The first European Society of Cardiology (ESC) Guidelines on Atrial Fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS) are published online today in European Heart Journal (1) and the European Journal of Cardio-Thoracic Surgery, and on the ESC Website. (2)
“These are the first guidelines to target every atrial fibrillation specialist,” said Dr Stefano Benussi (Switzerland), Task Force Co-Chairperson (EACTS). “They were written by clinical cardiologists, electrophysiologists, cardiac surgeons, a neurologist and a cardiovascular nurse.”
“Integrating input from the different specialties can improve outcomes in patients with atrial fibrillation. We wanted to put patients at the centre of the new guidelines,” said Professor Paulus Kirchhof (UK/Germany), Task Force Chairperson (ESC).
It is estimated that by 2030 there will be 14–17 million patients with atrial fibrillation in the European Union, with up to 215 000 newly diagnosed patients per year. Atrial fibrillation is associated with a 1.5–2 fold increased risk of death, and is responsible for 20–30% of all strokes. Oral anticoagulation with vitamin K antagonists (VKAs) or non-VKA oral anticoagulants (NOACs) can prevent the majority of ischaemic strokes in patients with atrial fibrillation and prolong life.
NOACs are recommended as the first line anticoagulant in eligible patients. NOACs prevent strokes as effectively (or slightly better) as warfarin (a VKA) and are associated with less intracranial bleeding and death. VKAs remain a valid treatment for stroke prevention in atrial fibrillation and should be the first choice in patients ineligible for NOACs, such as those with mechanical heart valves.
Endorsed by the European Stroke Organisation (ESO), the guidelines recommend what to do when patients develop complications on anticoagulation. Advice is given on reinitiation of anticoagulation after a bleed, how to manage bleeds, and how to manage patients who have an ischaemic stroke on anticoagulation.
“Previous guidelines focused on which patients should receive anticoagulation and that issue is largely settled,” said Professor Kirchhof. “The new guidelines also address the long-term challenges in anticoagulated atrial fibrillation patients that all too often lead to discontinuation of anticoagulant therapy despite prognostic benefits in the long term.”
Greater emphasis is placed on the early diagnosis of atrial fibrillation, before the first stroke. There is now sufficient evidence to support opportunistic and targeted electrocardiogram (ECG) screening, for example in people over 65 years of age and in high risk groups such as patients with pacemakers.
“Many people have atrial fibrillation and don’t know it, and will only find out when they develop a first stroke,” said Professor Kirchhof. “Early diagnosis enables us to prevent strokes with anticoagulation.”
Catheter ablation is recommended as a first line treatment in selected patients after research showed it was not less safe than antiarrhythmic drugs. Pulmonary vein isolation is recommended as the preferred first line target of ablation, with more extensive ablations reserved for repeat procedures in patients with recurrent atrial fibrillation (AF). Recurrence rates after catheter ablation are high in the long term, and hybrid therapy with antiarrhythmic drugs and catheter ablation and AF surgery are reasonable treatment option in patients who fail conventional rhythm control therapy.
The Task Force proposes creating AF Heart Teams with experience in antiarrhythmic drugs, catheter ablation and surgery to take difficult decisions on rhythm control and hybrid therapy. Similarly, AF Heart Teams should support complex decisions in stroke prevention. A new chapter on integrated management advises cooperation between patients, health professionals including general practitioners and cardiologists, and the AF Heart Team for complex cases.
Free smartphone tools are being provided by the ESC for patients with atrial fibrillation and their healthcare professionals to improve communication and encourage patient involvement in management via the ESC Pocket Guidelines App available free of charge from the Apple, Google Play and Amazon Store. (3)
Dr Benussi said: “There is growing awareness that we need teams to treat complex patients with atrial fibrillation. Putting patients at the centre of the treatment algorithm should improve the chances of getting rid of the arrhythmia, with the lowest possible risk. AF Heart Teams should be deployed particularly when the results of treatment are unsatisfactory.”
Professor Kirchhof said: “We hope this integrated and stepwise approach, culminating in the AF Heart Teams for difficult decisions, will ensure that all patients with atrial fibrillation in Europe have access to specialist care and treatment when they need it.”
(1 )2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. European Heart Journal. 2016. doi: 10.1093/eurheartj/ehw210
(3) The CATCH ME (Characterising Atrial fibrillation by Translating its Causes into Health Modifiers in the Elderly) tool was developed with support from the European Union’s Horizon 2020 research and innovation programme. For more information please visit www.catch-me.info and download it via the ESC Pocket Guidelines App http://www.escardio.org/Guidelines-&-Education/Clinical-Practice-Guidelines/Guidelines-derivative-products/ESC-Mobile-Pocket-Guidelines