. a www. DCC = direct current cardioversion. 2369-2429 . bLevel of evidence.escardio. AF = atrial fibrillation.

ECG = electrocardiogram.Atrial Fibrillation in : Class of recommendation. a b www. Level of evidence. AF = atrial fibrillation. 2369-2429 .escardio.org/guidelines European Heart Journal (2010) 31.

bLevel of evidence.org/guidelines European Heart Journal (2010) 31. 2369-2429 . a www. DCC = direct current cardioversion. AF = atrial fibrillation. UFH = unfractionated heparin.escardio. LMWH = low molecular weight heparin. VKA = vitamin K antagonist.Atrial Fibrillation in pregnancy Class of recommendation.

b Level of evidence. DCC = direct current cardioversion. a www.Atrial Fibrillation in pregnancy Class of recommendation. AF = atrial fibrillation.escardio. 2369-2429 .org/guidelines European Heart Journal (2010) 31.

AF = atrial fibrillation. a www.org/guidelines European Heart Journal (2010) 31.escardio. DCC = direct current cardioversion. 2369-2429 .Post-operative Atrial Fibrillation Class of recommendation. b Level of evidence.

escardio.org/guidelines European Heart Journal (2010) 31. a www. 2369-2429 .Post-operative Atrial Fibrillation Class of recommendation. bLevel of evidence. DCC = direct current cardioversion. AF = atrial fibrillation.

a www.Atrial Fibrillation in hyperthyroidism Class of recommendation. bLevel of evidence.org/guidelines European Heart Journal (2010) 31. AF = atrial fibrillation. 2369-2429 .escardio.

ECG = electrocardiogram. AP = accessory pathway. SCD = sudden cardiac death.AF in Wolff-Parkinson-White syndrome Class of recommendation. bLevel of evidence.org/guidelines European Heart Journal (2010) 31. 2369-2429 .escardio. AF = atrial fibrillation.. a www.

HCM = hypertrophic cardiomyopathy.escardio. a www. INR = international normalized ratio. AF = atrial fibrillation. bLevel of evidence. DCC = direct current cardioversion.org/guidelines European Heart Journal (2010) 31. 2369-2429 .AF in hypertrophic cardiomyopathy Class of recommendation.

escardio. AF = atrial fibrillation. bLevel of evidence.org/guidelines European Heart Journal (2010) 31. a www.Atrial Fribillation in pulmonary disease Class of recommendation. DCC = direct current cardioversion. 2369-2429 .