2024 ESC Guidelines for Management of Atrial Fibrillation: Key Points

The following are key points to remember from the 2024 European Society of Cardiology (ESC) guidelines for the management of atrial fibrillation (AF):

1. The guideline document recommends treatment using the AF-CARE pathway, which is comprised of:
   1. [C] Comorbidity and risk factor management,
   2. [A] Avoiding stroke and thromboembolism,
   3. [R] Reducing symptoms by rate and rhythm control, and
   4. [E] Evaluating and reassessing as patients’ disease and comorbidities progress.
2. Joint decision-making regarding the best option for AF management should be made between the patient and the provider supported by a multidisciplinary team. Education for patients, family members, caregivers, and health care professionals is recommended.
3. Hypertension, heart failure (HF), diabetes mellitus, obesity, obstructive sleep apnea, physical inactivity, and high alcohol intake should be evaluated and managed to avoid recurrences and progression of AF, improve success of AF treatments, and prevent AF-related adverse outcomes.
   1. Appropriate medical therapy for HF is recommended in AF patients with HF and impaired left ventricular ejection fraction (LVEF) to reduce symptoms and/or HF hospitalization and prevent AF recurrence. Sodium-glucose cotransporter-2 (SGLT2) inhibitors are recommended for patients with HF and AF regardless of LVEF to reduce the risk of HF hospitalization and cardiovascular death.
   2. Metformin or SGLT2 inhibitors should be considered for individuals needing pharmacological management of diabetes mellitus to prevent AF.
   3. Weight loss is recommended as part of comprehensive risk factor management in overweight and obese individuals with AF to reduce symptoms and AF burden, with a target of ≥10% reduction in body weight. 
   4. Management of obstructive sleep apnea may be considered as part of a comprehensive management of risk factors in individuals with AF to reduce recurrence and progression. When screening for obstructive sleep apnea in individuals with AF, using only symptom-based questionnaires is not recommended.
   5. A tailored exercise program is recommended in individuals with paroxysmal or persistent AF to improve cardiorespiratory fitness and reduce AF recurrence. Maintaining an active lifestyle is recommended to prevent AF, with the equivalent of 150–300 minutes per week of moderate-intensity or 75–150 minutes per week of vigorous-intensity aerobic physical activity.
   6. Reducing alcohol consumption to ≤3 standard drinks (≤30 grams of alcohol) per week is recommended as part of comprehensive risk factor management to reduce AF recurrence.
4. Assessment of the risk of thromboembolism may be done with locally validated risk tools or the CHA2-VA score and assessment of other risk factors.
   1. Oral anticoagulants are recommended for all eligible patients: if CHA2-VA = 1, anticoagulation should be considered; if CHA2-VA ≥2, anticoagulation is recommended.
   2. Direct oral anticoagulants (DOACs) (apixaban, dabigatran, edoxaban, and rivaroxaban) are preferred over vitamin K antagonists, except in patients with mechanical heart valves and mitral stenosis.
   3. Adding antiplatelet treatment to oral anticoagulation is not recommended in AF patients for the goal of preventing ischemic stroke or thromboembolism. Anticoagulants and antiplatelet agents should not be combined, unless the patient has an acute vascular event or needs interim treatment for procedures.
   4. Anticoagulation should be pursued according to the patient’s individual risk of thromboembolism, irrespective of whether they are in AF or sinus rhythm.
   5. Oral anticoagulation is recommended in all patients with AF and hypertrophic cardiomyopathy or cardiac amyloidosis, regardless of CHA2-VA score.
   6. A reduced dose of DOAC therapy is not recommended, unless patients meet DOAC-specific criteria, to prevent underdosing and avoidable thromboembolic events.
   7. All patients should be kept on an oral anticoagulant for ≥2 months after an AF ablation procedure irrespective of estimated thromboembolic risk.
   8. For a formal risk-score-based assessment of bleeding risk, the HAS-BLED score should be considered to help address modifiable bleeding risk factors, and to identify patients at high risk of bleeding (HAS-BLED score ≥3) for early and more frequent clinical review and follow-up.
5. Beta-blockers (any EF), digoxin (any EF), or diltiazem/verapamil (LVEF >40%) may be used as initial therapy, as an adjunct to rhythm control therapies, or as a sole treatment strategy to control heart rate and symptoms.
6. Rhythm control should be considered in all suitable AF patients including a cardioversion, antiarrhythmic drugs, and catheter or surgical ablation to reduce symptoms and morbidity.
   1. The primary indication for rhythm control is reduction in the AF-related symptoms and improvement in the quality of life.
   2. Implementation of a rhythm-control strategy should be considered within 12 months of diagnosis in selected patients with AF at risk of thromboembolic events to reduce the risk of cardiovascular death or hospitalization.
   3. Electrical cardioversion as a diagnostic tool should be considered in patients with persistent AF where there is uncertainty about the value of sinus rhythm restoration on symptoms, or to assess improvement in LV function.
   4. Catheter ablation should be considered as a second-line option if antiarrhythmic drugs fail to control AF in persistent AF, or as a first-line option in patients with paroxysmal AF.
   5. Repeat AF catheter ablation should be considered in patients with AF recurrence after initial catheter ablation, provided the patient’s symptoms were improved after the initial pulmonary vein isolation (PVI) or after failed initial PVI, to reduce symptoms, recurrence, and progression of AF.
7. Endoscopic or hybrid ablation should be considered if catheter ablation fails, or as an alternative to catheter ablation in persistent AF despite antiarrhythmic drugs.
   1. Continuation of oral anticoagulation is recommended in patients with AF at elevated thromboembolic risk after concomitant, endoscopic, or hybrid AF ablation, independent of rhythm outcome or left atrial appendage exclusion, to prevent ischemic stroke and thromboembolism.
   2. AF ablation during cardiac surgery should be performed in centers with experienced teams, especially for patients undergoing mitral valve surgery.
   3. Surgical closure of the left atrial appendage should be considered as an adjunct to oral anticoagulation in patients with AF undergoing endoscopic or hybrid AF ablation to prevent ischemic stroke and thromboembolism.
8. Patients should be periodically reassessed with attention to new modifiable risk factors that could slow or reverse the progression of AF, increase quality of life, and prevent adverse outcomes

1. https://academic.oup.com/eurheartj/advance-article/doi/10.1093/eurheartj/ehae176/7738779