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Thromb Haemost 2024; 124(12): 1087-1094
DOI: 10.1055/a-2434-9244
Invited Clinical Focus

The 2024 European Society of Cardiology Guidelines for Diagnosis and Management of Atrial Fibrillation: A Viewpoint from a Practicing Clinician's Perspective

Tatjana Potpara 
1   Medical Faculty, University of Belgrade, Belgrade, Serbia
2   Intensive Care for Arrhythmias, Cardiology Clinic, University Clinical Centre of Serbia, Belgrade, Serbia
,
Giulio F. Romiti 
3   Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
,
Christian Sohns
4   Clinic for Electrophysiology, Herz-und Diabeteszentrum NRW, Ruhr-Universität Bochum, Med. Fakultät OWL (Universität Bielefeld), Bad Oeynhausen, Germany
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Abstract

Atrial fibrillation (AF) is a complex disease requiring a multidomain and (usually) long-term management, thus posing a significant burden to patients with AF, practitioners, and health care system. Unlike cardiovascular conditions with a narrow referral pathway (e.g., acute coronary syndrome), AF may be first detected by a wide range of specialties (often noncardiology) or a general practitioner. Since timely initiated optimal management is essential for the prevention of AF-related complications, a concise and simple guidance is essential for practitioners managing AF patients, regardless of their specialty. Guideline-adherent management of patients with AF has been shown to translate to improved patient outcomes compared with guideline-nonadherent treatment. To facilitate guideline implementation in routine clinical practice, a good guideline document on AF should introduce only evidence-based new recommendations, while avoiding arbitrary changes, which may be confusing to practitioners. Herein, we discuss the main changes in the 2024 European Society of Cardiology (ESC) AF Guidelines relative to the previous 2020 ESC document. Whether the updates and new recommendations issued by the new guidelines will translate in high adherence in clinical practice (and hence improved prognosis of patients with AF) will need to be addressed in upcoming years.

Keywords

atrial fibrillation - guidelines - evidence-based recommendation


Publication History

Received: 27 September 2024

Accepted: 04 October 2024

Accepted Manuscript online:
07 October 2024

Article published online:
24 October 2024

© 2024. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

 

  • References

  • 1 Hindricks G, Potpara T, Dagres N. et al; ESC Scientific Document Group. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS): The Task Force for the diagnosis and management of atrial fibrillation of the European Society of Cardiology (ESC) Developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC. Eur Heart J 2021; 42 (05) 373-498
    CrossrefPubMedSearch in Google Scholar
  • 2 Lip GY, Laroche C, Popescu MI. et al. Improved outcomes with European Society of Cardiology guideline-adherent antithrombotic treatment in high-risk patients with atrial fibrillation: a report from the EORP-AF General Pilot Registry. Europace 2015; 17 (12) 1777-1786
    CrossrefPubMedSearch in Google Scholar
  • 3 Van Gelder IC, Rienstra M, Bunting KV. et al; ESC Scientific Document Group. 2024 ESC Guidelines for the management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J 2024; 45 (36) 3314-3414
    CrossrefPubMedSearch in Google Scholar
  • 4 Bhat A, Khanna S, Chen HHL. et al. Integrated care in atrial fibrillation: a road map to the future. Circ Cardiovasc Qual Outcomes 2021; 14 (03) e007411
    CrossrefPubMedSearch in Google Scholar
  • 5 Kirchhof P, Benussi S, Kotecha D. et al; ESC Scientific Document Group. 2016 ESC guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J 2016; 37 (38) 2893-2962
    CrossrefPubMedSearch in Google Scholar
  • 6 Stevens D, Harrison SL, Kolamunnage-Dona R, Lip GYH, Lane DA. The atrial fibrillation better care pathway for managing atrial fibrillation: a review. Europace 2021; 23 (10) 1511-1527
    CrossrefPubMedSearch in Google Scholar
  • 7 Luo X, Xu W, Ming WK. et al. Cost-effectiveness of mobile health-based integrated care for atrial fibrillation: model development and data analysis. J Med Internet Res 2022; 24 (04) e29408
    CrossrefPubMedSearch in Google Scholar
  • 8 Proietti M, Romiti GF, Olshansky B, Lane DA, Lip GYH. Improved outcomes by integrated care of anticoagulated patients with atrial fibrillation using the simple ABC (atrial fibrillation better care) pathway. Am J Med 2018; 131 (11) 1359-1366.e6
    CrossrefPubMedSearch in Google Scholar
  • 9 Proietti M, Lip GYH, Laroche C. et al; ESC-EORP Atrial Fibrillation General Long-Term Registry Investigators Group. Relation of outcomes to ABC (Atrial Fibrillation Better Care) pathway adherent care in European patients with atrial fibrillation: an analysis from the ESC-EHRA EORP Atrial Fibrillation General Long-Term (AFGen LT) Registry. Europace 2021; 23 (02) 174-183
    CrossrefPubMedSearch in Google Scholar
  • 10 Romiti GF, Proietti M, Vitolo M. et al; ESC-EHRA EORP-AF General Long-Term Registry Investigators. Clinical complexity and impact of the ABC (atrial fibrillation better care) pathway in patients with atrial fibrillation: a report from the ESC-EHRA EURObservational Research Programme in AF General Long-Term Registry. BMC Med 2022; 20 (01) 326
    CrossrefPubMedSearch in Google Scholar
  • 11 Guo Y, Lane DA, Wang L. et al; mAF-App II Trial Investigators. Mobile health technology to improve care for patients with atrial fibrillation. J Am Coll Cardiol 2020; 75 (13) 1523-1534
    CrossrefPubMedSearch in Google Scholar
  • 12 Guo Y, Guo J, Shi X. et al; mAF-App II Trial investigators. Mobile health technology-supported atrial fibrillation screening and integrated care: a report from the mAFA-II trial long-term extension cohort. Eur J Intern Med 2020; 82: 105-111
    CrossrefPubMedSearch in Google Scholar
  • 13 Romiti GF, Pastori D, Rivera-Caravaca JM. et al. Adherence to the ‘atrial fibrillation better care’ pathway in patients with atrial fibrillation: impact on clinical outcomes-a systematic review and meta-analysis of 285,000 patients. Thromb Haemost 2022; 122 (03) 406-414
    Thieme ConnectPubMedSearch in Google Scholar
  • 14 Romiti GF, Proietti M, Bonini N. et al; GLORIA-AF Investigators. Adherence to the atrial fibrillation better care (ABC) pathway and the risk of major outcomes in patients with atrial fibrillation: a post-hoc analysis from the prospective GLORIA-AF Registry. EClinicalMedicine 2022; 55: 101757
    CrossrefPubMedSearch in Google Scholar
  • 15 Krittayaphong R, Winijkul A, Methavigul K, Chichareon P, Lip GYH. Clinical outcomes of patients with atrial fibrillation in relation to multimorbidity status changes over time and the impact of ABC pathway compliance: a nationwide cohort study. J Thromb Thrombolysis 2024
    PubMedSearch in Google Scholar
  • 16 Yao Y, Guo Y, Lip GYH. mAF-App II Trial investigators. The effects of implementing a mobile health-technology supported pathway on atrial fibrillation-related adverse events among patients with multimorbidity: the mAFA-II randomized clinical trial. JAMA Netw Open 2021; 4 (12) e2140071
    CrossrefPubMedSearch in Google Scholar
  • 17 Romiti GF, Guo Y, Corica B, Proietti M, Zhang H, Lip GYH. mAF-App II trial investigators. Mobile health-technology-integrated care for atrial fibrillation: a win ratio analysis from the mAFA-II randomized clinical trial. Thromb Haemost 2023; 123 (11) 1042-1048
    Thieme ConnectPubMedSearch in Google Scholar
  • 18 Li M, Chu M, Shen Y. et al. A novel model of integrated care of older patients with atrial fibrillation in rural China. JACC Asia 2024
    PubMedSearch in Google Scholar
  • 19 Johnsen SP, Proietti M, Maggioni AP, Lip GYH. A multinational European network to implement integrated care in elderly multimorbid atrial fibrillation patients: the AFFIRMO consortium. Eur Heart J 2022; 43 (31) 2916-2918
    CrossrefPubMedSearch in Google Scholar
  • 20 Joglar JA, Chung MK, Armbruster AL. et al; Peer Review Committee Members. 2023 ACC/AHA/ACCP/HRS guideline for the diagnosis and management of atrial fibrillation: a report of the American College of Cardiology/American Heart Association Joint Committee on clinical practice guidelines. Circulation 2024; 149 (01) e1-e156
    CrossrefPubMedSearch in Google Scholar
  • 21 Kang DS, Yang PS, Kim D. et al. Racial differences in ischemic and hemorrhagic stroke: an ecological epidemiological study. Thromb Haemost 2024; 124 (09) 883-892
    Thieme ConnectPubMedSearch in Google Scholar
  • 22 Kang DS, Yang PS, Kim D. et al. Racial differences in bleeding risk: an ecological epidemiological study comparing Korea and United Kingdom subjects. Thromb Haemost 2024; 124 (09) 842-851
    Thieme ConnectPubMedSearch in Google Scholar
  • 23 Borre ED, Goode A, Raitz G. et al. Predicting thromboembolic and bleeding event risk in patients with non-valvular atrial fibrillation: a systematic review. Thromb Haemost 2018; 118 (12) 2171-2187
    Thieme ConnectPubMedSearch in Google Scholar
  • 24 Potpara TS, Polovina MM, Licina MM, Marinkovic JM, Prostran MS, Lip GY. Reliable identification of “truly low” thromboembolic risk in patients initially diagnosed with “lone” atrial fibrillation: the Belgrade atrial fibrillation study. Circ Arrhythm Electrophysiol 2012; 5 (02) 319-326
    CrossrefPubMedSearch in Google Scholar
  • 25 Brieger D, Amerena J, Attia J. et al; NHFA CSANZ Atrial Fibrillation Guideline Working Group. National Heart Foundation of Australia and the Cardiac Society of Australia and New Zealand: Australian clinical guidelines for the diagnosis and management of atrial fibrillation 2018. Heart Lung Circ 2018; 27 (10) 1209-1266
    CrossrefPubMedSearch in Google Scholar
  • 26 Chao TF, Joung B, Takahashi Y. et al. 2021 focused update consensus guidelines of the Asia Pacific Heart Rhythm Society on stroke prevention in atrial fibrillation: executive summary. Thromb Haemost 2022; 122 (01) 20-47
    Thieme ConnectPubMedSearch in Google Scholar
  • 27 Andrade JG, Aguilar M, Atzema C. et al; Members of the Secondary Panel. The 2020 Canadian Cardiovascular Society/Canadian Heart Rhythm Society comprehensive guidelines for the management of atrial fibrillation. Can J Cardiol 2020; 36 (12) 1847-1948
    CrossrefPubMedSearch in Google Scholar
  • 28 Wang Y, Guo Y, Qin M. et al; Expert Reviewers. 2024 Chinese Expert Consensus Guidelines on the diagnosis and treatment of atrial fibrillation in the elderly, endorsed by Geriatric Society of Chinese Medical Association (Cardiovascular Group) and Chinese Society of Geriatric Health Medicine (Cardiovascular Branch): executive summary. Thromb Haemost 2024; 124 (10) 897-911
    Thieme ConnectPubMedSearch in Google Scholar
  • 29 Nielsen PB, Skjøth F, Overvad TF, Larsen TB, Lip GYH. Female sex is a risk modifier rather than a risk factor for stroke in atrial fibrillation: should we use a CHA2DS2-VA score rather than CHA2DS2-VASc?. Circulation 2018; 137 (08) 832-840
    CrossrefPubMedSearch in Google Scholar
  • 30 Wagstaff AJ, Overvad TF, Lip GY, Lane DA. Is female sex a risk factor for stroke and thromboembolism in patients with atrial fibrillation? A systematic review and meta-analysis. QJM 2014; 107 (12) 955-967
    CrossrefPubMedSearch in Google Scholar
  • 31 Corica B, Lobban T, True Hills M, Proietti M, Romiti GF. Sex as a risk factor for atrial fibrillation-related stroke. Thromb Haemost 2024; 124 (04) 281-285
    Thieme ConnectPubMedSearch in Google Scholar
  • 32 Lang C, Seyfang L, Ferrari J. et al; Austrian Stroke Registry Collaborators. Do women with atrial fibrillation experience more severe strokes? Results from the Austrian Stroke Unit Registry. Stroke 2017; 48 (03) 778-780
    CrossrefPubMedSearch in Google Scholar
  • 33 Nielsen PB, Brøndum RF, Nøhr AK, Overvad TF, Lip GYH. Risk of stroke in male and female patients with atrial fibrillation in a nationwide cohort. Nat Commun 2024; 15 (01) 6728
    CrossrefPubMedSearch in Google Scholar
  • 34 Teppo K, Lip GYH, Airaksinen KEJ. et al. Comparing CHA2DS2-VA and CHA2DS2-VASc scores for stroke risk stratification in patients with atrial fibrillation: a temporal trends analysis from the retrospective Finnish AntiCoagulation in Atrial Fibrillation (FinACAF) cohort. Lancet Reg Health Eur 2024; 43: 100967
    CrossrefPubMedSearch in Google Scholar
  • 35 Teppo K, Airaksinen KEJ, Jaakkola J. et al. Ischaemic stroke in women with atrial fibrillation: temporal trends and clinical implications. Eur Heart J 2024; 45 (20) 1819-1827
    CrossrefPubMedSearch in Google Scholar
  • 36 Yoshimura HPR, Finan C, Schmidt AF, Lip GYH. Refining the CHA2DS2VASc risk stratification scheme: shall we drop the sex category criterion?. Europace 2024 ; available at: https://doi.org/10.1093/europace/euae280
    CrossrefPubMedSearch in Google Scholar
  • 37 Teppo K, Airaksinen KEJ, Jaakkola J. et al. Temporal trends of gender disparities in oral anticoagulant use in patients with atrial fibrillation. Eur J Clin Invest 2024; 54 (01) e14107
    CrossrefPubMedSearch in Google Scholar
  • 38 Gadsbøll K, Staerk L, Fosbøl EL. et al. Increased use of oral anticoagulants in patients with atrial fibrillation: temporal trends from 2005 to 2015 in Denmark. Eur Heart J 2017; 38 (12) 899-906
    PubMedSearch in Google Scholar
  • 39 Brieger D, Amerena J, Attia JR. et al. National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand: Australian clinical guidelines for the diagnosis and management of atrial fibrillation 2018. Med J Aust 2018; 209 (08) 356-362
    CrossrefPubMedSearch in Google Scholar
  • 40 Camm AJ, Kirchhof P, Lip GY. et al; European Heart Rhythm Association, European Association for Cardio-Thoracic Surgery. Guidelines for the management of atrial fibrillation: the Task Force for the Management of Atrial Fibrillation of the European Society of Cardiology (ESC). Eur Heart J 2010; 31 (19) 2369-2429
    CrossrefPubMedSearch in Google Scholar
  • 41 Camm AJ, Lip GY, De Caterina R. et al; ESC Committee for Practice Guidelines (CPG). 2012 focused update of the ESC Guidelines for the management of atrial fibrillation: an update of the 2010 ESC Guidelines for the management of atrial fibrillation. Developed with the special contribution of the European Heart Rhythm Association. Eur Heart J 2012; 33 (21) 2719-2747
    CrossrefPubMedSearch in Google Scholar
  • 42 Chao TF, Lip GYH, Lin YJ. et al. Incident risk factors and major bleeding in patients with atrial fibrillation treated with oral anticoagulants: a comparison of baseline, follow-up and delta HAS-BLED scores with an approach focused on modifiable bleeding risk factors. Thromb Haemost 2018; 118 (04) 768-777
    Thieme ConnectPubMedSearch in Google Scholar
  • 43 Esteve-Pastor MA, Rivera-Caravaca JM, Shantsila A, Roldán V, Lip GYH, Marín F. Assessing bleeding risk in atrial fibrillation patients: comparing a bleeding risk score based only on modifiable bleeding risk factors against the HAS-BLED Score. The AMADEUS trial. Thromb Haemost 2017; 117 (12) 2261-2266
    Thieme ConnectPubMedSearch in Google Scholar
  • 44 Guo Y, Zhu H, Chen Y, Lip GYH. Comparing bleeding risk assessment focused on modifiable risk factors only versus validated bleeding risk scores in atrial fibrillation. Am J Med 2018; 131 (02) 185-192
    CrossrefPubMedSearch in Google Scholar
  • 45 Chao TF, Lip GYH, Lin YJ. et al. Major bleeding and intracranial hemorrhage risk prediction in patients with atrial fibrillation: attention to modifiable bleeding risk factors or use of a bleeding risk stratification score? A nationwide cohort study. Int J Cardiol 2018; 254: 157-161
    CrossrefPubMedSearch in Google Scholar
  • 46 Gorog DA, Gue YX, Chao TF. et al. Assessment and mitigation of bleeding risk in atrial fibrillation and venous thromboembolism: executive summary of a European and Asia-Pacific expert consensus paper. Thromb Haemost 2022; 122 (10) 1625-1652
    Thieme ConnectPubMedSearch in Google Scholar
  • 47 Winijkul A, Kaewkumdee P, Yindeengam A, Lip GYH, Krittayaphong R. Clinical outcomes of patients with atrial fibrillation who survived from bleeding event: the results from COOL-AF Thailand registry. Thromb Haemost 2024; 124 (11) 991-1002
    PubMedSearch in Google Scholar
  • 48 Hilkens NA, Algra A, Greving JP. Predicting major bleeding in ischemic stroke patients with atrial fibrillation. Stroke 2017; 48 (11) 3142-3144
    CrossrefPubMedSearch in Google Scholar
  • 49 Olesen JB, Lip GY, Lindhardsen J. et al. Risks of thromboembolism and bleeding with thromboprophylaxis in patients with atrial fibrillation: a net clinical benefit analysis using a ‘real world’ nationwide cohort study. Thromb Haemost 2011; 106 (04) 739-749
    PubMedSearch in Google Scholar
  • 50 January CT, Wann LS, Alpert JS. et al; ACC/AHA Task Force Members. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines and the Heart Rhythm Society. Circulation 2014; 130 (23) 2071-2104
    CrossrefPubMedSearch in Google Scholar
  • 51 Potpara T, Grygier M, Häusler KG. et al. Practical guide on left atrial appendage closure for the non-implanting physician: an international consensus paper. Europace 2024; 26 (04) euae035
    CrossrefPubMedSearch in Google Scholar
  • 52 Kirchhof P, Camm AJ, Goette A. et al; EAST-AFNET 4 Trial Investigators. Early rhythm-control therapy in patients with atrial fibrillation. N Engl J Med 2020; 383 (14) 1305-1316
    CrossrefPubMedSearch in Google Scholar
  • 53 Chao TF, Chan YH, Chiang CE. et al. Early rhythm control and the risks of ischemic stroke, heart failure, mortality, and adverse events when performed early (<3 months): a nationwide cohort study of newly diagnosed patients with atrial fibrillation. Thromb Haemost 2022; 122 (11) 1899-1910
    Thieme ConnectPubMedSearch in Google Scholar
  • 54 Sohns C, Fox H, Marrouche NF. et al; CASTLE HTx Investigators. Catheter ablation in end-stage heart failure with atrial fibrillation. N Engl J Med 2023; 389 (15) 1380-1389
    CrossrefPubMedSearch in Google Scholar
  • 55 Marrouche NF, Brachmann J, Andresen D. et al; CASTLE-AF Investigators. Catheter ablation for atrial fibrillation with heart failure. N Engl J Med 2018; 378 (05) 417-427
    CrossrefPubMedSearch in Google Scholar
  • 56 Kirchhof P, Toennis T, Goette A. et al; NOAH-AFNET 6 Investigators, NOAH-AFNET6 sites and investigators. Anticoagulation with edoxaban in patients with atrial high-rate episodes. N Engl J Med 2023; 389 (13) 1167-1179
    CrossrefPubMedSearch in Google Scholar
  • 57 Healey JS, Lopes RD, Granger CB. et al; ARTESIA Investigators. Apixaban for stroke prevention in subclinical atrial fibrillation. N Engl J Med 2024; 390 (02) 107-117
    CrossrefPubMedSearch in Google Scholar
  • 58 McIntyre WF, Benz AP, Becher N. et al. Direct oral anticoagulants for stroke prevention in patients with device-detected atrial fibrillation: a study-level meta-analysis of the NOAH-AFNET 6 and ARTESiA trials. Circulation 2024; 149 (13) 981-988
    CrossrefPubMedSearch in Google Scholar
  • 59 Cabana MD, Rand CS, Powe NR. et al. Why don't physicians follow clinical practice guidelines? A framework for improvement. JAMA 1999; 282 (15) 1458-1465
    CrossrefPubMedSearch in Google Scholar