Riscul de Avc Severitatea Simptomelor Severitatea Poverii Bolii Severitatea Substratului (

Figure 5 4S-AF scheme as an example of structured
Schema 4S a fibrilației
characterization of AF
atriale
Riscul de Severitatea Severitatea Severitatea

AVC (St) simptomelor (Sy) poverii bolii (Sb) substratului (Su)
©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
Recomandări forcaracterizarea
pentru structured characterization
structurată aof
FAAF
Recommendations Class Level

Structured
Caracterizareacharacterization of care
structurată a FA, AF, which
includeincludes
evaluarea clinical
clinicăassessment
a riscului deofAVC,
stroke
statutulrisk, symptomșistatus,
simptomatic evaluareaburden of AF, and
substratului, evaluation
trebuie luată înof substrate, la toți
considerarea
should becuconsidered
pacienții FA, pentru in all AF patients,
evaluarea tode
nivelurilor streamline the assessment
îngrijire medicală, pentru aof AF IIa C
informa decizia
patients asuprahealthcare
at different tacticii de tratament și a facilita
levels, inform treatmentmanagementul optim al
decision-making,
pacienților.
and facilitate optimal management of AF patients.
©ESC
Figura 6. Sistemele utilizate pentru
Figure 6 Systems used for AF screening
screeningul FA.
Palparea pulsului, monitorizarea TA automată,

Pulse palpation, automated BP monitors, single-lead ECG devices, PPG devices, other sensors (using
seismocardiography, accelerometers, and gyroscopes, etc.) used in applications for smartphones,
monitorizarea ECG cu o singura derivație,
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
alte aparate senzoriale sau aplicații din telefonul mobil,
©ESC
sensor for PPG and alerting the consumer of a pulse irregularity (based on a specific algorithm for AF
©ESC ceasuri smart.

detection analysing pulse irregularity and variability
Table5.5Sensibilitatea
Tabelul Sensitivity and specificity of
și specificitatea various
diferitor AF screening
instrumente tools
de screening
aleconsidering
FA. ECG în 12the
derivații – standartul
12-lead ECG as the de gold
aur. standard
Sensitivity
Sensibilitate Specificity
Specificitate
Pulse taking Ps
Monitorizarea 87−97% 70−81%
Automated
Monitoare TABP 93−100% 86−92%
monitors
automate
Single
ECG cu lead ECG
o derivație 94−98% 76−95%
Smartphone apps
Aplicații-smartphone 91.5−98.5% 91.4−100%
Watches
Ceasuri 97−99% 83−94%
©ESC
Figura
Figure7. Potențialele
7 Potential beneficii
benefits fromșiand
riscuri
risksale
of screeningului FA
screening for AF
Screeningul
AF SCREENINGFA
RISCURI BENEFICII
BENEFITS
RISKS
-Rezultatele anormale pot cauza Prevenția:
anxietate Prevention of:
•Abnormal results may cause anxiety -AVC
• Stroke/SE using OAC in patients at risk
-instalarea ulterioară a simptomelor
•ECG misinterpretation results may • Subsequent onset of symptoms
-Interpretarea incorectă a ECG poate
lead to overdiagnosis and
duce la diagnostic și tratament Prevention/reversal of:
Prevenția/anularea:
overtreatment
greșite • Electrical/mechanical
-remodelarea atrial remodelling
atrială mecanică/electrică
•ECG may detect other abnormalities • AF-related
-afectarea haemodynamic
hemodinamică derangements
datorată AF
(true
-ECG or false
poate positives)
detecta alte that may
anormalități • Atrial and ventricular
-cardiomiopatie indusă tachycardia-induced cardiopmyopathy
de tahicardie atrială/ventriculară
lead tosau
(pozitive invasive tests and care pot
fals pozitive) Prevention/reduction of:
treatments
conduce that have testelor
la efectuarea the potential • AF-related morbidity; hospitalization; mortality
Prevenția/diminuarea:
for serious
invazive ce potharm (e.g.,(angiografia,
dăuna angiography /
-morbiditatea
Reduction of:asociată cu FA, spitalizarea, mortalitatea
revascularisation
revascularizare with bleeding,
cu sîngerare,
contrast-induced nephropathy and • The outcomes associated with conditions / diseases associated with AF that
nefropatia indusă de substanța de Diminuarea:
are discovered and treated as a consequence of the examinations prompted by
allergic reactions to the contrast)
©ESC
contrast) -rezultatelor asociate cu co-morbiditățile FA , care sunt descoperite și tratate
AF detection
ca urmare a examinărilor pentru diagnosticul FA
Recommendations
Recomandări for screening
pentru screeningul FA (1)to detect AF (1)
Recommendations
Recomandări Class
Clasa Level
Nivel
Opportunistic screening
Screeningul oportunist al for AF by
FA prin pulse takingpulsului
determinarea or ECGsau
rhythm strip is ECG este
înregistrarea I B
recommended in patients
recomandat la pacienții ≥65 years
cu vîrsta of age.
≥65 ani.
ItEste
is recommended
recomandat deto interrogate
a interoga pacemakers
în mod and implantable
regulat pace-makerul cardioverter
sau defibrilatoarele I B
defibrillators on a regular
implantabile pentru basis
a depista for AHRE.
episoadele dea frecvență atrială înaltă.
©ESC
a See sections for diagnostic criteria for AF and AHRE, and for the management of patients with AHRE.
Recommendations
Recomandări for screening
pentru screeningul FA (2)to detect AF (2)
Recommendations
Recomandări Class
Clasa Level
Nivel
When screening
În timpul for AFFA,
screeningului it isserecommended
recomandă ca: that:
• The individuals undergoing screening are informed about the significance
•Pacienții să fie informați
and treatment despreofimportanța
implications diagnosticării și tratamentului FA.
detecting AF.
••ÎnA cazurile de detecție
structured referralaplatform
FA, se recomandă o evaluare
is organized clinică pentru cases
for screen-positive confirmarea
for
diagnosticului și oferireaclinical
further physician-led unui management
evaluation optimal.
to confirm the diagnosis of AF and I B
•Diagnosticul
provide optimaldefinitiv de FA se stabilește
management doarwith
of patients dupăconfirmed
prezența ECG AF.într-o singură
•derivație
Definiteînregistrata
diagnosis of ≥30AFsecinsau ECG în 12 derivații,
screen-positive cases care confirmă FA
is established only after
physician reviews the single-lead ECG recording of ≥30 seconds or 12-lead
• ECG and confirms that it shows AF.
Screeningul ECG sistematic trebuie luat în considerare la indivizii cu vîrsta ≥75 ani,
Systematic ECG
sau cei cu risc screening
înalt de AVC. should be considered to detect AF in individuals
IIa B
aged ≥75 years, or those at high risk of stroke.
©ESC
Figura 8.8 Diagnosticul
Figure și supravegherea
Diagnostic work-up pacienților
and follow-up cu FA
in AF patients
All
ToțiAF patients
pacienții cu FA Selected AFselectați
Pacienți patients Structured
Evaluare în follow-up
dinamică
Monitorizarea
Ambulatory ECGambulatorie a ECG:
monitoring:
Istoricul history:
Medical medical: •Control adecvat
• Adequacy al frecvenței
of rate control ••Pentru a asigura
To ensure management
continued optimal
•Asocierea simptomelor cu recurrences
recurențele FA optim continuu.
management
• AF-related symptoms • Relate symptoms to AF
•Simptome ale FA
••Pattern
AF pattern
al FA Transoesophageal echocardiography: • A cardiologist / AF specialist
Ecocardiografia transesofagiană:
••Co-morbidități
Concomitant conditions • Valvularvalvulară
•Patologia heart disease •Un cardiolog coordonează
coordinates the follow-up in
••Scorul
CHA2DS 2-VASc score
CHA2DS2-VASc • LAA thrombus
•Trombi managementul
collaboration împreună cu
with specially
intracavitari
cTnT-hs, CRP, BNP/NT-ProBNP asistenta medicală
trained nurses și medicii
and primaryde
ECG în 12
12-lead derivații
ECG cTnT-înalt
Cognitivesenzitivă,
functionPCR, BNP/NT-pro-
assessment familie.
care physicians
Thyroid and kidney function, BNP.
Funcția renală
electrolytes și full
and tiroidiană,
blood Coronary CTA or ischaemia imaging:
Evaluarea funcției cognitive.
electroliții,
count • Patients with suspected CAD
hemoleucograma CTBrain CT andalMRI:
angiografic arterelor coronariene la
Transthoracic • Patients
pacienții with suspected
cu suspecție stroke
de boală arteială
Ecocardiografia
echocardiography coronariană.
transtoracică LGE-CMR of the LA:
• To help decision-making in AF
©ESC
CTtreatment
cerebral/RMN:
•Suspecție de AVC
Table6.6Clasificarea
Tabelul EHRA symptom scale după EHRA
simptomelor
Score
Scor Symptoms
Simptome Description
Descriere
1 None
Nici unul AF
FA does not cause
nu cauzează any
nici un symptoms
simptom
2a Mild
Ușoare Normal daily
Activitățile activity
zilnice nu suntnot affected
afectate by symptoms
de simptomele FA related to AF
2b Moderate
Moderate Normal daily
zilnice not
nu sunt affected
afectate bydar
de FA, symptoms related pacientul
acestea deranjează to AF, but
patient troubled by symptoms
3 Severe
Severe Normal daily
zilnice affectedde
sunt influențate bysimptomele
symptomsFArelated to AF
4 Disabling
Ft. severe Normal daily
zilnice discontinued
sunt întrerupte
©ESC
Figure9.9
Figura
Imagistica
Imaging inîn AF
FA
©ESC
2020 ESC Guidelines for the diagnosis and management of atrial fibrillation
Recommendations
Recomandări pentru for diagnostic
evaluarea evaluation
diagnostică of patients
a pacienților cu FAwith AF
Recommendations
Recomandări Class
Clasa Level
Nivel
InLapatients
paciențiiwith AF, se
cu FA, it isrecomandă:
recommended to:
••De
Evaluate AF-related
a evalua simptomelesymptoms (including
asociate fatigue, tiredness,
FA (fatigabilitate, exertional
oboseală, dispnee,
shortnessdureri
palpitații, of breath, palpitations,
retrosternale) anda chest
și de pain)statutul
cuantifica and quantify the patient
simptomatic
symptom status using the modified EHRA symptom scale before and after I C
utilizând scala EHRA, înainte și după inițierea tratamentului.
•initiation of treatment.
De a evalua simptomele asociate FA înainte și după cardioversie în cazul
• Evaluate AF-related symptoms before and after cardioversion of persistent
FA persistente.
AF to aid rhythm control treatment decisions.
©ESC
Figure 10 Components
Figura 10. Componenteleof integrated AF global
managementului management
al FA
©ESC
©ESC
Figure 11 11.
Figura
Integrated AF
Echipa din cadrul
management team
managementului FA.
(an example)
©ESC
©ESC
Recommendations
Recomandări about integrated
pentru managementul AFalmanagement
global FA
Recommendations
Recomandări Class
Clasa Level
Nivel
To optimize
Pentru shareddeciziilor
optimizarea decision-making about specific
privind opțiunile AF treatment
de tratament option(s) in
luate în considerare
consideration, it iseste
la pacienții cu FA, recommended
recomandat cathat physicians:
medicul să:
••Informeze
Inform the patient despre
pacientul about the advantages/limitations
avantajele/limitările and benefit/risks
și riscuri/beneficii asociate cu
I C
associated
opțiunea with the treatment
de tratament respectivă option(s) being considered; and
••Să
Discuss
discutethe potentialtratamentului
importanța burden of thecutreatment
pacientul șiwith
să iathe patient andpărerea
în considerare include
acestuia
the patient’s perception of treatment burden into the treatment decision.
It is recommended
Este recomandat de to routinely
a observa collect
toate PROs to
beneficiile measure treatment
tratamentului success
pentru a îmbunătăți
I C
and improve
eficiența patient care.
acestuia.
Integrated
Managementul management
integrat cuwith a structured
implicarea multidisciplinary
unei echipe approach
multidisciplinare, trebuie
including healthcare
utilizat la toți paciențiiprofessionals, patients, and their family/carers, should IIa B
be useda in
pentru all AF patients
îmbunătăți to improve
rezultatele clinice. clinical outcomes.
©ESC
Table 7.
Tabelul 7 Factorii
Stroke risk factors
de risc pentruinAVC
patients withcu
la pacienții AFFA
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
©ESC
Table
Tabelul88.CHA 2DSCHA2DS2-VASc
Scorul 2-VASc score (1)
(1)
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.
©ESC
Table 88.CHA
Tabelul 2DSCHA2DS2-VASc
(2)
CHA2DS2-VASc score
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
©ESC
oral anticoagulation.
Table 88.CHA
Tabelul 2DS
CHA2DS2-VASc (3)
CHA2DS2-VASc score
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
©ESC
Tabelul 9. Factori de risc pentru sîngerare în caz de tratament cu
Table 9 factors
anticoagulante forșibleeding
orale with OAC and antiplatelet therapy
antitrombotice.
Non-modifiable
Nemodificabili Potentially modifiable
Potențial modificabili Modifiable
Modificabili Biomarkers
Biomarkeri
Age >65 years Extreme frailty ц
Anemie Hypertension/elevate SBP
HTA GDF-15
Vîrsta≥65 ani Cistatina-C/CKD-
Previous major bleeding excessive risk of Administrarea
Concomitant Cystatin C
Sîngerări în antecedente Trombocite scăzute EPI
Severe renal impairment (on fallsa antiplatelet/NSAID
concomitentă cu / CKD-EPI
Insuficiență renală Afectare renală cu GDF-15
dialysis or renal transplant) Anaemia antiagregant/AINS
Excessive alcohol intake cTnT-hs
avansată clearence-lui cTnT-hs
Severe hepatic dysfunction Reduced platelet
creatininei ≤60 Neaderența
Non-adherence la to
tratament
OAC Von Willebrand
Disfuncție hepatică Factorul Von
(cirrhosis) count or function Terapie
Hazardousdehobbies
punte cu/ factor (+ other
severă mL/min Willebrand (+alți
Malignancy Renal impairment
Managementul heparina
occupations coagulation
Boli maligne markeri ai
Genetic factors (e.g., CYP 2C9 with CrCl <60 mL/min Control
Bridging INR (ținta
therapy 2-3)
with markers)
strategic al coagulării)
Factori genetici
polymorphisms) VKA management TTR≥70%
antagonișilor de heparin
AVC în antecedente
Previous stroke, small-vessel strategyb Dozarea și (target
monitorizarea
vit.K INR control 2.0–
Diabet zaharat
disease, etc. corectă a TTR >70%c
3.0), target
Demență/afecțiuni
Diabetes mellitus anticoagulantelor
Appropriate choice of OAC
cognitiveimpairment/dementia
Cognitive and correct dosingd
©ESC
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.
Tabelul 10.Clinical
Table 10 Factoririsk
de factors
risc clinici ai scorului
in the HAS-BLED HAS-BLED
score (1) (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
©ESC
a Haemorrhagic stroke would also score 1 point under the ‘B’ criterion.
Table 10
Tabelul 10.Clinical risk
Factori de factors
risc in scorului
clinici ai the HAS-BLED score
HAS-BLED (2) (2)
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.
©ESC
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%.
©ESC
©ESC
Recommendations
Recomandări pentru for the prevention
prevenția of thromboembolic
evenimentelor trombembolice la
events
paciențiiincu
AFFA(1)
(1)
Recommendations
Recomandări Class
Clasa Level
Nivel
For stroke
Pentru prevention
prevenția AVC-uluiin
la AF patients
pacienții cu FAwho are
și care eligible
sunt eligibilifor OAC,
pentru NOACs are
anticoagulantele
recommended
orale, NOAC-urilein preference
sunt to decît
mai preferate VKAsanatagoniștii
(excludingde patients
vit.K (cuwith mechanical
excepția pacienților cu I A
valve mecanice
heart valves orsau stenoză mitrală de la moderat
moderate-to-severe la severă).
mitral stenosis).
For stroke
Pentru risk assessment,
evaluarea riscului de AVC,aeste
risk-factor−based approach
recomandată utilizarea is recommended,
scorului CHA2DS2-VASc
using
pentruthe CHA2DS2pacienților
identificarea -VASc clinical
cu riscstroke risk score to initially
scăzut (CHA2DS2-VASc=0 pentruidentify patients
bărbați sau =1
I A
at ‘lowfemei),
pentru strokecare
risk’
nu(CHA 2DS2-VASc score = 0 in men, or 1 in women) who
ar trebui să primească terapie antitrombotică.
should not be offered antithrombotic therapy.
OAC is anticoagulantă
Terapia recommended forsestroke
orală prevention
recomandă in cu
la pacienții AFFA
patients
cu scorulwith CHA 2DS2-
CHA2DS2-VASc≥2
pentruscore
bărbați≥2și in
≥3 men
pentruorfemei,
I A
VASc ≥3 inpentru
women.prevenția AVC –urilor.
©ESC
Recommendations
events
paciențiiincu
AFFA(2)
(2)
Recommendations
Recomandări Class
Clasa Level
Nivel
OAC should be considered

Anticoagulantele orale trebuiefor stroke
luate prevention
în considerare in AFprevenția
pentru patients AVCwithlaapacienții
CHA2DScu 2-VASc
FA,
cu scorul
score of 1CHA2DS2-VASc
in men or 2 in=1women.la bărbațiTreatment
și =2 la femei. Tratamentul
should trebuie individualizat
be individualized based on net IIa B
luînd în benefit
clinical considerare
andbeneficiile
consideration cliniceofșipatient
preferințele pacientului.
values and preferences.
For bleeding
Pentru riskriscului
evaluarea assessment,
de sîngerarea formal structured
se recomandă risk-score−based
utilizarea bleeding
scorurilor de risc, pentru risk
assessment is recommended
identificarea factorilor to help identify
de risc nemodificabili non-modifiable
și modificabili and address
și pentru a identifica pacienții cu
modifiable bleedingpentru
risc înalt de sîngerare risk factors in allîn AF
o urmărire patients,
dinamică mai and to identify patients
frecventă. 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
Scorul HAS-BLEDrisk-score−based assessment
trebuie utilizat pentru ajustarea offactorilor
bleedingderisk, the HAS-BLED
risc modificabili scorea
și pentru
should bepacienții
identifica consideredcu risctodehelp address
sîngerare modifiable
sporit bleeding risk factors, and to
(HAS-BLED≥3). IIa B
identify patients at high risk of bleeding (HAS-BLED score ≥3) for early and more
©ESC
frequent clinical review and follow-up.
Recommendations
events
paciențiiincu
AFFA(3)
(3)
Recommendations
Recomandări Class
Clasa Level
Nivel
Evaluarea
Stroke riscului
and de sîngerare,
bleeding precum și riscului
risk reassessment de AVC la intervals
at periodic intervale periodice este
is recommended
recomandată
to pentru informarea
inform treatment decisionsreferitor
(e.g. la deciziile de
initiation of tratament (ex.initierea
OAC in patients no longer at I B
anticoagulantelor orale la pacienții cu risc scăzut de AVC) și pentru corijarea factorilor dea
low risk of stroke) and address potentially modifiable bleeding risk factors.
risc modificabili.
In
La patients
pacienții cuwith
FA cuAF initially
risc de AVC at lowscăzut,
inițial risk ofprima
stroke, firstareassessment
evaluare of strokela
riscului trebuie efectuată
IIa B
risk should
4-6 luni de la be made
prima at 4−6 months after the index evaluation.
evaluare.
IfDacă
a VKA is used, anatagoniștii
se utilizează a target INRvit.K,
of 2.0−3.0 is recommended,
se recomandă ținta INR de 2-3,with individual
TTR≥70%.
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.).
©ESC
Recommendations
events
paciențiiincu
AFFA(4)
(4)
Recommendations
Recomandări Class
Clasa Level
Nivel
In
La patients onutilizează
pacienții ce VKAs with low timevit.K
antagoniștii in INR therapeutic
și INR se include înrange (e.g.
țintele TTR <70%),
terpeutice (iar
recommended options are:
TTR<70%), se recomandă:
I B
••Trecerea la NOAC,
Switching asigurîndu-ne
to a NOAC de o bună
but ensuring goodaderență la tratament,
adherence sau
and persistence with
therapy; or
••Eforturi
Efforts de
to aimprove TTRTTR
îmbunătăți (e.g. education/counselling andmai
(educație/consiliere/verificarea more frequent
frecventă INR
a INR).
IIa B
checks).
Antiplatelet therapy alone
Terapia antitrombotică (monotherapy
(monoterapie or aspirin
sau combinarea in combination
aspirinei withnu se
cu clopidogrel)
III A
clopidogrel) is notprevenția
recomandă pentru recommended for stroke
AVC la pacienții prevention in AF.
cu FA.
Estimated
Doar riscul bleeding
estimat derisk, in theînabsence
sîngerare, absențaof absolute contraindications
contraindicațiilor absolute pentruto OAC,
anticoagulantele orale, nu trebuie să ghideze decizia III A
should not in itself guide treatment decisions to de
usea OAC
le uiliza
forpentru
strokeprevenția AVC.
prevention.
Clinical pattern
Patternul ofFA
clinic al AF(ex.paroxistică/persistentă/permanentă)
(i.e. first detected, paroxysmal, persistent, long-standing
nu trebuie persistent,
să condiționeze III B
©ESC
permanent) should
indicațiile pentru not condition
profilaxia the indication to thromboprophylaxis.
antitrombotică.
Recommendations
events
paciențiiincu
AFFA(5)
(5)
Recommendations
Recomandări for occlusion
pentru ocluzia oratriului
apendicelui exclusion of the LAA
stîng (AAS). Class
Clasa Level
Nivel
LAA occlusion
Ocluzia may
AAS trebuie beînconsidered
luată considerare for stroke
pentru prevention
prevenția AVC-uluiin
la patients with
pacienții cu FA șiAF
cu
and contraindications
contraindicații foranticoagulantă
pentru terapie long-term anticoagulant treatment intracraniană
îndelungată (ex.hemoragie (e.g. intracranial
fără IIb B
o cauză reversibilă).
bleeding without a reversible cause).
Surgical occlusion
Ocluzia sau excludereaorpe exclusion of theaLAA
cale chirurgicală may beatriului
apendicelui considered for stroke
stîng trebuie
considerată lainpacienții cu with
FA supuși intervențieipecardiac
cord. surgery. IIb C
prevention patients AF undergoing
©ESC
Figure13.
Figura 13Schema
Outlineterapiei
of ratedecontrol
controltherapy
a frecvenței pulsului.
©ESC
Table 13
Tabelul 13.Drugs for rate utilizate
Medicamente control pentru
in AFa (1)
controlul frcvenței în FA (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
Nebivolol N/A 2.5−10 mg o.d.
Carvedilol N/A 3.125−50 mg b.i.d.
©ESC
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.
Table 13
in AFa (2)
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
©ESC
mortality
a All rate control drugs are contraindicated in Wolff−Parkinson−White syndrome, also i.v. amiodarone.
Table 13
in AFa (3)

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.
dLoading regimen may vary; i.v. dosage should be considered when calculating total load.
©ESC
Selectarea
medicamentelor
pentru controlul
frecvenței.
Reevaluarea
a Clinical clinică
reassessment trebuie
should be să fie
focusată pe prezența simptomelor
focused on evaluation of resting
și calitatea
heart vieții pacienților cu FA.
rate, AF/AFL-related
În cazul &
symptoms controlul
quality ofsuboptimal
life. In case al
frecvenței (FCC>110
suboptimal rate control (resting b/min),
înrăutățirea
heart rate >110simptomelor
bpm), worsening sauof a
calității vieții, de
symptoms or quality of life luat în
considerare
consider linia&,aif2-a
2nd line și a 3-a de
necessary,
tratament.
3rd line treatment options. bCareful
institution of beta-blocker and
©ESC
NDCC, 24-hour Holter to check for
bradycardia.
Recomandări
Recommendationspentru controlul
for ventricular frecvenței
rate control in patients
with AF (1)(1)
cardiace
Beta-blockers, diltiazem,sau
B-blocantele, diltiazemul or verapamil
verapamilulare recommended
sunt recomandate ca as terapie
first-choice drugs
de prima I B
to control
linie pentruheart rate frecvenței
controlul in AF patients withlaLVEF
cardiace ≥40%.
pacienții cu FA și FE ≥40.
Beta-blockers and/or
B-blocantele și/sau digoxin
digoxina arerecomandate
sunt recommended to control
pentru controlulheart rate in AF
frecvenței
I B
patients
cardiace with LVEF <40%.
la pacienții cu FA și FE <40.
Combination therapymedicamente
Combinarea diferitor comprising different rate controlling
pentru controlul drugs
FCC ar trebui a should
luată în be
IIa B
considerare ifdacă
considered nu sedrug
a single poatedoes
atinge
notfrecvența
achieve dorită cu unheart
the target singurrate.
preparat.
AFCC
resting
≤110 heart
b/minutrate of <110
trebuie bpm
să fie (i.e.
ținta lenient
inițială rate control)
la pacienții la careshould be
s-a inițiat
IIa B
considered as the initial
controlul frecvenței heart rate target for rate control therapy.
cardiace.
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.
©ESC
Recomandări pentru
Recommendations controlulrate
for ventricular frecvenței
control in patients
with AF (2)
cardiace (2)
Atrioventricular node ablation trebuie
Ablaţia nodului atrioventricular should considerată
be considered to control
pentru heart
controlul rate in
frecvenţei
patients
cardiace unresponsive
la pacienţii careornuintolerant to intensive
răspund sau rate andtratamentul
care nu tolerează rhythm control
intensiv
IIa B
therapy,
de controland not eligible
al frecvenţei şi afor rhythmacceptând
ritmului, control by LA ablation,
faptul că aceşti accepting
pacienţi vorthat
these
devenipatients will become pacemaker dependent.
stimulodependenţi.
In
Lapatients
paciențiiwith haemodynamic
hemodinamic instabiliinstability or severely
sau cu FE sever depressed
scăzută, LVEF,
amiodarona i/v trebuie IIb B
intravenous amiodarone
considerată pentru may
controlul bealconsidered
acut frecvenței for acute control of heart rate.
cardiace.
©ESC
Strategia de control a
ritmului, pentru ameliorarea
simptomelor asociate FA –
îmbunătățirea calității vieții.
De a confirma:
• Prevenția AVC-ului
• Controlul ritmului
• Reducerea riscului CV.
a Consider cardioversion to
confirm that the absence of
symptoms is not due to unconscious adaptation to
©ESC
reduced physical and/or mental capacity.
©ESC
Recomandări pentru
Recommendations controlul
for rhythm controlritmului

Rhythm controlcontrolul
Terapia pentru therapyritmului
is recommended for symptom
este recomandată pentruand QoL
îmbunătățirea
I A
improvement
simptomelor lainpacienții
symptomatic
cu FA patients with AF.
©ESC
Cardioversia
a Alternatively a
la
VKA can be used, accounting for the
©ESC
pacienții cu FA
time needed to achieve therapeutic anticoagulant
effect.
©ESC

Riscul de Avc Severitatea Simptomelor Severitatea Poverii Bolii Severitatea Substratului (

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Riscul de Avc Severitatea Simptomelor Severitatea Poverii Bolii Severitatea Substratului (

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Figure 5 4S-AF scheme as an example of structured

Riscul de Severitatea Severitatea Severitatea

Recommendations Class Level

Palparea pulsului, monitorizarea TA automată,

©ESC ceasuri smart.

Most commonly Positive Other clinical Imaging biomarkers Blood/urine

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

Risk factors and definitions Points

OAC should be considered

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

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