European Heart Journal ESC GUIDELINES doi:10.1093/eurheartj/ehq278Guidelines for the management of atrialﬁbrillationThe Task Force for the Management of Atrial Fibrillation of theEuropean Society of Cardiology (ESC)Developed with the special contribution of the European Heart Rhythm Association(EHRA)†Endorsed by the European Association for Cardio-Thoracic Surgery (EACTS)Authors/Task Force Members: A. John Camm (Chairperson) (UK)*, Paulus Kirchhof(Germany), Gregory Y. H.Lip (UK), UlrichSchotten (The Netherlands), IreneSavelieva(UK), Sabine Ernst (UK), Isabelle C. Van Gelder (The Netherlands), Nawwar Al-Attar(France), Gerhard Hindricks (Germany), Bernard Prendergast (UK), Hein Heidbuchel(Belgium), Ottavio Alﬁeri (Italy), Annalisa Angelini (Italy), Dan Atar (Norway),Paolo Colonna (Italy), Raffaele De Caterina (Italy), Johan De Sutter (Belgium),Andreas Goette (Germany), Bulent Gorenek (Turkey), Magnus Heldal (Norway),Stefan H.Hohloser (Germany), PhilippeKolh (Belgium), Jean-YvesLe Heuzey (France),Piotr Ponikowski (Poland), Frans H. Rutten (The Netherlands).ESC Committee for Practice Guidelines (CPG): Alec Vahanian (Chairperson) (France), Angelo Auricchio(Switzerland), Jeroen Bax (The Netherlands), Claudio Ceconi (Italy), Veronica Dean (France), Gerasimos Filippatos(Greece), Christian Funck-Brentano (France), Richard Hobbs (UK), Peter Kearney (Ireland), Theresa McDonagh(UK), Bogdan A. Popescu (Romania), Zeljko Reiner (Croatia), Udo Sechtem (Germany), Per Anton Sirnes(Norway), Michal Tendera (Poland), Panos E. Vardas (Greece), Petr Widimsky (Czech Republic).Document Reviewers: Panos E. Vardas (CPG Review Coordinator) (Greece), Vazha Agladze (Georgia), Etienne Aliot(France), ToshoBalabanski (Bulgaria), CarinaBlomstrom-Lundqvist (Sweden), AlessandroCapucci (Italy), HarryCrijns ¨ ¨(The Netherlands), Bjorn Dahlof (Sweden), Thierry Folliguet (France), Michael Glikson (Israel), Marnix Goethals(Belgium), Dietrich C. Gulba (Germany), Siew Yen Ho (UK), Robert J. M. Klautz (The Netherlands), Sedat Kose(Turkey), John McMurray (UK), Pasquale Perrone Filardi (Italy), Pekka Raatikainen (Finland), Maria Jesus Salvador ˜(Spain), Martin J. Schalij (The Netherlands), Alexander Shpektor (Russian Federation), Joao Sousa (Portugal),Janina Stepinska (Poland), Hasso Uuetoa (Estonia), Jose Luis Zamorano (Spain), Igor Zupan (Slovenia).The disclosure forms of the authors and reviewers are available on the ESC website www.escardio.org/guidelines* Corresponding author. A. John Camm, St George’s University of London, Cranmer Terrace, London SW17 ORE, UK. Tel: +44 20 8725 3414, Fax: +44 20 8725 3416, Email:email@example.comThe content of these European Society of Cardiology (ESC) Guidelines has been published for personal and educational use only. No commercial use is authorized. No part of theESC Guidelines may be translated or reproduced in any form without written permission from the ESC. Permission can be obtained upon submission of a written request to OxfordUniversity Press, the publisher of the European Heart Journal and the party authorized to handle such permissions on behalf of the ESC.† Other ESC entities having participated in the development of this document:Associations: European Association of Echocardiography (EAE), European Association for Cardiovascular Prevention & Rehabilitation (EACPR), Heart Failure Association (HFA).Working Groups: Cardiovascular Surgery, Developmental Anatomy and Pathology, Cardiovascular Pharmacology and Drug Therapy, Thrombosis, Acute Cardiac Care, ValvularHeart Disease.Councils: Cardiovascular Imaging, Cardiology Practice, Cardiovascular Primary Care.Disclaimer. The ESC Guidelines represent the views of the ESC and were arrived at after careful consideration of the available evidence at the time they were written. Healthprofessionals are encouraged to take them fully into account when exercising their clinical judgement. The guidelines do not, however, override the individual responsibility of healthprofessionals to make appropriate decisions in the circumstances of the individual patients, in consultation with that patient, and where appropriate and necessary the patient’sguardian or carer. It is also the health professional’s responsibility to verify the rules and regulations applicable to drugs and devices at the time of prescription.& The European Society of Cardiology 2010. All rights reserved. For Permissions please email: firstname.lastname@example.org
ESC Guidelines Page 3 of 61AF-CHF Atrial Fibrillation and Congestive Heart Failure EAPCI European Association of Percutaneous Cardio-AFFIRM Atrial Fibrillation Follow-up Investigation of vascular Interventions Rhythm Management EHRA European Heart Rhythm AssociationANDROMEDA ANtiarrhythmic trial with DROnedarone in ECG electrocardiogram Moderate-to-severe congestive heart failure EMA European Medicines Agency Evaluating morbidity DecreAse EURIDIS EURopean trial In atrial ﬁbrillation or ﬂutterAP accessory pathway patients receiving Dronedarone for the maInten-APAF Ablation for Paroxysmal Atrial Fibrillation study ance of Sinus rhythmARB angiotensin receptor blocker GISSI-AF Gruppo Italiano per lo Studio della Sopravvi-ARMYDA Atorvastatin for Reduction of MYocardial Dys- venza nell’Insufﬁcienza cardiaca Atrial Fibrillation rhythmia After cardiac surgery GPI glycoprotein inhibitorATHENA A placebo-controlled, double-blind, parallel arm GRACE Global Registry of Acute Coronary Events Trial to assess the efﬁcacy of dronedarone HAS-BLED hypertension, abnormal renal/liver function (1 400 mg b.i.d. for the prevention of cardiovascular point each), stroke, bleeding history or predispo- Hospitalisation or death from any cause in sition, labile INR, elderly (.65), drugs/alcohol patiENts with Atrial ﬁbrillation/atrial ﬂutter concomitantly (1 point each)ATRIA AnTicoagulation and Risk factors In Atrial HOPE Heart Outcomes Prevention Evaluation ﬁbrillation HOT CAFE How to Treat Chronic Atrial FibrillationAVRO A Phase III prospective, randomized, double- HR hazard ratio blind, Active-controlled, multicentre, superiority HT hypertension study of Vernakalant injection vs. amiodarone INR international normalized ratio in subjects with Recent Onset atrial ﬁbrillation i.v. intravenousAVERROES Apixaban VERsus acetylsalicylic acid to pRevent J-RHYTHM Japanese Rhythm Management Trial for Atrial strOkES FibrillationBAFTA Birmingham Atrial Fibrillation Treatment of the LA left atrial Aged LAA left atrial appendageb.i.d. bis in die (twice daily) LIFE Losartan Intervention For Endpoint reduction inbpm beats per minute hypertensionCABG coronary artery bypass graft LMWH low molecular weight heparinCACAF Catheter Ablation for the Cure of Atrial Fibrilla- LoE level of evidence tion study LV left ventricularCFAE complex fractionated atrial electrogram LVEF left ventricular ejection fractionCHA2DS2-VASc cardiac failure, hypertension, age ≥75 (doubled), o.d. omni die (every day) diabetes, stroke (doubled)-vascular disease, age OAC oral anticoagulant 65 –74 and sex category (female) OR odds ratioCHADS2 cardiac failure, hypertension, age, diabetes, MRI magnetic resonance imaging stroke (doubled) NYHA New York Heart AssociationCHARISMA Clopidogrel for High Athero-thrombotic Risk and PAD peripheral artery disease Ischemic Stabilisation, Management, and Avoidance PCI percutaneous interventionCHARM Candesartan in Heart failure: Assessment of PIAF Pharmacological Intervention in Atrial Fibrillation Reduction in Mortality and morbidity PPI proton pump inhibitorCI conﬁdence interval PROTECT-AF System for Embolic PROTECTion in patientsCOPD chronic obstructive pulmonary disease with Atrial FibrillationCPG clinical practice guidelines PUFA polyunsaturated fatty acidCRT cardiac resynchronization therapy PV pulmonary veinCT computed tomography PVI pulmonary vein isolationCV cardioversion RACE RAte Control versus Electrical cardioversion forDAFNE Dronedarone Atrial FibrillatioN study after Elec- persistent atrial ﬁbrillation trical cardioversion RACE II RAte Control Efﬁcacy in permanent atrialDCC direct current cardioversion ﬁbrillationDIONYSOS Randomized Double blind trIal to evaluate efﬁ- RAAFT Radiofrequency Ablation Atrial Fibrillation Trial cacy and safety of drOnedarone [400 mg b.i.d.] RE-LY Randomized Evaluation of Long-term anticoagu- versus amiodaroNe [600 mg q.d. for 28 daYS, lant therapY with dabigatran etexilate then 200 mg qd thereafter] for at least 6 RIKS-HIA Register of Information and Knowledge about mOnths for the maintenance of Sinus rhythm Swedish Heart Intensive care Admissions in patients with atrial ﬁbrillation RR relative risk
Page 4 of 61 ESC GuidelinesSAFE-T Sotalol, Amiodarone, atrial Fibrillation Efﬁcacy Table 1 Classes of recommendations TrialSAFE Screening for AF in the ElderlySCD sudden cardiac death Classes of Deﬁnition recommendationsSPAF Stroke Prevention in Atrial FibrillationSTAF Strategies of Treatment of Atrial Fibrillation Class I Evidence and/or general agreementSTEMI ST segment elevation myocardial infarction that a given treatment or procedure is beneﬁcial, useful, effective.STOP-AF Sustained Treatment Of Paroxysmal Atrial Fibrillation Class II Conﬂicting evidence and/or aTIA transient ischaemic attack divergence of opinion about the usefulness/efﬁcacy of the givent.i.d. ter in die (three times daily) treatment or procedure.TIMI Thrombolysis In Myocardial InfarctionTOE transoesophageal echocardiogram Class IIa Weight of evidence/opinion is in favour of usefulness/efﬁcacy.TRANSCEND Telmisartan Randomized AssessmeNt Study in aCE iNtolerant subjects with cardiovascular Class IIb Usefulness/efﬁcacy is less well Disease established by evidence/opinion.UFH unfractionated heparin Class III Evidence or general agreement thatVALUE Valsartan Antihypertensive Long-term Use the given treatment or procedure is Evaluation not useful/effective, and in some cases may be harmful.VKA vitamin K antagonistWASPO Warfarin versus Aspirin for Stroke Prevention in Octogenarians with AF1. Preamble Table 2 Levels of evidenceGuidelines summarize and evaluate all currently available evidenceon a particular issue with the aim of assisting physicians in selecting Level of Data derived from multiple randomized evidence A clinical trials or meta-analyses.the best management strategy for an individual patient sufferingfrom a given condition, taking into account the impact onoutcome, as well as the risk –beneﬁt ratio of particular diagnostic Level of Data derived from a single randomized evidence B clinical trial or large non-randomized studies.or therapeutic means. Guidelines are no substitutes for textbooks.The legal implications of medical guidelines have been discussed Level of Consensus of opinion of the experts and/orpreviously. evidence C small studies, retrospective studies, registries. A large number of Guidelines have been issued in recent yearsby the European Society of Cardiology (ESC) as well as by othersocieties and organizations. Because of the impact on clinical prac-tice, quality criteria for development of guidelines have been estab-lished in order to make all decisions transparent to the user. The ESC and was developed without any involvement of the pharma-recommendations for formulating and issuing ESC Guidelines can ceutical, device, or surgical industry.be found on the ESC Web Site (http://www.escardio.org/ The ESC Committee for Practice Guidelines (CPG) supervisesknowledge/guidelines/rules). and coordinates the preparation of new Guidelines produced by In brief, experts in the ﬁeld are selected and undertake a com- Task Forces, expert groups, or consensus panels. The Committeeprehensive review of the published evidence for management and/ is also responsible for the endorsement process of these Guide-or prevention of a given condition. A critical evaluation of diagnos- lines or statements. Once the document has been ﬁnalized andtic and therapeutic procedures is performed, including assessment approved by all the experts involved in the Task Force, it is sub-of the risk –beneﬁt ratio. Estimates of expected health outcomes mitted to outside specialists for review. The document is revised,for larger societies are included, where data exist. The level of evi- ﬁnally approved by the CPG, and subsequently published.dence and the strength of recommendation of particular treatment After publication, dissemination of the message is of paramountoptions are weighed and graded according to pre-deﬁned scales, as importance. Pocket-sized versions and personal digital assistant-outlined in Tables 1 and 2. downloadable versions are useful at the point of care. Some The experts of the writing panels have provided disclosure surveys have shown that the intended users are sometimesstatements of all relationships they may have that might be per- unaware of the existence of guidelines, or simply do not translateceived as real or potential sources of conﬂicts of interest. These them into practice. Thus, implementation programmes for newdisclosure forms are kept on ﬁle at the European Heart House, guidelines form an important component of knowledge dissemina-headquarters of the ESC. Any changes in conﬂict of interest that tion. Meetings are organized by the ESC, and directed towards itsarise during the writing period must be notiﬁed to the ESC. The member National Societies and key opinion leaders in Europe.Task Force report received its entire ﬁnancial support from the Implementation meetings can also be undertaken at national
ESC Guidelines Page 5 of 61levels, once the guidelines have been endorsed by the ESC The problem of early recognition of AF is greatly aggravated bymember societies, and translated into the national language. the often ‘silent’ nature of the rhythm disturbance. In aboutImplementation programmes are needed because it has been one-third of patients with this arrhythmia, the patient is notshown that the outcome of disease may be favourably inﬂuenced aware of so-called ‘asymptomatic AF’. Much earlier detection ofby the thorough application of clinical recommendations. the arrhythmia might allow the timely introduction of therapies Thus, the task of writing Guidelines covers not only the inte- to protect the patient, not only from the consequences of thegration of the most recent research, but also the creation of edu- arrhythmia, but also from progression of AF from ancational tools and implementation programmes for the easily treated condition to an utterly refractory problem.recommendations. The loop between clinical research, writing of Monitoring and screening as advocated in this guideline may helpguidelines, and implementing them into clinical practice can then to do this.only be completed if surveys and registries are performed to Non-pharmacological interventions to control the occurrenceverify that real-life daily practice is in keeping with what is rec- of AF or to limit its expression have been eagerly and substantiallyommended in the guidelines. Such surveys and registries also developed in the past decade. Ablation techniques, usually donemake it possible to evaluate the impact of implementation of the percutaneously using a catheter, have proved successful in theguidelines on patient outcomes. Guidelines and recommendations treatment of AF, particularly by reducing the symptomaticshould help the physicians to make decisions in their daily practice; burden associated with the arrhythmia, to such an extent that ahowever, the ultimate judgement regarding the care of an individ- ‘cure’ may be achieved in some patients. The new guidelines recog-ual patient must be made by the physician in charge of their care. nize these advances. When applied in concert with major new drug developments such as novel antithrombotic agents and emerging safer antiarrhythmic drugs, these therapeutic options should help2. Introduction to improve outcomes in AF patients.Atrial ﬁbrillation (AF) is the most common sustained cardiac The expanding and diversifying possibilities and restraints ofarrhythmia, occurring in 1–2% of the general population. Over 6 medical care within Europe make it difﬁcult to formulate guidelinesmillion Europeans suffer from this arrhythmia, and its prevalence that are valid throughout Europe. There are differences in the avail-is estimated to at least double in the next 50 years as the popu- ability of therapies, delivery of care, and patient characteristics inlation ages. It is now 4 years since the last AF guideline was pub- Europe and in other parts of the world. Therefore, these Europeanlished, and a new version is now needed. guidelines, though based largely on globally acquired data, are likely AF confers a 5-fold risk of stroke, and one in ﬁve of all strokes is to require some modiﬁcations when applied to multiple healthcareattributed to this arrhythmia. Ischaemic strokes in association with settings.AF are often fatal, and those patients who survive are left more dis-abled by their stroke and more likely to suffer a recurrence thanpatients with other causes of stroke. In consequence, the risk of 2.1 Epidemiologydeath from AF-related stroke is doubled and the cost of care is AF affects 1– 2% of the population, and this ﬁgure is likely toincreased 1.5-fold. There has been much research into stroke pre- increase in the next 50 years.1 – 2 In acute stroke patients, systema-vention, which has inﬂuenced this guideline. tic electrocardiographic (ECG) monitoring would identify AF in 1 In the majority of patients there appears to be an inexorable in 20 subjects, a far greater number than would have beenprogression of AF to persistent or permanent forms, associated detected by standard 12-lead ECG recordings. AF may longwith further development of the disease that may underlie the remain undiagnosed (silent AF),3 and many patients with AF willarrhythmia. Some advance has been made in the understanding never present to hospital.4 Hence, the ‘true’ prevalence of AF isof the dynamic development of AF from its preclinical state as probably closer to 2% of the population.3an ‘arrhythmia-in-waiting’ to its ﬁnal expression as an irreversible The prevalence of AF increases with age, from ,0.5% at 40 –50and end-stage cardiac arrhythmia associated with serious adverse years, to 5–15% at 80 years.1 – 2,5 – 7 Men are more often affectedcardiovascular events. Much recent therapeutic effort with than women. The lifetime risk of developing AF is 25% in‘upstream therapies’ has been expended to slow or halt the pro- those who have reached the age of 40.8 The prevalence and inci-gression of AF due to underlying cardiovascular disease and to dence of AF in non-Caucasian populations is less well studied. TheAF itself. Limited success has been achieved and is recognized in incidence of AF appears to be increasing (13% in the past twothis guideline. decades). Clinical frustration has been fuelled by numerous clinical trialsthat have demonstrated that the strategic aim of maintaining 2.1.1 Atrial ﬁbrillation-related cardiovascular eventssinus rhythm has no demonstrable value when compared with (‘outcomes’)the laissez-faire approach of leaving AF unchecked apart from AF is associated with increased rates of death, stroke and otherrestriction of the ventricular rate. No advantage from strict rate thrombo-embolic events, heart failure and hospitalizations,control has been established. These sobering ﬁndings are clearly degraded quality of life, reduced exercise capacity, and left ventri-at odds with the severe complications associated with AF in cular (LV) dysfunction (Table 3).surveys and epidemiological studies. However, new antiarrhythmic Death rates are doubled by AF, independently of other knownapproaches may offer added value and have stimulated additions to predictors of mortality.3,9 Only antithrombotic therapy has beenthese guidelines. shown to reduce AF-related deaths.10
Page 6 of 61 ESC Guidelines Ageing increases the risk of developing AF, possibly through Table 3 Clinical events (outcomes) affected by AF age-dependent loss and isolation of atrial myocardium and associ- ated conduction disturbances (see Section 2.2). Relative change in AF Outcome parameter Hypertension is a risk factor for incident (ﬁrst diagnosed) AF patients and for AF-related complications such as stroke and systemic 1. Death Death rate doubled. thrombo-embolism. Stroke risk increased; AF is Symptomatic heart failure [New York Heart Association 2. Stroke (includes haemorrhagic associated with more severe stroke and cerebral bleeds) (NYHA) classes II –IV] is found in 30% of AF patients,14,15 and stroke. AF is found in up to 30–40% of heart failure patients, depending Hospitalizations are frequent in 3. Hospitalizations AF patients and may contribute to on the underlying cause and severity of heart failure. Heart reduced quality of life. failure can be both a consequence of AF (e.g. tachycardiomyopathy Wide variation, from no effect to or decompensation in acute onset AF) and a cause of the arrhyth- major reduction. mia due to increased atrial pressure and volume overload, 4. Quality of life and exercise AF can cause marked distress secondary valvular dysfunction, or chronic neurohumoral capacity through palpitations and other stimulation. AF-related symptoms. Tachycardiomyopathy should be suspected when LV dys- Wide variation, from no change to function is found in patients with a fast ventricular rate but no 5. Left ventricular function tachycardiomyopathy with acute heart failure. signs of structural heart disease. It is conﬁrmed by normalization or improvement of LV function when good AF rate control or reversion to sinus rhythm is achieved. AF ¼ atrial ﬁbrillation. Outcomes are listed in hierarchical order modiﬁed from a suggestion put forward Valvular heart diseases are found in 30% of AF in a recent consensus document.3 The prevention of these outcomes is the main patients.14,15 AF caused by left atrial (LA) distension is an therapeutic goal in AF patients. early manifestation of mitral stenosis and/or regurgitation. AF occurs in later stages of aortic valve disease. While ‘rheumatic AF’ was a frequent ﬁnding in the past, it is now relatively rare in Stroke in AF is often severe and results in long-term disability Europe.or death. Approximately every ﬁfth stroke is due to AF; further- Cardiomyopathies, including primary electrical cardiac dis-more, undiagnosed ‘silent AF’ is a likely cause of some ‘cryptogenic’ eases,16 carry an increased risk for AF, especially in young patients.strokes.3,11 Paroxysmal AF carries the same stroke risk as perma- Relatively rare cardiomyopathies are found in 10% of AFnent or persistent AF.12 patients.14,15 A small proportion of patients with ‘lone’ AF carry Hospitalizations due to AF account for one-third of all admis- known mutations for ‘electrical’ cardiomyopathies.sions for cardiac arrhythmias. Acute coronary syndrome (ACS), Atrial septal defect is associated with AF in 10–15% ofaggravation of heart failure, thrombo-embolic complications, and patients in older surveys. This association has important clinicalacute arrhythmia management are the main causes. implications for the antithrombotic management of patients with Cognitive dysfunction, including vascular dementia, may be previous stroke or transient ischaemic attack (TIA) and an atrialrelated to AF. Small observational studies suggest that asympto- septal defect.matic embolic events may contribute to cognitive dysfunction in Other congenital heart defects at risk of AF include patientsAF patients in the absence of an overt stroke.11 with single ventricles, after Mustard operation for transposition of Quality of life and exercise capacity are impaired in patients the great arteries, or after Fontan surgery.with AF. Patients with AF have a signiﬁcantly poorer quality of life Coronary artery disease is present in ≥20% of the AF popu-compared with healthy controls, the general population, or lation.14,15 Whether uncomplicated coronary artery disease per sepatients with coronary heart disease in sinus rhythm.13 (atrial ischaemia) predisposes to AF and how AF interacts with Left ventricular (LV) function is often impaired by the irre- coronary perfusion17 are uncertain.gular, fast ventricular rate and by loss of atrial contractile function Overt thyroid dysfunction can be the sole cause of AF andand increased end-diastolic LV ﬁlling pressure. Both rate control may predispose to AF-related complications. In recent surveys,and maintenance of sinus rhythm can improve LV function in AF hyperthyroidism or hypothyroidism was found to be relativelypatients. uncommon in AF populations,14,15 but subclinical thyroid dysfunc- tion may contribute to AF. Obesity is found in 25% of AF patients,15 and the mean body2.1.2 Cardiovascular and other conditions associated with mass index was 27.5 kg/m2 in a large, German AF registry (equiv-atrial ﬁbrillation alent to moderately obese).AF is associated with a variety of cardiovascular conditions.14,15 Diabetes mellitus requiring medical treatment is found in 20%Concomitant medical conditions have an additive effect on the of AF patients, and may contribute to atrial damage.perpetuation of AF by promoting a substrate that maintains AF Chronic obstructive pulmonary disease (COPD) is found(see Section 2.2). Conditions associated with AF are also in 10 –15% of AF patients, and is possibly more a marker formarkers for global cardiovascular risk and/or cardiac damage cardiovascular risk in general than a speciﬁc predisposing factorrather than simply causative factors. for AF.
ESC Guidelines Page 7 of 61 Sleep apnoea, especially in association with hypertension, dia- normal atrial refractoriness occurs within a few days after restor-betes mellitus, and structural heart disease, may be a pathophysio- ation of sinus rhythm.logical factor for AF because of apnoea-induced increases in atrial Perturbation of atrial contractile function also occurs within dayspressure and size, or autonomic changes. of AF. The main cellular mechanisms of atrial contractile dysfunc- Chronic renal disease is present in 10 –15% of AF patients. tion are down-regulation of the Ca2+ inward current, impairedRenal failure may increase the risk of AF-related cardiovascular release of Ca2+ from intracellular Ca2+ stores, and alterations ofcomplications, although controlled data are sparse. myoﬁbrillar energetics. In patients with ‘lone’ AF, ﬁbrosis and inﬂammatory changes have been documented.202.2 Mechanisms of atrial ﬁbrillation2.2.1 Atrial factors 2.2.2 Electrophysiological mechanismsPathophysiological changes preceding atrial ﬁbrillation The initiation and perpetuation of a tachyarrhythmia requires bothAny kind of structural heart disease may trigger a slow but pro- triggers for its onset and a substrate for its maintenance. Thesegressive process of structural remodelling in both the ventricles mechanisms are not mutually exclusive and are likely to co-existand the atria. In the atria, proliferation and differentiation of ﬁbro- at various times.blasts into myoﬁbroblasts and enhanced connective tissue depo-sition and ﬁbrosis are the hallmarks of this process. Structural Focal mechanismsremodelling results in electrical dissociation between muscle Focal mechanisms potentially contributing to the initiation and per-bundles and local conduction heterogeneities facilitating the petuation of AF have attracted much attention.21 Cellular mechan-initiation and perpetuation of AF. This electroanatomical substrate isms of focal activity might involve both triggered activity andpermits multiple small re-entrant circuits that can stabilize the re-entry. Because of shorter refractory periods as well as abruptarrhythmia. Structural abnormalities reported in patients with AF changes in myocyte ﬁbre orientation, the pulmonary veins (PVs)are summarized in Table 4. have a stronger potential to initiate and perpetuate atrial tachyarrhythmias. Ablation of sites with a high dominant frequency, mostly locatedPathophysiological changes as a consequence of atrial ﬁbrillation at or close to the junction between the PVs and the left atrium,After the onset of AF, changes of atrial electrophysiological prop- results in progressive prolongation of the AF cycle length and con-erties, mechanical function, and atrial ultrastructure occur with version to sinus rhythm in patients with paroxysmal AF, while indifferent time courses and with different pathophysiological conse- persistent AF, sites with a high dominant frequency are spreadquences.18 Shortening of the atrial effective refractory period throughout the entire atria, and ablation or conversion to sinuswithin the ﬁrst days of AF has been documented in humans.19 rhythm is more difﬁcult.The electrical remodelling process contributes to the increasingstability of AF during the ﬁrst days after its onset. The main cellular The multiple wavelet hypothesismechanisms underlying the shortening of the refractory period are According to the multiple wavelet hypothesis, AF is perpetuated bydown-regulation of the L-type Ca2+ inward current and continuous conduction of several independent wavelets propagat-up-regulation of inward rectiﬁer K+ currents. Recovery of ing through the atrial musculature in a seemingly chaotic manner. Fibrillation wavefronts continuously undergo wavefront–waveback Table 4 Structural abnormalities associated with AF interactions, resulting in wavebreak and the generation of new wavefronts, while block, collision, and fusion of wavefronts tend Extracellular matrix alterations to reduce their number. As long as the number of wavefronts Interstitial and replacement ﬁbrosis does not decline below a critical level, the multiple wavelets will sustain the arrhythmia. While in most patients with paroxysmal Inﬂammatory changes AF localized sources of the arrhythmia can be identiﬁed, such Amyloid deposit attempts are often not successful in patients with persistent or Myocyte alterations permanent AF. Apoptosis Necrosis 2.2.3 Genetic predisposition Hypertrophy AF has a familial component, especially AF of early onset.22 During the past years, numerous inherited cardiac syndromes associated Dedifferentiation with AF have been identiﬁed. Both short and long QT syndromes Gap junction redistribution and Brugada syndrome are associated with supraventricular Intracellular substrate accumulation (haemocromatosis, glycogen) arrhythmias, often including AF.23 AF also frequently occurs in a Microvascular changes variety of inherited conditions, including hypertrophic cardiomyo- Endocardial remodelling (endomyocardial ﬁbrosis) pathy, a familial form of ventricular pre-excitation, and abnormal LV hypertrophy associated with mutations in the PRKAG gene. AF ¼ atrial ﬁbrillation. Other familial forms of AF are associated with mutations in the gene coding for atrial natriuretic peptide,24 loss-of-function
Page 8 of 61 ESC Guidelinesmutations in the cardiac sodium channel gene SCN5A,25 or gain of Thrombo-embolismfunction in a cardiac potassium channel.26 Furthermore, several Risk of stroke and systemic embolism in patients with AF is linkedgenetic loci close to the PITX2 and ZFHX3 genes associate with to a number of underlying pathophysiological mechanisms.29 ‘FlowAF and cardioembolic stroke in population-wide studies.27 The abnormalities’ in AF are evidenced by stasis within the left atrium,pathophysiological role of other genetic defects in the initiation with reduced left atrial appendage (LAA) ﬂow velocities, and visu-and perpetuation of AF is currently unknown.23 alized as spontaneous echo-contrast on transoesophageal echocar- diography (TOE). ‘Endocardial abnormalities’ include progressive atrial dilatation, endocardial denudation, and oedematous/ﬁbroe-2.2.4 Clinical correlates lastic inﬁltration of the extracellular matrix. The LAA is the domi-Atrioventricular conduction nant source of embolism (.90%) in non-valvular AF.29In patients with AF and a normal conduction system [in the ‘Abnormalities of blood constituents’ are well described in AFabsence of accessory pathways (APs) or His–Purkinje dysfunc- and include haemostatic and platelet activation, as well as inﬂam-tion], the atrioventricular node functions as a frequency ﬁlter pre- mation and growth factor abnormalities.29venting excessive ventricular rates. The main mechanisms limitingatrioventricular conduction are intrinsic refractoriness of the atrio-ventricular node and concealed conduction. Electrical impulses 3. Detection, ‘natural’ history, andreaching the atrioventricular node may not be conducted to theventricles, but may alter atrioventricular node refractoriness, acute managementslowing or blocking subsequent atrial beats. 3.1 Deﬁnition Fluctuations in sympathetic and parasympathetic tone result in AF is deﬁned as a cardiac arrhythmia with the followingvariability of the ventricular rate during the diurnal cycle or characteristics:during exercise. The high variability of the ventricular rate isoften a therapeutic challenge. Digitalis, which slows down the ven- (1) The surface ECG shows ‘absolutely’ irregular RR intervals (AFtricular rate by an increase in parasympathetic tone, is effective for is therefore sometimes known as arrhythmia absoluta), i.e. RRcontrolling heart rate at rest, but to a lesser extent during exercise. intervals that do not follow a repetitive pattern.b-Blockers and non-dihydropyridine calcium channel antagonists (2) There are no distinct P waves on the surface ECG. Somereduce the ventricular rate during both rest and exercise. apparently regular atrial electrical activity may be seen in In patients with pre-excitation syndromes, fast and potentially some ECG leads, most often in lead V1.life-threatening ventricular rates may occur. In patients with AF (3) The atrial cycle length (when visible), i.e. the interval betweenand pre-excitation syndromes, administration of compounds that two atrial activations, is usually variable and ,200 msslow atrioventricular nodal conduction without prolonging atrial/ (.300 bpm).AP refractory periods (e.g. verapamil, diltiazem, and digitalis) canaccelerate conduction via the AP. Differential diagnosis Several supraventricular arrhythmias, most notably atrial tachycar- dias and atrial ﬂutter, but also rare forms of frequent atrial ectopyHaemodynamic changes or even dual antegrade atrioventricular nodal conduction, mayFactors affecting haemodynamic function in patients with AF present with rapid irregular RR intervals and mimic AF. Mostinvolve loss of coordinated atrial contraction, high ventricular atrial tachycardias and ﬂutters show longer atrial cycle lengthsrates, irregularity of the ventricular response, and decrease in myo- ≥200 ms. Patients on antiarrhythmic drugs may have slowercardial blood ﬂow, as well as long-term alterations such as atrial atrial cycle lengths during AF.and ventricular cardiomyopathy. An ECG recording during the arrhythmia is usually needed to Acute loss of coordinated atrial mechanical function after the differentiate the common diagnosis of AF from other rare supra-onset of AF reduces cardiac output by 5–15%. This effect is ventricular rhythms with irregular RR intervals, or the commonmore pronounced in patients with reduced ventricular compliance occurrence of ventricular extrasystoles. Any episode of suspectedin whom atrial contraction contributes signiﬁcantly to ventricular AF should be recorded by a 12-lead ECG of sufﬁcient duration andﬁlling. High ventricular rates limit ventricular ﬁlling due to the quality to evaluate atrial activity. Occasionally, when the ventricularshort diastolic interval. Rate-related interventricular or intraventri- rate is fast, atrioventricular nodal blockade during the Valsalvacular conduction delay may lead to dyssynchrony of the left ventri- manoeuvre, carotid massage, or intravenous (i.v.) adenosinecle and reduce cardiac output further. administration30 can help to unmask atrial activity. In addition, irregularity of the ventricular rate can reduce cardiacoutput. Because of force –interval relationships, ﬂuctuations of the 3.2 DetectionRR intervals cause a large variability in the strengths of subsequent An irregular pulse should always raise the suspicion of AF, but anheart beats, often resulting in pulse deﬁcit. ECG recording is necessary to diagnose AF. Any arrhythmia that Persistent elevation of ventricular rates above 120 –130 bpm has the ECG characteristics of AF and lasts sufﬁciently long for amay produce ventricular tachycardiomyopathy.28 Reduction of 12-lead ECG to be recorded, or at least 30 s on a rhythm strip,the heart rate may restore normal ventricular function and should be considered as AF.3,31 The heart rate in AF can be calcu-prevent further dilatation and damage to the atria. lated from a standard 12-lead ECG by multiplying the number of
ESC Guidelines Page 9 of 61RR intervals on the 10 s strip (recorded at 25 mm/s) by six. Therisk of AF-related complications is not different between shortAF episodes and sustained forms of the arrhythmia.12 It is there- ‘Upstream’ therapy of concomitant conditionsfore important to detect paroxysmal AF in order to prevent AnticoagulationAF-related complications (e.g. stroke). However, short ‘atrial high- Rate controlrate episodes’, e.g. detected by pacemakers, deﬁbrillators, or other Antiarrhythmic drugs ﬁrst documentedimplanted devices, may not be associated with thrombo-embolic Ablationcomplications unless their duration exceeds several hours (see CardioversionSection 3.4). AF may manifest initially as an ischaemic stroke or TIA, and it is AFreasonable to assume that most patients experience asymptomatic, silent paroxysmal persistent long-standing permanent persistentoften self-terminating, arrhythmia episodes before AF is ﬁrst diag-nosed. The rate of AF recurrence is 10% in the ﬁrst year after theinitial diagnosis, and 5% per annum thereafter. Co-morbidities Figure 1 ‘Natural’ time course of AF. AF ¼ atrial ﬁbrillation.and age signiﬁcantly accelerate both the progression of AF and The dark blue boxes show a typical sequence of periods in AFthe development of complications.3,23 against a background of sinus rhythm, and illustrate the pro- gression of AF from silent and undiagnosed to paroxysmal and chronic forms, at times symptomatic. The upper bars indicate3.3 ‘Natural’ time course therapeutic measures that could be pursued. Light blue boxesAF progresses from short, rare episodes, to longer and more fre- indicate therapies that have proven effects on ‘hard outcomes’quent attacks. Over time (years), many patients will develop sus- in AF, such as stroke or acute heart failure. Red boxes indicatetained forms of AF (Figure 1). Only a small proportion of therapies that are currently used for symptom relief, but may inpatients without AF-promoting conditions (see Section 2.1.2) will the future contribute to reduction of AF-related complications.remain in paroxysmal AF over several decades (2–3% of AF Rate control (grey box) is valuable for symptom relief and maypatients).32 The distribution of paroxysmal AF recurrences is not improve cardiovascular outcomes.random, but clustered.3 ‘AF burden’ can vary markedly overmonths or even years in individual patients.3 Asymptomatic AF iscommon even in symptomatic patients, irrespective of whether Holter recordings or external event recorders should be con-the initial presentation was persistent or paroxysmal. This has sidered. In patients with rhythm or rate control treatment andimportant implications for (dis)continuation of therapies aimed at without further arrhythmia- or therapy-related symptoms, apreventing AF-related complications. 12-lead ECG should be recorded at regular intervals. In patients receiving antiarrhythmic drug therapy, the frequency of 12-lead3.4 Electrocardiogram techniques to ECG recording depends on the type of antiarrhythmic drug treat- ment, the potential side effects, complications, and risks ofdiagnose and monitor atrial ﬁbrillation proarrhythmia.The intensity and duration of monitoring should be determined bythe clinical need to establish the diagnosis, and should be driven Tools for non-continuous ECG monitoringmainly by the clinical impact of AF detection. More intense AF Available non-continuous ECG methods include scheduled orrecording is usually necessary in clinical trials than in clinical symptom-activated standard ECGs, Holter (24 h to 7 days) moni-practice.3,33 toring and transtelephonic recordings, patient- and automaticallyPatients with suspected but undiagnosed atrial ﬁbrillation activated devices, and external loop recorders. If AF is present atIn patients with suspected AF, a 12-lead ECG is recommended as the time of recording, use of the standard 12-lead ECG is sufﬁcientthe ﬁrst step to establish the diagnosis. Clinical symptoms such as to conﬁrm the diagnosis. In paroxysmal AF, prolonged non-palpitations or dyspnoea should trigger ECG monitoring to continuous recording will facilitate AF detection. It has been esti-demonstrate AF, or to correlate symptoms with the underlying mated that 7 day Holter ECG recording or daily andrhythm. There are only limited data comparing the value of differ- symptom-activated event recordings may document the arrhyth-ent monitoring strategies.3,34 – 37 More intense and prolonged mia in 70% of AF patients, and that their negative predictivemonitoring is justiﬁed in highly symptomatic patients [European value for the absence of AF is between 30 and 50%.3 In stroke sur-Heart Rhythm Association IV (EHRA IV)—see Section 3.6], vivors, a step-wise addition of ﬁve daily short-term ECGs, one 24 hpatients with recurrent syncope, and patients with a potential indi- Holter ECG, and another 7 day Holter ECG will each increase thecation for anticoagulation (especially after cryptogenic stroke).34,38 detection rate of AF by a similar extent.34In selected patients, implantation of a leadless AF monitoringdevice may be considered to establish the diagnosis.39 Tools for continuous ECG monitoring Implantable devices capable of intracardiac atrial electrogramPatients with known atrial ﬁbrillation recording such as dual-chamber pacemakers and deﬁbrillatorsIndications for AF monitoring in patients with previously diagnosed can detect AF appropriately, particularly when an arrhythmia dur-AF differ compared with undiagnosed patients. When arrhythmia- ation ≥5 min is used as a cut-off value. Longer atrial high-rate epi-or therapy-related symptoms are suspected, monitoring using sodes (e.g. .5.5 h) may be associated with thrombo-embolic
Page 10 of 61 ESC Guidelinesevents.35,36 Leadless implantable loop recorders provide continu- strategy be adopted, the arrhythmia is redesignated as ‘long-ous AF monitoring over a 2 year period with automatic AF detec- standing persistent AF’.tion based on RR interval analysis. Preliminary clinical data indicate This classiﬁcation is useful for clinical management of AF patientsgood sensitivity but less speciﬁcity for AF detection.40 No data (Figure 2), especially when AF-related symptoms are also con-exist on the implementation of such devices in the clinical sidered. Many therapeutic decisions require careful considerationroutine of AF monitoring. of additional individual factors and co-morbidities. Silent AF (asymptomatic) may manifest as an AF-related com- plication (ischaemic stroke or tachycardiomyopathy) or may be3.5 Types of atrial ﬁbrillation diagnosed by an opportunistic ECG. Silent AF may present as any of the temporal forms of AF.Clinically, it is reasonable to distinguish ﬁve types of AF based onthe presentation and duration of the arrhythmia: ﬁrst diagnosed,paroxysmal, persistent, long-standing persistent, and permanent 3.6 Initial managementAF (Figure 2). A thorough medical history should be obtained from the patient with suspected or known AF (Table 5). The acute management(1) Every patient who presents with AF for the ﬁrst time is con- of AF patients should concentrate on relief of symptoms and sidered a patient with ﬁrst diagnosed AF, irrespective of assessment of AF-associated risk. Clinical evaluation should the duration of the arrhythmia or the presence and severity include determination of the EHRA score (Table 6 3), estimation of AF-related symptoms. of stroke risk (see Section 4.1), and search for conditions that pre-(2) Paroxysmal AF is self-terminating, usually within 48 h. dispose to AF (see Section 2.1.2) and for complications of the Although AF paroxysms may continue for up to 7 days, the arrhythmia (see Section 2.1.1). The 12-lead ECG should be 48 h time point is clinically important—after this the likelihood of spontaneous conversion is low and anticoagulation must be considered (see Section 4.1). Table 5 Relevant questions to be put to a patient with(3) Persistent AF is present when an AF episode either lasts suspected or known AF longer than 7 days or requires termination by cardioversion, either with drugs or by direct current cardioversion (DCC). Does the heart rhythm during the episode feel regular or irregular?(4) Long-standing persistent AF has lasted for ≥1 year when Is there any precipitating factor such as exercise, emotion, or alcohol it is decided to adopt a rhythm control strategy. intake?(5) Permanent AF is said to exist when the presence of the Are symptoms during the episodes moderate or severe—the severity arrhythmia is accepted by the patient (and physician). Hence, may be expressed using the EHRA score,3 which is similar to the CCS-SAF score.41 rhythm control interventions are, by deﬁnition, not pursued in patients with permanent AF. Should a rhythm control Are the episodes frequent or infrequent, and are they long or short lasting? Is there a history of concomitant disease such as hypertension, coronary heart disease, heart failure, peripheral vascular disease, cerebrovascular disease, stroke, diabetes, or chronic pulmonary disease? First diagnosed episode of atrial ﬁbrillation Is there an alcohol abuse habit? Is there a family history of AF? Paroxysmal (usually <48 h) AF ¼ atrial ﬁbrillation; CCS-SAF ¼ Canadian Cardiovascular Society Severity in Atrial Fibrillation; EHRA ¼ European Heart Rhythm Association. Persistent (>7 days or requires CV) Long-standing Persistent (>1 year) Table 6 EHRA score of AF-related symptoms Permanent Classiﬁcation of AF-related symptoms (EHRA score) (accepted) EHRA class Explanation EHRA I ‘No symptoms’ Figure 2 Different types of AF. AF ¼ atrial ﬁbrillation; CV ¼ EHRA II ‘Mild symptoms’; normal daily activity not affected cardioversion. The arrhythmia tends to progress from paroxysmal EHRA III ‘Severe symptoms’; normal daily activity affected (self-terminating, usually ,48 h) to persistent [non-self-terminating or requiring cardioversion (CV)], long-standing persistent (lasting ‘Disabling symptoms’; normal daily activity EHRA IV longer than 1 year) and eventually to permanent (accepted) AF. discontinued First-onset AF may be the ﬁrst of recurrent attacks or already be deemed permanent. AF ¼ atrial ﬁbrillation; EHRA ¼ European Heart Rhythm Association.
ESC Guidelines Page 11 of 61inspected for signs of structural heart disease (e.g. acute or remote † Is anticoagulation now necessary—have new risk factors devel-myocardial infarction, LV hypertrophy, bundle branch block or oped, or has the need for anticoagulation passed, e.g. post-ventricular pre-excitation, signs of cardiomyopathy, or ischaemia). cardioversion in a patient with low thrombo-embolic risk? † Have the patient’s symptoms improved on therapy; if not,Diagnostic evaluation should other therapy be considered?A recently suggested symptom score (EHRA score,3 Table 6) pro- † Are there signs of proarrhythmia or risk of proarrhythmia; if so,vides a simple clinical tool for assessing symptoms during AF. A should the dose of an antiarrhythmic drug be reduced or avery similar scale has been validated by the Canadian Cardiovascu- change made to another therapy?lar Society.41 The EHRA score only considers symptoms that are † Has paroxysmal AF progressed to a persistent/permanent form,attributable to AF and reverse or reduce upon restoration of in spite of antiarrhythmic drugs; in such a case, should anothersinus rhythm or with effective rate control. therapy be considered? The initial diagnostic work-up is driven by the initial presen- † Is the rate control approach working properly; has the target fortation. The time of onset of the arrhythmia episode should heart rate at rest and during exercise been reached?be established to deﬁne the type of AF (Figure 2). Most patients At follow-up visits, a 12-ECG should be recorded to document thewith AF ,48 h in duration can be cardioverted (see Section rhythm and rate, and to investigate disease progression. For those4.1.7) on low molecular weight heparin (LMWH) without risk on antiarrhythmic drug therapy it is important to assess potentialfor stroke. If AF duration is .48 h or there is doubt about its dur- proarrhythmic ECG precursors such as lengthening of PR, QRS,ation, TOE may be used to rule out intracardiac thrombus prior or QT intervals, non-sustained ventricular tachycardia, or pauses.to cardioversion,42 although it can be difﬁcult in patients in acute If any worsening of symptoms occurs, repeated blood tests, long-distress and may not be available in emergency settings. The trans- term ECG recordings and a repeat echocardiogram should bethoracic echocardiogram can provide useful information to guide considered.clinical decision making, but cannot exclude thrombus in the LAA. The patient should be fully informed about the pros and cons of Patients with AF and signs of acute heart failure require the different treatment options, whether it is anticoagulation, rateurgent rate control and often cardioversion. An urgent echocar- control drugs, antiarrhythmic drugs, or interventional therapy. It isdiogram should be performed in haemodynamically compromised also appropriate to inform the patient with ‘lone’ or idiopathic AFpatients to assess LV and valvular function and right ventricular about the good prognosis, once cardiovascular disease has beenpressure. excluded. Patients with stroke or TIA require immediate stroke diagno-sis, usually via emergency computed tomography (CT) and ade-quate cerebral revascularization. 4. Management Patients should be assessed for risk of stroke. Most patients withacute AF will require anticoagulation unless they are at low risk of Management of AF patients is aimed at reducing symptoms and atthrombo-embolic complications (no stroke risk factors) and no preventing severe complications associated with AF. These thera-cardioversion is necessary (e.g. AF terminates within 24–48 h). peutic goals need to be pursued in parallel, especially upon the After the initial management of symptoms and complications, initial presentation of newly detected AF. Prevention of AF-relatedunderlying causes of AF should be sought. An echocardiogram complications relies on antithrombotic therapy, control of ventri-is useful to detect ventricular, valvular, and atrial disease as well cular rate, and adequate therapy of concomitant cardiac diseases.as rare congenital heart disease. Thyroid function tests (usually These therapies may already alleviate symptoms, but symptommeasurement of serum thyroid-stimulating hormone), a full blood relief may require additional rhythm control therapy by cardiover-count, a serum creatinine measurement and analysis for proteinuria, sion, antiarrhythmic drug therapy, or ablation therapy (Figure 3).measurement of blood pressure, and a test for diabetes mellitus(usually a fasting glucose measurement) are useful. A serum test 4.1 Antithrombotic managementfor hepatic function may be considered in selected patients. A Cohort data as well as the non-warfarin arms of clinical trials havestress test is reasonable in patients with signs or risk factors for cor- identiﬁed clinical and echocardiographic risk factors that can beonary artery disease. Patients with persistent signs of LV dysfunc- related to an increased risk of stroke in AF.47,48 These risktion and/or signs of myocardial ischaemia are candidates for factors are limited to those documented in these studies, whilstcoronary angiography. many other potential risk factors were not systematically documented.3.7 Clinical follow-up Two recent systematic reviews have addressed the evidence base for stroke risk factors in AF,47,48 and concluded that priorThe specialist caring for the AF patient should not only perform stroke/TIA/thrombo-embolism, age, hypertension, diabetes, andthe baseline assessment and institute the appropriate treatment, structural heart disease are important risk factors. The presencebut also suggest a structured plan for follow-up. of moderate to severe LV systolic dysfunction on two-dimensional Important considerations during follow-up of the AF patient are transthoracic echocardiography is the only independent echocar-listed below: diographic risk factor for stroke on multivariable analysis. On† Has the risk proﬁle changed (e.g. new diabetes or hypertension), TOE, the presence of LA thrombus relative risk (RR) 2.5; P ¼ especially with regard to the indication for anticoagulation? 0.04], complex aortic plaques (RR 2.1; P ,0.001), spontaneous
Page 12 of 61 ESC Guidelines Recommendations for diagnosis and initial management Recommendations Classa Levelb Ref.c The diagnosis of AF requires documentation by ECG. I B 3, 31 In patients with suspected AF, an attempt to record an ECG should be made when symptoms suggestive of AF occur. I B 3, 43 A simple symptom score (EHRA score) is recommended to quantify AF-related symptoms. I B 3, 41 All patients with AF should undergo a thorough physical examination, and a cardiac- and arrhythmia-related history I C should be taken. In patients with severe symptoms, documented or suspected heart disease, or risk factors, an echocardiogram is I B 3, 23, 44 recommended. In patients treated with antiarrhythmic drugs, a 12-lead ECG should be recorded at regular intervals during follow-up. I C In patients with suspected symptomatic AF, additional ECG monitoring should be considered in order to document IIa B 3, 33 the arrhythmia. Additional ECG monitoring should be considered for detection of ‘silent’ AF in patients who may have sustained an IIa B 3, 34 AF-related complication. In patients with AF treated with rate control, Holter ECG monitoring should be considered for assessment of rate IIa C control or bradycardia. In young active patients with AF treated with rate control, exercise testing should be considered in order to assess IIa C ventricular rate control. In patients with documented or suspected AF, an echocardiogram should be considered. IIa C Patients with symptomatic AF or AF-related complications should be considered for referral to a cardiologist. IIa C A structured follow-up plan prepared by a specialist is useful for follow-up by a general or primary care physician. IIa C In patients treated with rhythm control, repeated ECG monitoring may be considered to assess the efﬁcacy of IIb B 3, 45, 46 treatment. Most patients with AF may beneﬁt from specialist follow-up at regular intervals. IIb C a Class of recommendation. b Level of evidence. c References. AF ¼ atrial ﬁbrillation; ECG ¼ electrocardiogram; EHRA ¼ European Heart Rhythm Association. Atrial ﬁbrillation Record Presentation 12-lead ECG EHRA score Associated disease Initial assessment Anticoagulation Assess issues TE Risk Oral anticoagulant Aspirin None Rate and rhythm AF type Symptoms Rate control control ± Rhythm control Antiarrhythmic drugs Ablation Treatment of underlying disease Consider ‘Upstream’ therapy referral ACEIs/ARBs Statins/PUFAs Others Figure 3 The management cascade for patients with AF. ACEI ¼ angiotensin-converting enzyme inhibitor; AF ¼ atrial ﬁbrillation; ARB ¼ angiotensin receptor blocker; PUFA ¼ polyunsaturated fatty acid; TE ¼ thrombo-embolism.