ESC GUIDELINES
2016 ESC Guidelines for the management of atrial
fibrillation developed in collaboration with EA CTS
The Task Force for the 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
Endorsed by the European Stroke Organisation (ESO)
Authors/Task Force Members: Paulus Kirchhof (Chairperson) (U K/G erm any),
*
Stefano Benussi
*
1
(Co-Chairperson) (Switzerland), Dipak Kotecha (UK),
Anders Ahlsson
1
(Sweden), Dan Atar (Norway), Barbara Casadei (UK),
Manuel Castella
1
(Spain), Hans-Christoph Diener
2
(Germany), Hein Heidbuchel
(Belgium), Jeroen Hendriks (The Netherlands), Gerhard Hindricks (Germany),
Antonis S. Manolis (Greece), Jonas Oldgren (Sweden), Bogdan Alexandru Popescu
(Romania), Ulrich Schotten (The Netherlands), Bart Van Putte
1
(The Netherlands),
and Panagiotis Vardas (Greece)
Document Reviewers: Stefan Agewall (CPG Review Co-ordinator) (Norway), John Camm (CPG Review
Co-ordinator) (UK), Gonzalo Baron Esquivias (Spain), Werner Budts (Belgium), Scipione Carerj (Italy),
Filip Casselman (Belgium), Antonio Coca (Spain), Raffaele De Caterina (Italy), Spiridon Deftereos (Greece),
Dobromir Dobrev (Germany), Jose
´
M. Ferro (Portugal), Gerasimos Filippatos (Greece), Donna Fitzsimons (UK),
* Corresponding authors: Paulus Kirchhof, Institute of Cardiovascular Sciences, University of Birmingham, SWBH and UHB NHS trusts, IBR, Room 136, Wolfson Drive, Birmingham
B15 2TT, United Kingdom, Tel: +44 121 4147042, E-mail:
p.kirchhof@bham.ac.uk; Stefano Benussi, Department of Cardiovascular Surgery, University Hospital Zurich, Ra¨mistrasse
100, 8091 Zu¨rich, Switzerland, Tel: +41(0)788933835, E-mail:
stefano.benussi@usz.ch.
1
Representing the European Association for Cardio-Thoracic Surgery (EACTS)
2
Representing the European Stroke Association (ESO)
ESC Committee for Practice Guidelines (CPG) and National Cardiac Societies Reviewers can be found in the Appendix.
ESC entities having participated in the development of this document:
Associations: European Association for Cardiovascular Prevention and Rehabilitation (EACPR), European Association of Cardiovascular Imaging (EACVI), European Heart Rhythm
Association (EHRA), Hea rt Failure Association (HFA).
Councils: Council on Cardiovascular Nursing and Allied Professions, Council for Cardiology Practice, Council on Cardiovascular Primary Care, Council on Hypertension.
Working Groups: Cardiac Cellular Electrophysiology, Cardiovascular Pharmacotherapy, Grown-up Congenital Heart Disease, Thrombosis, Valvular Heart Disease.
The 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 the ESC
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 Oxford Uni-
versity Press, the publisher of the European Heart Journal and the party authorized to handle such permissions on behalf of the ESC (journals.permissions@oup.com).
Disclaimer. The ESC Guidelines represent the views of the ESC and were produced after careful consideration of the scientific and medical knowledge and the evidence available at
the time of their publication. The ESC is not responsible in the event of any contradiction, discrepancy and/or ambiguity between the ESC Guidelines and any other official recom-
mendations or guidelines issued by the relevant public health authorities, in particular in relation to good use of healthcare or therapeutic strategies. Health professionals are encour-
aged to take the ES C Guidelines fully into ac count when exercising their clinical judgment, a s well as in the determination and the implementation of preventive, diagnostic or
therapeutic medical strategies; however, the ESC Guidelines do not override, in any way whatsoever, the individual responsibility of health professionals to make appropriate and
accurate decisions in consideration of each patient’s health condition and in consultation with that patient and, where appropriate and/or necessary, the patient’s caregiver. Nor
do the ESC Guidelines exempt health professionals from taking into full and careful consideration the relevant official updated recommendations or guidelines issued by the competent
public health authorities, in order to manage each patient’s case in light of the scientifically accepted data pursuant to their respective ethical and professional obligations. It is also the
health professional’s responsibility to verify the applicable rules and regulations relating to drugs and medical devices at the time of prescription.
& The European Society of Cardiology 2016. All rights reserved. For permissions please email: journals.permissions@oup.com.
doi:10.1093/europace/euw295
Europace (2016) 18, 1609–1678
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Bulent Gorenek (Turkey), Maxine Guenoun (France), Stefan H. Hohnloser (Germany), Philippe Kolh (Belgium),
GregoryY.H.Lip(UK),AthanasiosManolis(Greece),JohnMcMurray(UK),PiotrPonikowski(Poland),RaphaelRosenhek
(Austria), Frank Ruschitzka (Switzerland), Irina Savelieva (UK), Sanjay Sharma (UK), Piotr Suwalski (Poland),
Juan Luis Tamargo (Spain), Clare J. Taylor (UK), Isabelle C. Van Gelder (The Netherlands), Adriaan A. Voors (The
Netherlands), Stephan Windeck er (Switzerland), Jose Luis Zamorano (Spain), and Katja Zeppenfeld (The Netherlands)
The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website
http://www.escardio.org/guidelines.
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Keywords Guidelines † Atrial fibrillation † Anticoagulation † Vitamin K antagonists † Non-vitamin K antagonist oral
anticoagulants † Left atrial appendage occlusion † Rate control † Cardioversion † Rhythm control †
Antiarrhythmic drugs † Upstream therapy † Catheter ablation † AF surgery † Valve repair † Pulmonary
vein isolation † Left atrial ablation
Table of Contents
Abbreviations and acronyms . . . . . . . . . . . . . . . . . . . . . . . .
4
1. Preamble . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
2. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
3. Epidemiology and impact for patients . . . . . . . . . . . . . . . . . 7
3.1 Incidence and prevalence of atrial fibrillation . . . . . . . . 7
3.2 Morbidity, mortality, and healthcare burden of atrial
fibrillation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
7
3.3 Impact of evidence-based management on outcomes in
atrial fibrillation patients . . . . . . . . . . . . . . . . . . . . . . . .
8
3.4 Gender . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
4. Pathophysiological and genetic aspects that guide management 9
4.1 Genetic predisposition . . . . . . . . . . . . . . . . . . . . . . 9
4.2 Mechanisms leading to atrial fibrillation . . . . . . . . . . . . 9
4.2.1 Remodelling of atrial structure and ion channel
function . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
4.2.2 Electrophysiological mechanisms of atrial fibrillation . 9
4.2.2.1 Focal initiation and maintenance of atrial
fibrillation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
4.2.2.2 The multiple wavelet hypothesis and rotors as
sources of atrial fibrillation. . . . . . . . . . . . . . . . . . . 10
5. Diagnosis and timely detection of atrial fibrillation . . . . . . . . 10
5.1 Overt and silent atrial fibrillation . . . . . . . . . . . . . . . . 10
5.2 Screening for silent atrial fibrillation . . . . . . . . . . . . . . 11
5.2.1 Screening for atrial fibrillation by electrocardiogram in
the community . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
5.2.2 Prolonged monitoring for paroxysmal atrial
fibrillation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
5.2.3 Patients with pacemakers and implanted devices . . . 12
5.2.4 Detection of atrial fibrillation in stroke survivors . . . 13
5.3 Electrocardiogram detection of atrial flutter . . . . . . . . . 13
6. Classification of atrial fibrillation . . . . . . . . . . . . . . . . . . . . 13
6.1 Atrial fibrillation pattern . . . . . . . . . . . . . . . . . . . . . 13
6.2 Atrial fibrillation types reflecting different causes of the
arrhythmia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
14
6.3 Symptom burden in atrial fibrillation . . . . . . . . . . . . . . 14
7. Detection and management of risk factors and concomitant
cardiovascular diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . .
15
7.1 Heart failure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
7.1.1 Patients with atrial fibrillation and heart failure with
reduced ejection fraction . . . . . . . . . . . . . . . . . . . . . . 16
7.1.2 Atrial fibrillation patients with heart failure with
preserved ejection fraction . . . . . . . . . . . . . . . . . . . . . 16
7.1.3 Atrial fibrillation patients with heart failure with mid-
range ejection fraction . . . . . . . . . . . . . . . . . . . . . . . . 16
7.1.4 Prevention of atrial fibrillation in heart failure . . . . . 16
7.2 Hypertension . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
7.3 Valvular heart disease . . . . . . . . . . . . . . . . . . . . . . . 17
7.4 Diabetes mellitus . . . . . . . . . . . . . . . . . . . . . . . . . . 18
7.5 Obesity and weight loss . . . . . . . . . . . . . . . . . . . . . . 18
7.5.1 Obesity as a risk factor . . . . . . . . . . . . . . . . . . . 18
7.5.2 Weight reduction in obese patients with atrial
fibrillation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
7.5.3 Catheter ablation in obese patients . . . . . . . . . . . 18
7.6 Chronic obstructive pulmonary disease, sleep apnoea, and
other respiratory diseases . . . . . . . . . . . . . . . . . . . . . . .
18
7.7 Chronic kidney disease . . . . . . . . . . . . . . . . . . . . . . 19
8. Integrated management of patients with atrial fibrillation . . . . 19
8.1 Evidence supporting integrated atrial fibrillation care . . . 20
8.2 Components of integrated atrial fibrillation care . . . . . . 21
8.2.1 Patient involvement . . . . . . . . . . . . . . . . . . . . . . 21
8.2.2 Multidisciplinary atrial fibrillation teams . . . . . . . . . 21
8.2.3 Role of non-specialists . . . . . . . . . . . . . . . . . . . . 21
8.2.4 Technology use to support atrial fibrillation care . . . 21
8.3 Diagnostic workup of atrial fibrillation patients . . . . . . . 21
8.3.1 Recommended evaluation in all atrial fibrillation
patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
8.3.2 Additional investigations in selected patients with
atrial fibrillation . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
8.4 Structured follow-up . . . . . . . . . . . . . . . . . . . . . . . . 22
8.5 Defining goals of atrial fibrillation management . . . . . . . 22
9. Stroke prevention therapy in atrial fibrillation patients . . . . . . 22
9.1 Prediction of stroke and bleeding risk . . . . . . . . . . . . . 22
9.1.1 Clinical risk scores for stroke and systemic embolism 22
9.1.2 Anticoagulation in patients with a CHA
2
DS
2
-VASc
score of 1 in men and 2 in women . . . . . . . . . . . . . . . . 22
9.1.3 Clinical risk scores for bleeding . . . . . . . . . . . . . . 23
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9.2 Stroke prevention . . . . . . . . . . . . . . . . . . . . . . . . . . 24
9.2.1 Vitamin K antagonists . . . . . . . . . . . . . . . . . . . . 24
9.2.2 Non-vitamin K antagonist oral anticoagulants . . . . . 24
9.2.2.1 Apixaban . . . . . . . . . . . . . . . . . . . . . . . . . 25
9.2.2.2 Dabigatran . . . . . . . . . . . . . . . . . . . . . . . . 25
9.2.2.3 Edoxaban . . . . . . . . . . . . . . . . . . . . . . . . . 25
9.2.2.4 Rivaroxaban . . . . . . . . . . . . . . . . . . . . . . . 26
9.2.3 Non-vitamin K antagonist oral anticoagulants or
vitamin K antagonists . . . . . . . . . . . . . . . . . . . . . . . . . 27
9.2.4 Oral anticoagulation in atrial fibrillation patients with
chronic kidney disease . . . . . . . . . . . . . . . . . . . . . . . . 27
9.2.5 Oral anticoagulation in atrial fibrillation patients on
dialysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
9.2.6 Patients with atrial fibrillation requiring kidney
transplantation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
9.2.7 Antiplatelet therapy as an alternative to oral
anticoagulants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
9.3 Left atrial appendage occlusion and exclusion . . . . . . . . 29
9.3.1 Left atrial appendage occlusion devices . . . . . . . . . 29
9.3.2 Surgical left atrial appendage occlusion or exclusion . 29
9.4 Secondary stroke prevention . . . . . . . . . . . . . . . . . . 29
9.4.1 Treatment of acute ischaemic stroke . . . . . . . . . . 29
9.4.2 Initiation of anticoagulation after transient ischaemic
attack or ischaemic stroke . . . . . . . . . . . . . . . . . . . . . 29
9.4.3 Initiation of anticoagulation after intracranial
haemorrhage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
9.5 Strategies to minimize bleeding on anticoagulant therapy 31
9.5.1 Uncontrolled hypertension . . . . . . . . . . . . . . . . . 31
9.5.2 Previous bleeding event . . . . . . . . . . . . . . . . . . . 31
9.5.3 Labile international normalized ratio and adequate
non-vitamin K antagonist oral anticoagulant dosing . . . . . 31
9.5.4 Alcohol abuse . . . . . . . . . . . . . . . . . . . . . . . . . 31
9.5.5 Falls and dementia . . . . . . . . . . . . . . . . . . . . . . 31
9.5.6 Genetic testing . . . . . . . . . . . . . . . . . . . . . . . . . 31
9.5.7 Bridging periods off oral anticoagulation . . . . . . . . 31
9.6 Management of bleeding events in anticoagulated patients
with atrial fibrillation . . . . . . . . . . . . . . . . . . . . . . . . . . .
32
9.6.1 Management of minor, moderate, and severe
bleeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
9.6.2 Oral anticoagulation in atrial fibrillation patients at risk
of or having a bleeding event . . . . . . . . . . . . . . . . . . . 33
9.7 Combination therapy with oral anticoagulants and
antiplatelets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
34
9.7.1 Antithrombotic therapy after acute coronary
syndromes and percutaneous coronary intervention in
patients requiring oral anticoagulation . . . . . . . . . . . . . . 34
10. Rate control therapy in atrial fibrillation . . . . . . . . . . . . . . 36
10.1 Acute rate control . . . . . . . . . . . . . . . . . . . . . . . . 36
10.2 Long-term pharmacological rate control . . . . . . . . . . 36
10.2.1 Beta-blockers . . . . . . . . . . . . . . . . . . . . . . . . . 36
10.2.2 Non-dihydropyridine calcium channel blockers . . . 37
10.2.3 Digitalis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
10.2.4 Amiodarone . . . . . . . . . . . . . . . . . . . . . . . . . . 38
10.3 Heart rate targets in atrial fibrillation . . . . . . . . . . . . 39
10.4 Atrioventricular node ablation and pacing . . . . . . . . . 39
11. Rhythm control therapy in atrial fibrillation . . . . . . . . . . . . 40
11.1 Acute restoration of sinus rhythm . . . . . . . . . . . . . . 40
11.1.1 Antiarrhythmic drugs for acute restoration of sinus
rhythm (‘pharmacological cardioversion’) . . . . . . . . . . . . 40
11.1.2 ‘Pill in the pocket’ cardioversion performed by
patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
11.1.3 Electrical cardioversion . . . . . . . . . . . . . . . . . . 40
11.1.4 Anticoagulation in patients undergoing
cardioversion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
11.2 Long-term antiarrhythmic drug therapy . . . . . . . . . . . 41
11.2.1 Selection of antiarrhythmic drugs for long-term
therapy: safety first! . . . . . . . . . . . . . . . . . . . . . . . . . . 42
11.2.1.1 Amiodrone . . . . . . . . . . . . . . . . . . . . . . . 42
11.2.1.2 Dronedarone . . . . . . . . . . . . . . . . . . . . . 42
11.2.1.3 Flecainide and propafenone . . . . . . . . . . . . 42
11.2.1.4 Quinidine and disopyramide . . . . . . . . . . . . 42
11.2.1.5 Sotalol . . . . . . . . . . . . . . . . . . . . . . . . . . 43
11.2.1.6 Dofetilide . . . . . . . . . . . . . . . . . . . . . . . . 43
11.2.2 Twelve-lead electrocardiogram as a tool to identify
patients at risk of pro-arrhythmia . . . . . . . . . . . . . . . . . 43
11.2.3 New antiarrhythmic drugs . . . . . . . . . . . . . . . . . 43
11.2.4 Antiarrhythmic effects of non-antiarrhythmic drugs 44
11.3 Catheter ablation . . . . . . . . . . . . . . . . . . . . . . . . . 46
11.3.1 Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
11.3.2 Techniques and technologies . . . . . . . . . . . . . . . 46
11.3.3 Outcome and complications . . . . . . . . . . . . . . . 47
11.3.3.1 Outcome of catheter ablation for atrial
fibrillation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
11.3.3.2 Complications of catheter ablation for atrial
fibrillation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
11.3.4 Anticoagulation:– before, during, and after ablation 47
11.3.5 Ablation of atrial fibrillation in heart failure patients 48
11.3.6 Follow-up after catheter ablation . . . . . . . . . . . . 48
11.4 Atrial fibrillation surgery . . . . . . . . . . . . . . . . . . . . . 48
11.4.1 Concomitant atrial fibrillation surgery . . . . . . . . . 48
11.4.2 Stand-alone rhythm control surgery . . . . . . . . . . 49
11.5 Choice of rhythm control following treatment failure . . 50
11.6 The atrial fibrillation Heart Team . . . . . . . . . . . . . . . 50
12. Hybrid rhythm control therapy . . . . . . . . . . . . . . . . . . . . 51
12.1 Combining antiarrhythmic drugs and catheter ablation . 51
12.2 Combining antiarrhythmic drugs and pacemakers . . . . 52
13. Specific situations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
13.1 Frail and ‘elderly’ patients . . . . . . . . . . . . . . . . . . . . 52
13.2 Inherited cardiomyopathies, channelopathies, and
accessory pathways . . . . . . . . . . . . . . . . . . . . . . . . . . .
52
13.2.1 Wolff – Parkinson – White syndrome . . . . . . . . . . 52
13.2.2 Hypertrophic cardiomyopathy . . . . . . . . . . . . . . 53
13.2.3 Channelopathies and arrhythmogenic right
ventricular cardiomyopathy . . . . . . . . . . . . . . . . . . . . 53
13.3 Sports and atrial fibrillation . . . . . . . . . . . . . . . . . . . 54
13.4 Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
13.4.1 Rate control . . . . . . . . . . . . . . . . . . . . . . . . . 54
13.4.2 Rhythm control . . . . . . . . . . . . . . . . . . . . . . . 54
13.4.3 Anticoagulation . . . . . . . . . . . . . . . . . . . . . . . 54
13.5 Post-operative atrial fibrillation . . . . . . . . . . . . . . . . 55
13.5.1 Prevention of post-operative atrial fibrillation . . . . 55
13.5.2 Anticoagulation . . . . . . . . . . . . . . . . . . . . . . . 55
13.5.3 Rhythm control therapy in post-operative atrial
fibrillation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
13.6 Atrial arrhythmias in grown-up patients with congenital
heart disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
13.6.1 General management of atrial arrhythmias in grown-
up patients with congenital heart disease . . . . . . . . . . . . 56
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13.6.2 Atrial tachyarrhythmias and atrial septal defects . . . 56
13.6.3 Atrial tachyarrhythmias after Fontan operation . . . 56
13.6.4 Atrial tachyarrhythmias after tetralogy of Fallot
correction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
13.7 Management of atrial flutter . . . . . . . . . . . . . . . . . . 57
14. Patient involvement, education, and self-management . . . . . 57
14.1 Patient-centred care . . . . . . . . . . . . . . . . . . . . . . . 57
14.2 Integrated patient education . . . . . . . . . . . . . . . . . . 57
14.3 Self-management and shared decision-making . . . . . . . 57
15. Gaps in evidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
15.1 Major health modifiers causing atrial fibrillation . . . . . . 58
15.2 How much atrial fibrillation constitutes a mandate for
therapy? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
58
15.3 Atrial high-rate episodes and need for anticoagulation . 58
15.4 Stroke risk in specific populations . . . . . . . . . . . . . . . 58
15.5 Anticoagulation in patients with severe chronic kidney
disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
58
15.6 Left atrial appendage occlusion for stroke prevention . . 58
15.7 Anticoagulation in atrial fibrillation patients after a
bleeding or stroke event . . . . . . . . . . . . . . . . . . . . . . . .
58
15.8 Anticoagulation and optimal timing of non-acute
cardioversion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
58
15.9 Competing causes of stroke or transient ischaemic attack
in atrial fibrillation patients . . . . . . . . . . . . . . . . . . . . . . .
58
15.10 Anticoagulation in patients with biological heart valves
(including transcatheter aortic valve implantation) and non-
rheumatic valve disease . . . . . . . . . . . . . . . . . . . . . . . . .
59
15.11 Anticoagulation after ‘successful’ catheter ablation . . . 59
15.12 Comparison of rate control agents . . . . . . . . . . . . . 59
15.13 Catheter ablation in persistent and long-standing
persistent AF . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
59
15.14 Optimal technique for repeat catheter ablation . . . . . 59
15.15 Combination therapy for maintenance of sinus rhythm 59
15.16 Can rhythm control therapy convey a prognostic
benefit in atrial fibrillation patients? . . . . . . . . . . . . . . . . .
59
15.17 Thoracoscopic ‘stand-alone’ atrial fibrillation surgery . 59
15.18 Surgical exclusion of the left atrial appendage . . . . . . 59
15.19 Concomitant atrial fibrillation surgery . . . . . . . . . . . 59
16. To do and not to do messages from the Guidelines . . . . . . 60
17. A short summary of the management of atrial fibrillation
patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
62
18. Web addenda . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
19. Appendix . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
20. References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
Abbreviations and acronyms
ABC age, biomarkers, clinical history
ACE angiotensin-converting enzyme
ACS acute coronary syndromes
AF atrial fibrillation
AFFIRM Atrial Fibrillation Follow-up Investi gation of
Rhythm Management
AFNET German Competence NETwork on Atrial
Fibrillation
AngII angiotensin II
AHRE atrial high rate episodes
APACHE-AF Apixaban versus Antiplatelet drugs or no
antithrombotic drugs after anticoagulation-
associated intraCerebral HaEmorrhage in
patients with Atrial Fibrillation
ARB angiotensin receptor blocker
ARISTOTLE Apixaban for Reduction in Stroke and Other
Thromboembolic Events in Atrial Fibrillation
ARNI angiotensin receptor neprilysin inhibition
ARTESiA Apixaban for the Reduction of Thrombo-Em-
bolism in Patients With Device-Detected
Sub-Clinical Atrial Fibrillation
ATRIA AnTicoagulation and Risk factors In Atrial
fibrillation
AV Atrioventricular
AXAFA Anticoagulation using the direct factor Xa in-
hibitor apixaban during Atrial Fibrillation
catheter Ablation: Compariso n to vitamin K
antagonist therapy
BAFTA Birmi ngham Atria l Fibrillation Treatment of
the Aged Study
BMI body mass index
b.p.m. beats per minute
CABANA Catheter Ablation versus Antiarrhythmic
Drug Therapy for Atrial Fibrillation Trial
CABG coronary artery bypass graft
CAD coronary artery disease
CHA
2
DS
2
-VASc Congestive Heart fai lure, hypertensio n, Age
≥75 (doubled), Diabe tes, Stroke (doubled),
Vascular disease, Age 65–74, and Sex (female)
CHADS
2
Cardiac failure, Hypertension, Age, Diabetes,
Stroke (Doubled)
CI confidence interval
CKD chronic kidney disease
CPG Committee for Practice Guidelines
CrCl creatinine clearance
CT computed tomography
CV cardiovascular
CYP2D6 cytochrome P450 2D6
CYP3A4 cytochrome P450 3A4
DIG Digitalis Investigation Group
EACTS European Association for Cardio-Thoracic
Surgery
EAST Early treatment of Atrial fibrillation for Stroke
prevention Trial
ECG electrocardiogram/electrocardiography
EHRA European Heart Rhythm Association
ENGAGE AF-TIMI
48
Effective Anticoagulation with Factor Xa
Next Generation in Atrial Fibrillation–
Thrombolysis in Myocardial Infarction 48
EORP EURObservational Research Programme
ESC European Society of Cardiology
ESO European stroke Organisation
FAST Atrial Fibrillation Catheter Ablation vs. Surgi-
cal Ablation Treatment
FEV1 forced expiratory volume in 1 s
FFP four-factor prothr ombin comple x concentrates
FXII factor XII
GDF-15 growth differentiation factor 15
GFR glomerular filtration rate
ESC Guidelines1612
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GUCH grown-up congenital heart disease
HARMONY A Study to Evaluate the Effec t of Ranolazine
and Dronedarone When Given Alone and
in Combination in Patients With Paroxysmal
Atrial Fibrillation
HAS-BLED hypertension, abnormal rena l/liver function
(1 point each), stroke, bleeding history or
predisposition, labile INR, elderly (.65
years), drugs/alcohol concomitantly (1 point
each)
HEMORR
2
HAGES Hepatic or renal disease, ethanol abuse,
malignancy history, older age .75, reduced
platelet count/function/antiplatelet, rebleed-
ing risk (scores double), hypertension
(uncontrolled), anaemia, genetic factors, ex-
cessive fall risk, stroke history
HF heart failure
HFmrEF heart failure with mid-range ejection fraction
HFpEF heart failure with preserved ejection fraction
HFrEF heart failure with reduced ejection fraction
HR hazard ratio
ICD implantable cardioverter defibrillator
IHD ischaemic heart disease
IL-6 interleukin 6
INR international normalized ratio
i.v. intravenous
LA left atrium/atrial
LAA left atrial appendage
LAAOS Left Atrial Appendage Occlusion Study
LV left ventricular
LVEF left ventricular ejection fraction
LVH left ventricular hypertrophy
MANTRA-PAF Medical ANtiarrhythmic Treatment or Radio-
frequency Ablation in Paroxysmal Atrial
Fibrillation
MERLIN Metabolic Efficiency With Ranolazine for Less
Ischemia in Non ST-Elevation Acute Coron-
ary Syndromes
MRA Mineralocorticoid receptor antagonist
MRI magnetic resonance imaging
NIHSS National Institutes of Health stroke severity
scale
NOAC non-vitamin K antagonist oral anticoagulant
NOAH Non vitamin K antagonist Oral anticoagulants
in patients with Atrial High rate episodes
(NOAH)
NYHA New York Heart Association
OAC oral anticoagulation/oral anticoagulant
OR odds ratio
ORBIT Outcomes Registry for Better Informed
Treatment of Atrial Fibrillation
PAFAC Prevention of Atrial Fibrillation After Cardio-
version trial
PAI-1 plasminogen activator inhibitor 1
PCI percutaneous coronary intervention
PCC prothrombin complex concentrates
PICOT Population, Intervention, Comparison, Out-
come, Time
PREVAIL Prospective Randomized Eval uation of th e
Watchman LAA Closure Device In Patients
with AF Versus Long Term Warfarin Therapy
trial
PROTECT AF Watchman Left Atrial Appendage System for
Embolic Protection in Patients With AF trial
PUFA polyunsaturated fatty acid
PVI pulmonary vein isolation
QoL quality of life
RACE Rate Control Efficacy in Permanent Atrial
Fibrillation
RATE-AF Rate Control Therapy Evaluation in Perman-
ent Atrial Fibrillation
RCT randomized controlled trial
RE-CIRCUIT Randomized Evaluation of Da bigatran Etexi-
late Compared to warfarIn in pulmonaRy
Vein Ablation: Assessment of an Uninterrupt-
ed periproCedUral antIcoagulation sTrategy
RE-LY Randomized Evaluation of Long-Term Antic-
oagulation Therapy
RF radiofrequency
ROCKET-AF Rivaroxaban Once Daily Oral Direct Factor
Xa Inhibition Compared with Vitamin K
Antagonism for Prevention of Stroke and
Embolism Trial in Atrial Fibrillation
RR risk ratio
rtPA recombinant tissue plasminogen activator
SAMe-TT
2
R
2
Sex (female), age (,60 years), medical history
(two of the following: hypertension, diabetes,
mi, pad, congestive heart failure, history of
strok e, pulmonary disease, hepatic or renal dis-
ease), treatment (interacting medications e.g.
amiodarone), tobacco use (within 2 years; scores
double), race (non-Caucasian; scores double)
SD standard deviation
SPAF Stroke Prevention in Atrial Fibrillation
SR sinus rhythm
TF tissue factor
TIA transient ischaemic attack
TIMI Thrombolysis in Myocardial Infarction
TOE transoesophageal echocardiography
TTR time in therapeutic range
UFH unfractionated heparin
VKA vitamin K antagonist
VT Ventricular tachycardia
VVI Ventricular pacing, ventricular sensing, inhib-
ited response pacemaker
WOEST What is the Optimal antiplatElet and anti-
coagulant therapy in patients with oral anti-
coagulation and coronary StenTing
WPW Wolff-Parkinson-White syndrome
1. Preamble
Guidelines summarize and evaluate all available evidence on a par-
ticular issue at the time of the writing process, with the aim of assist-
ing health professionals in selecting the best management strategies
ESC Guidelines
1613
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