ESC 2024 2024 ESC Guidelines for the management of atrial fibrillation (EACTS)
European Society of Cardiology｜循環器 / 不整脈｜101 ページ｜チャンク 1067｜推奨 284 件｜current
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| 頁 | クラス | レベル | 推奨文 | 表 |
|---|---|---|---|---|
| p.9 | I | C | A transthoracic echocardiogram is recommended in patients with an AF diagnosis where this will guide treatment decisions. | Table 3 New recommendations |
| p.9 | I | C | decision-making, facilitating open discussion of both the benefit and risk associated with each treatment option. | Table 3 New recommendations |
| p.9 | I | C | Access to patient-centred management according to the AF-CARE principles is recommended in all patients with AF, regardless of gender, ethnicity, and socioeconomic status, to ensure equality in healthcare provision and improve outcomes. | Table 3 New recommendations |
| p.9 | IIa | B | Patient-centred AF management with a multidisciplinary approach should be considered in all patients with AF to optimize management and improve outcomes. | Table 3 New recommendations |
| p.9 | I | C | Diuretics are recommended in patients with AF, HF, and congestion to alleviate symptoms and facilitate better AF management. | Table 3 New recommendations |
| p.9 | I | B | hospitalization and prevent AF recurrence. | Table 3 New recommendations |
| p.9 | I | A | reduce the risk of HF hospitalization and cardiovascular death. | Table 3 New recommendations |
| p.9 | I | C | to reduce burden, recurrence, and progression of AF. | Table 3 New recommendations |
| p.9 | IIb | C | index ≥40 kg/m2 c where a rhythm control strategy is planned, to reduce recurrence and progression of AF. | Table 3 New recommendations |
| p.9 | IIb | B | reduce recurrence and progression. | Table 3 New recommendations |
| p.9 | III | B | When screening for obstructive sleep apnoea in individuals with AF, using only symptom-based questionnaires is not recommended. | Table 3 New recommendations |
| p.9 | I | A | Oral anticoagulation is recommended in patients with clinical AF at elevated thromboembolic risk to prevent ischaemic stroke and thromboembolism. | Table 3 New recommendations |
| p.9 | I | C | A CHA2DS2-VA score of 2 or more is recommended as an indicator of elevated thromboembolic risk for decisions on initiating oral anticoagulation. | Table 3 New recommendations |
| p.9 | IIa | C | A CHA2DS2-VA score of 1 should be considered an indicator of elevated thromboembolic risk for decisions on initiating oral anticoagulation. | Table 3 New recommendations |
| p.9 | I | B | Oral anticoagulation is recommended in all patients with AF and hypertrophic cardiomyopathy or cardiac amyloidosis, regardless of CHA2DS2-VA score, to prevent ischaemic stroke and thromboembolism. | Table 3 New recommendations |
| p.9 | I | B | Individualized reassessment of thromboembolic risk is recommended at periodic intervals in patients with AF to ensure anticoagulation is started in appropriate patients. | Table 3 New recommendations |
| p.9 | IIb | B | Direct oral anticoagulant therapy may be considered in patients with asymptomatic device-detected subclinical AF and elevated thromboembolic risk to prevent ischaemic stroke and thromboembolism, excluding patients at high risk of bleeding. | Table 3 New recommendations |
| p.9 | III | B | A reduced dose of DOAC therapy is not recommended, unless patients meet DOAC-specific criteria, to prevent underdosing and avoidable thromboembolic events. | Table 3 New recommendations |
| p.9 | IIb | B | Maintaining VKA treatment rather than switching to a DOAC may be considered in patients aged ≥75 years on clinically stable therapeutic VKA with polypharmacy to prevent excess bleeding risk. | Table 3 New recommendations |
| p.9 | III | B | thromboembolism. | Table 3 New recommendations |
| p.10 | III | B | Adding antiplatelet treatment to anticoagulation is not recommended in patients with AF to prevent recurrent embolic stroke. | |
| p.10 | III | B | Switching from one DOAC to another, or from a DOAC to a VKA, without a clear indication is not recommended in patients with AF to prevent recurrent embolic stroke. | |
| p.10 | IIa | C | 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 ischaemic stroke and thromboembolism. | |
| p.10 | IIb | C | Stand-alone endoscopic surgical closure of the left atrial appendage may be considered in patients with AF and contraindications for long-term anticoagulant treatment to prevent ischaemic stroke and thromboembolism. | |
| p.10 | IIa | B | reverse the antithrombotic effect. | |
| p.10 | I | B | a sole treatment strategy to control heart rate and reduce symptoms. | |
| p.10 | I | B | rate and reduce symptoms. | |
| p.10 | I | A | thromboembolic risk reduction. | |
| p.10 | IIa | B | rhythm control approach. | |
| p.10 | IIa | B | haemodynamic compromise as an alternative to immediate cardioversion. | |
| p.10 | IIa | B | thromboembolic events to reduce the risk of cardiovascular death or hospitalization. | |
| p.10 | III | C | Early cardioversion is not recommended without appropriate anticoagulation or transoesophageal echocardiography if AF duration is longer than 24 h, or there is scope to wait for spontaneous cardioversion. | |
| p.10 | IIa | C | sinus rhythm restoration on symptoms, or to assess improvement in left ventricular function. | |
| p.10 | IIa | C | Atrial fibrillation catheter ablation should be considered in patients with AF-related bradycardia or sinus pauses on AF termination to improve symptoms and avoid pacemaker implantation. | |
| p.10 | IIa | B | 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 PVI or after failed initial PVI, to reduce symptoms, recurrence, and progression of AF. | |
| p.10 | I | A | stroke and thromboembolism. | |
| p.11 | I | C | 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 LAA exclusion, to prevent ischaemic stroke and thromboembolism. | |
| p.11 | I | C | strategy, independent of oral anticoagulant use, to prevent peri-procedural ischaemic stroke and thromboembolism. | |
| p.11 | IIa | B | to improve patient experiences. | |
| p.11 | III | B | Antiplatelet therapy beyond 12 months is not recommended in stable patients with chronic coronary or vascular disease treated with oral anticoagulation, due to lack of efficacy and to avoid major bleeding. | |
| p.11 | IIa | C | prevent ischaemic stroke and systemic thromboembolism. | |
| p.11 | I | A | Peri-operative amiodarone therapy is recommended where drug therapy is desired to prevent post-operative AF after cardiac surgery. | |
| p.11 | IIa | B | Concomitant posterior peri-cardiotomy should be considered in patients undergoing cardiac surgery to prevent post-operative AF. | |
| p.11 | III | A | ischaemic stroke and thromboembolism. | |
| p.11 | I | B | thromboembolism. | |
| p.11 | I | B | appropriate management. | |
| p.11 | IIa | B | or ≥65 years with additional CHA2DS2-VA risk factors to ensure earlier detection of AF. | |
| p.11 | I | B | Appropriate medical HF therapy is recommended in individuals with HFrEF to prevent AF. | |
| p.11 | I | B | Maintaining normal weight (BMI 20–25 kg/m2) is recommended for the general population to prevent AF. | |
| p.11 | I | B | 150 min per week of vigorous intensity aerobic physical activity. | |
| p.11 | I | B | Avoidance of binge drinking and alcohol excess is recommended in the general population to prevent AF. | |
| p.11 | IIa | B | Weight reduction should be considered in obese individuals to prevent AF. | |
| p.12 | I | A | stratification and treatment. | Table 4 Revised recommendations |
| p.12 | I | B | and risk of stroke and bleeding. | Table 4 Revised recommendations |
| p.12 | IIa | B | considered for OAC therapy. | Table 4 Revised recommendations |
| p.12 | IIb | C | undergoing cardiac surgery. | Table 4 Revised recommendations |
| p.12 | I | B | to ensure safety and prevent bleeding. | Table 4 Revised recommendations |
| p.12 | I | B | Section 3.2—Diagnostic criteria for AF ECG documentation is required to establish the diagnosis of AF. A standard 12-lead ECG recording or a single-lead ECG tracing of ≥30 s showing heart rhythm with no discernible repeating P waves and irregular RR intervals (when atrioventricular conduction is not impaired) is diagnostic of clinical AF. | Table 4 Revised recommendations |
| p.12 | I | C | In patients with AF, it is recommended to: • Evaluate AF-related symptoms (including fatigue, tiredness, exertional shortness of breath, palpitations, and chest pain) and quantify the patient symptom status using the modified EHRA symptom scale before and after initiation of treatment. • Evaluate AF-related symptoms before and after cardioversion of persistent AF to aid rhythm control treatment decisions. | Table 4 Revised recommendations |
| p.12 | IIa | B | Attention to good BP control is recommended in AF patients with hypertension to reduce AF recurrences In obese patients with AF, weight loss together with management of other risk factors should be considered to reduce AF incidence, AF progression, AF recurrences, and symptoms. | Table 4 Revised recommendations |
| p.12 | IIa | C | Physical activity should be considered to help prevent AF incidence or recurrence, with the exception of excessive endurance exercise, which may promote AF. Advice and management to avoid alcohol excess should be considered for AF prevention and in AF patients Section 6.6—Surgical left atrial appendage occlusion Surgical occlusion or exclusion of the LAA may be | Table 4 Revised recommendations |
| p.12 | IIa | B | considered for stroke prevention in patients with AF Section 6.7—Bleeding risk 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. | Table 4 Revised recommendations |
| p.12 | I | B | Confirmation by an electrocardiogram (12-lead, multiple, or single leads) is recommended to establish the diagnosis of clinical AF and commence risk Evaluating the impact of AF-related symptoms is recommended before and after major changes in treatment to inform shared decision-making and guide treatment choices. | Table 4 Revised recommendations |
| p.12 | I | B | Blood pressure lowering treatment is recommended in patients with AF and hypertension to reduce recurrence and progression of AF and prevent adverse cardiovascular events. | Table 4 Revised recommendations |
| p.12 | I | B | 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% or more reduction in body weight. | Table 4 Revised recommendations |
| p.12 | I | B | A tailored exercise programme is recommended in individuals with paroxysmal or persistent AF to improve cardiorespiratory fitness and reduce AF recurrence. | Table 4 Revised recommendations |
| p.12 | I | B | 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. | Table 4 Revised recommendations |
| p.12 | I | B | Surgical closure of the left atrial appendage is recommended as an adjunct to oral anticoagulation in patients with AF undergoing cardiac surgery to prevent ischaemic stroke and thromboembolism. Assessment and management of modifiable bleeding risk factors is recommended in all patients eligible for oral anticoagulation, as part of shared decision-making | Table 4 Revised recommendations |
| p.13 | IIa | B | AF catheter ablation for PVI should/may be considered as first-line rhythm control therapy to improve symptoms in selected patients with symptomatic: • Paroxysmal AF episodes. Thoracoscopic procedures—including hybrid surgical | |
| p.13 | IIa | B | ablation—should be considered in patients who have symptomatic paroxysmal or persistent AF refractory to AAD therapy and have failed percutaneous AF ablation, or with evident risk factors for catheter ablation failure, to maintain long-term sinus rhythm. The decision must be supported by an experienced team of electrophysiologists and surgeons. | |
| p.13 | IIb | C | Thoracoscopic procedures—including hybrid surgical ablation—may be considered in patients with persistent AF with risk factors for recurrence, who remain symptomatic during AF despite at least one failed AAD and who prefer further rhythm control therapy. | |
| p.13 | IIa | A | Concomitant AF ablation should be considered in patients undergoing cardiac surgery, balancing the benefits of freedom from atrial arrhythmias and the risk factors for recurrence (left atrial dilatation, years in AF, age, renal dysfunction, and other cardiovascular risk factors). | |
| p.13 | IIb | B | Section 9.6—Post-operative AF Long-term OAC therapy to prevent thromboembolic events may be considered in patients at risk for stroke with post-operative AF after cardiac surgery, considering the anticipated net clinical benefit of OAC therapy and informed patient preferences. | |
| p.13 | I | A | Catheter ablation is recommended as a first-line option within a shared decision-making rhythm control strategy in patients with paroxysmal AF, to reduce symptoms, recurrence, and progression of AF. Endoscopic and hybrid ablation procedures may be | |
| p.13 | IIb | B | considered in patients with symptomatic paroxysmal AF refractory to AAD therapy and failed percutaneous catheter ablation strategy to prevent symptoms, recurrence, and progression of AF, within a shared decision-making rhythm control team of electrophysiologists and surgeons. | |
| p.13 | IIa | A | Endoscopic and hybrid ablation procedures should be considered in patients with symptomatic persistent AF refractory to AAD therapy to prevent symptoms, recurrence, and progression of AF, within a shared decision-making rhythm control team of electrophysiologists and surgeons. | |
| p.13 | I | A | Concomitant surgical ablation is recommended in patients undergoing mitral valve surgery and AF suitable for a rhythm control strategy to prevent symptoms and recurrence of AF, with shared decision-making supported by an experienced team of electrophysiologists and arrhythmia surgeons. | |
| p.13 | IIa | B | Long-term oral anticoagulation should be considered in patients with post-operative AF after cardiac and non-cardiac surgery at elevated thromboembolic risk, to prevent ischaemic stroke and thromboembolism. | |
| p.15 | I | A | Confirmation by an electrocardiogram (12-lead, multiple, or single leads) is recommended to establish the diagnosis of clinical AF and commence risk stratification and treatment.25–29 AF, atrial fibrillation. aClass of recommendation. bLevel of evidence. | Recommendation Table 1 — Recommendations for the diagnosis of AF (see also Evidence Table 1) |
| p.15 | I | B | Evaluating the impact of AF-related symptoms is recommended before and after major changes in treatment to inform shared decision-making and guide treatment choices.17,36,46–55 AF, atrial fibrillation. aClass of recommendation. bLevel of evidence. © ESC 2024 | Recommendation Table 2 — Recommendations for symptom evaluation in patients with AF (see also Evidence Table 2) |
| p.15 | I | C | A transthoracic echocardiogram is recommended in patients with an AF diagnosis where this will guide treatment decisions.59,65,67 AF, atrial fibrillation. aClass of recommendation. bLevel of evidence. | Recommendation Table 3 — Recommendations for diagnostic evaluation in patients with new AF (see also Evidence Table 3) |
| p.19 | I | C | Education directed to patients, family members, caregivers, and healthcare professionals is recommended to optimize shared decision-making, facilitating open discussion of both the benefit and risk associated with each treatment option.94,103 | Recommendation Table 4 — Recommendations for patient-centred care and education (see also Evidence Table 4) |
| p.19 | I | C | Access to patient-centred management according to the AF-CARE principles is recommended in all patients with AF, regardless of gender, ethnicity, and socioeconomic status, to ensure equality in healthcare provision and improve outcomes. | Recommendation Table 4 — Recommendations for patient-centred care and education (see also Evidence Table 4) |
| p.19 | IIa | B | Patient-centred AF management with a multidisciplinary approach should be considered in all patients with AF to optimize management and improve outcomes.79,121–124 | Recommendation Table 4 — Recommendations for patient-centred care and education (see also Evidence Table 4) |
| p.26 | I | B | Identification and management of risk factors and comorbidities is recommended as an integral part of AF care.39,125–127 | Recommendation Table 5 — Recommendations for comorbidity and risk factor management in AF (see also Evidence Table 5) |
| p.26 | I | B | Blood pressure lowering treatment is recommended in patients with AF and hypertension to reduce recurrence and progression of AF and prevent adverse cardiovascular events.126–130 | Recommendation Table 5 — Recommendations for comorbidity and risk factor management in AF (see also Evidence Table 5) |
| p.26 | I | C | Diuretics are recommended in patients with AF, HF, and congestion to alleviate symptoms and facilitate better AF management. | Recommendation Table 5 — Recommendations for comorbidity and risk factor management in AF (see also Evidence Table 5) |
| p.26 | I | B | Appropriate medical therapy for HF is recommended in AF patients with HF and impaired LVEF to reduce symptoms and/or HF hospitalization and prevent AF recurrence.131–137 | Recommendation Table 5 — Recommendations for comorbidity and risk factor management in AF (see also Evidence Table 5) |
| p.26 | I | A | Sodium-glucose cotransporter-2 inhibitors are recommended for patients with HF and AF regardless of left ventricular ejection fraction to reduce the risk of HF hospitalization and cardiovascular death.136,138–140 | Recommendation Table 5 — Recommendations for comorbidity and risk factor management in AF (see also Evidence Table 5) |
| p.26 | I | C | Effective glycaemic control is recommended as part of comprehensive risk factor management in individuals with diabetes mellitus and AF, to reduce burden, recurrence, and progression of AF. | Recommendation Table 5 — Recommendations for comorbidity and risk factor management in AF (see also Evidence Table 5) |
| p.26 | I | B | 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% or more reduction in body weight.125–128 | Recommendation Table 5 — Recommendations for comorbidity and risk factor management in AF (see also Evidence Table 5) |
| p.26 | I | B | A tailored exercise programme is recommended in individuals with paroxysmal or persistent AF to improve cardiorespiratory fitness and reduce AF recurrence.141–146 | Recommendation Table 5 — Recommendations for comorbidity and risk factor management in AF (see also Evidence Table 5) |
| p.26 | I | B | 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.126,127,147 | Recommendation Table 5 — Recommendations for comorbidity and risk factor management in AF (see also Evidence Table 5) |
| p.26 | IIb | C | Bariatric surgery may be considered in conjunction with lifestyle changes and medical management in individuals with AF and body mass index ≥40 kg/m2 c where a rhythm control strategy is planned, to reduce recurrence and progression of AF. | Recommendation Table 5 — Recommendations for comorbidity and risk factor management in AF (see also Evidence Table 5) |
| p.26 | IIb | B | Management of obstructive sleep apnoea may be considered as part of a comprehensive management of risk factors in individuals with AF to reduce recurrence and progression.126–128,148–154 | Recommendation Table 5 — Recommendations for comorbidity and risk factor management in AF (see also Evidence Table 5) |
| p.26 | III | B | When screening for obstructive sleep apnoea in individuals with AF, using only symptom-based questionnaires is not recommended.155–157 | Recommendation Table 5 — Recommendations for comorbidity and risk factor management in AF (see also Evidence Table 5) |
| p.29 | I | A | Oral anticoagulation is recommended in patients with clinical AF at elevated thromboembolic risk to prevent ischaemic stroke and thromboembolism.239,240 | Recommendation Table 6 — Recommendations to assess and manage thromboembolic risk in AF (see also Evidence Table 6) |
| p.29 | I | C | A CHA2DS2-VA score of 2 or more is recommended as an indicator of elevated thromboembolic risk for decisions on initiating oral anticoagulation. | Recommendation Table 6 — Recommendations to assess and manage thromboembolic risk in AF (see also Evidence Table 6) |
| p.29 | I | B | Oral anticoagulation is recommended in all patients with AF and hypertrophic cardiomyopathy or cardiac amyloidosis, regardless of CHA2DS2-VA score, to prevent ischaemic stroke and thromboembolism.270–276 | Recommendation Table 6 — Recommendations to assess and manage thromboembolic risk in AF (see also Evidence Table 6) |
| p.29 | I | B | Individualized reassessment of thromboembolic risk is recommended at periodic intervals in patients with AF to ensure anticoagulation is started in appropriate patients.277–280 | Recommendation Table 6 — Recommendations to assess and manage thromboembolic risk in AF (see also Evidence Table 6) |
| p.29 | IIa | C | decisions on initiating oral anticoagulation. | Recommendation Table 6 — Recommendations to assess and manage thromboembolic risk in AF (see also Evidence Table 6) |
| p.29 | IIb | B | Direct oral anticoagulant therapy may be considered in patients with asymptomatic device-detected subclinical AF and elevated thromboembolic risk to prevent ischaemic stroke and thromboembolism, excluding patients at high risk of bleeding.281,282 | Recommendation Table 6 — Recommendations to assess and manage thromboembolic risk in AF (see also Evidence Table 6) |
| p.29 | III | A | Antiplatelet therapy is not recommended as an alternative to anticoagulation in patients with AF to prevent ischaemic stroke and thromboembolism.242,283 | Recommendation Table 6 — Recommendations to assess and manage thromboembolic risk in AF (see also Evidence Table 6) |
| p.29 | III | B | Using the temporal pattern of clinical AF (paroxysmal, persistent, or permanent) is not recommended to determine the need for oral anticoagulation.284,285 Continued | Recommendation Table 6 — Recommendations to assess and manage thromboembolic risk in AF (see also Evidence Table 6) |
| p.31 | I | A | Direct oral anticoagulants are recommended in preference to VKAs to prevent ischaemic stroke and thromboembolism, except in patients with mechanical heart valves or moderate-to-severe mitral stenosis.25–28,292–294 | Recommendation Table 7 — Recommendations for oral anticoagulation in AF (see also Evidence Table 7) |
| p.31 | I | B | A target INR of 2.0–3.0 is recommended for patients with AF prescribed a VKA for stroke prevention to ensure safety and effectiveness.295–298 | Recommendation Table 7 — Recommendations for oral anticoagulation in AF (see also Evidence Table 7) |
| p.31 | I | B | Switching to a DOAC is recommended for eligible patients that have failed to maintain an adequate time in therapeutic range on a VKA (TTR <70%) to prevent thromboembolism and intracranial haemorrhage.299–303 | Recommendation Table 7 — Recommendations for oral anticoagulation in AF (see also Evidence Table 7) |
| p.31 | IIa | A | Keeping the time in therapeutic range above 70% should be considered in patients taking a VKA to ensure safety and effectiveness, with INR checks at appropriate frequency and patient-directed education and counselling.304–308 | Recommendation Table 7 — Recommendations for oral anticoagulation in AF (see also Evidence Table 7) |
| p.31 | IIb | B | Maintaining VKA treatment rather than switching to a DOAC may be considered in patients aged ≥75 years on clinically stable therapeutic VKA with polypharmacy to prevent excess bleeding risk.309 | Recommendation Table 7 — Recommendations for oral anticoagulation in AF (see also Evidence Table 7) |
| p.31 | III | B | A reduced dose of DOAC therapy is not recommended, unless patients meet DOAC-specific criteria,c to prevent underdosing and avoidable thromboembolic events.310–312 | Recommendation Table 7 — Recommendations for oral anticoagulation in AF (see also Evidence Table 7) |
| p.33 | III | B | Adding antiplatelet treatment to oral anticoagulation is not recommended in AF patients for the goal of preventing ischaemic stroke or thromboembolism.345,347,353 AF, atrial fibrillation. aClass of recommendation. bLevel of evidence. | Recommendation Table 8 — Recommendations for combining antiplatelet drugs with anticoagulants for stroke prevention (see also Evidence Table 8) |
| p.33 | IIa | B | A thorough diagnostic work-up should be considered in patients taking an oral anticoagulant and presenting with ischaemic stroke or thromboembolism to prevent recurrent events, including assessment of non-cardioembolic causes, | Recommendation Table 9 — Recommendations for thromboembolism despite anticoagulation (see also Evidence Table 9) |
| p.33 | III | B | vascular risk factors, dosage, and adherence.356,357 Adding antiplatelet treatment to anticoagulation is not recommended in patients with AF to prevent recurrent embolic stroke.356,359 | Recommendation Table 9 — Recommendations for thromboembolism despite anticoagulation (see also Evidence Table 9) |
| p.33 | III | B | Switching from one DOAC to another, or from a DOAC to a VKA, without a clear indication is not recommended in patients with AF to prevent recurrent embolic stroke.252,356,359 © ESC 2024 | Recommendation Table 9 — Recommendations for thromboembolism despite anticoagulation (see also Evidence Table 9) |
| p.34 | IIb | C | Percutaneous LAA occlusion may be considered in patients with AF and contraindications for long-term anticoagulant treatment to prevent ischaemic stroke and thromboembolism.372,376,386,387 AF, atrial fibrillation; LAA, left atrial appendage. aClass of recommendation. bLevel of evidence. | Recommendation Table 10 — Recommendations for percutaneous left atrial appendage occlusion (see also Evidence Table 10) |
| p.35 | I | B | Surgical closure of the left atrial appendage is recommended as an adjunct to oral anticoagulation in patients with AF undergoing cardiac surgery to prevent ischaemic stroke and thromboembolism.400,401,408–412 | Recommendation Table 11 — Recommendations for surgical left atrial appendage occlusion (see also Evidence Table 11) |
| p.35 | IIa | C | 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 ischaemic stroke and thromboembolism.402,403 | Recommendation Table 11 — Recommendations for surgical left atrial appendage occlusion (see also Evidence Table 11) |
| p.35 | IIb | C | Stand-alone endoscopic surgical closure of the left atrial appendage may be considered in patients with AF and contraindications for long-term anticoagulant treatment to prevent ischaemic stroke and thromboembolism.399,405,406,413 AF, atrial fibrillation. aClass of recommendation. bLevel of evidence. | Recommendation Table 11 — Recommendations for surgical left atrial appendage occlusion (see also Evidence Table 11) |
| p.35 | I | B | Assessment and management of modifiable bleeding risk factors is recommended in all patients eligible for oral anticoagulation, as part of shared © ESC 2024 decision-making to ensure safety and prevent bleeding.439–444 | Recommendation Table 12 — Recommendations for assessment of bleeding risk (see also Evidence Table 12) |
| p.35 | III | B | Use of bleeding risk scores to decide on starting or withdrawing oral anticoagulation is not recommended in patients with AF to avoid under-use of anticoagulation.431,445,446 AF, atrial fibrillation. aClass of recommendation. bLevel of evidence. | Recommendation Table 12 — Recommendations for assessment of bleeding risk (see also Evidence Table 12) |
| p.38 | I | C | Interrupting anticoagulation and performing diagnostic or treatment interventions is recommended in AF patients with active bleeding until the cause of bleeding is identified and resolved. | Recommendation Table 13 — Recommendations for management of bleeding in anticoagulated patients (see also Evidence Table 13) |
| p.38 | IIa | C | Prothrombin complex concentrates should be considered in AF patients on VKAs who develop a life-threatening bleed, or bleed into a critical site, to reverse the antithrombotic effect.450 | Recommendation Table 13 — Recommendations for management of bleeding in anticoagulated patients (see also Evidence Table 13) |
| p.38 | IIa | B | Specific antidotes should be considered in AF patients on a DOAC who develop a life-threatening bleed, or bleed into a critical site, to reverse the antithrombotic effect.451,455,456 | Recommendation Table 13 — Recommendations for management of bleeding in anticoagulated patients (see also Evidence Table 13) |
| p.38 | I | B | Rate control therapy is recommended in patients with AF, as initial therapy in the acute setting, an adjunct to rhythm control therapies, or as a sole treatment strategy to control heart rate and reduce symptoms.458–460 | Recommendation Table 14 — Recommendations for heart rate control in patients with AF (see also Evidence Table 14) |
| p.38 | I | B | Beta-blockers, diltiazem, verapamil, or digoxin are recommended as first-choice drugs in patients with AF and LVEF >40% to control heart rate and reduce symptoms.48,461,462 | Recommendation Table 14 — Recommendations for heart rate control in patients with AF (see also Evidence Table 14) |
| p.38 | I | B | Beta-blockers and/or digoxin are recommended in patients with AF and LVEF ≤40% to control heart rate and reduce symptoms.40,185,463–465 | Recommendation Table 14 — Recommendations for heart rate control in patients with AF (see also Evidence Table 14) |
| p.38 | IIa | C | Combination rate control therapy should be considered if a single drug does not control symptoms or heart rate in patients with AF, providing that bradycardia can be avoided, to control heart rate and reduce symptoms. | Recommendation Table 14 — Recommendations for heart rate control in patients with AF (see also Evidence Table 14) |
| p.38 | IIa | B | Lenient rate control with a resting heart rate of < 110 b.p.m. should be considered as the initial target for patients with AF, with stricter control reserved for those with continuing AF-related symptoms.459,460,466 | Recommendation Table 14 — Recommendations for heart rate control in patients with AF (see also Evidence Table 14) |
| p.38 | IIa | B | © ESC 2024 Atrioventricular node ablation in combination with pacemaker implantation should be considered in patients unresponsive to, or ineligible for, intensive rate and rhythm control therapy to control heart rate and reduce symptoms.467–469 | Recommendation Table 14 — Recommendations for heart rate control in patients with AF (see also Evidence Table 14) |
| p.38 | IIa | B | Atrioventricular node ablation combined with cardiac resynchronization therapy should be considered in severely symptomatic patients with permanent AF and at least one hospitalization for HF to reduce symptoms, physical limitations, recurrent HF hospitalization, and mortality.470,471 | Recommendation Table 14 — Recommendations for heart rate control in patients with AF (see also Evidence Table 14) |
| p.38 | IIb | B | Intravenous amiodarone, digoxin, or landiolol may be considered in patients with AF who have haemodynamic instability or severely depressed LVEF to achieve acute control of heart rate.472,473 | Recommendation Table 14 — Recommendations for heart rate control in patients with AF (see also Evidence Table 14) |
| p.42 | I | C | Electrical cardioversion is recommended in AF patients with acute or worsening haemodynamic instability to improve immediate patient outcomes.520 | Recommendation Table 15 — Recommendations for general concepts in rhythm control (see also Evidence Table 15) |
| p.42 | I | A | Direct oral anticoagulants are recommended in preference to VKAs in eligible patients with AF undergoing cardioversion for thromboembolic risk reduction.293,319–321,521 | Recommendation Table 15 — Recommendations for general concepts in rhythm control (see also Evidence Table 15) |
| p.42 | I | B | Therapeutic oral anticoagulation for at least 3 weeks (adherence to DOACs or INR ≥2.0 for VKAs) is recommended before scheduled cardioversion of AF and atrial flutter to prevent procedure-related thromboembolism.319–321 | Recommendation Table 15 — Recommendations for general concepts in rhythm control (see also Evidence Table 15) |
| p.42 | I | B | Transoesophageal echocardiography is recommended if 3 weeks of therapeutic oral anticoagulation has not been provided, for exclusion of cardiac thrombus to enable early cardioversion.319–321,522 | Recommendation Table 15 — Recommendations for general concepts in rhythm control (see also Evidence Table 15) |
| p.42 | I | B | Oral anticoagulation is recommended to continue for at least 4 weeks in all patients after cardioversion and long-term in patients with thromboembolic risk factor(s) irrespective of whether sinus rhythm is achieved, to prevent thromboembolism.239,319,320,523,524 | Recommendation Table 15 — Recommendations for general concepts in rhythm control (see also Evidence Table 15) |
| p.42 | IIa | B | Cardioversion of AF (either electrical or pharmacological) should be considered in symptomatic patients with persistent AF as part of a rhythm control approach.52,525,526 | Recommendation Table 15 — Recommendations for general concepts in rhythm control (see also Evidence Table 15) |
| p.42 | IIa | B | A wait-and-see approach for spontaneous conversion to sinus rhythm within 48 h of AF onset should be considered in patients without haemodynamic compromise as an alternative to immediate cardioversion.10,525 | Recommendation Table 15 — Recommendations for general concepts in rhythm control (see also Evidence Table 15) |
| p.42 | IIa | B | 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.17,527 | Recommendation Table 15 — Recommendations for general concepts in rhythm control (see also Evidence Table 15) |
| p.42 | IIa | B | Initiation of therapeutic anticoagulation should be considered as soon as possible in the setting of unscheduled cardioversion for AF or atrial flutter to prevent procedure-related thromboembolism.319–321,528 | Recommendation Table 15 — Recommendations for general concepts in rhythm control (see also Evidence Table 15) |
| p.42 | IIa | C | Repeat transoesophageal echocardiography should be considered before cardioversion if thrombus has been identified on initial imaging to ensure thrombus resolution and prevent peri-procedural thromboembolism.529 | Recommendation Table 15 — Recommendations for general concepts in rhythm control (see also Evidence Table 15) |
| p.42 | III | C | Early cardioversion is not recommended without appropriate anticoagulation or transoesophageal echocardiography if AF duration is longer than 24 h, or there is scope to wait for spontaneous cardioversion.522 | Recommendation Table 15 — Recommendations for general concepts in rhythm control (see also Evidence Table 15) |
| p.43 | IIa | C | 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 left ventricular function.548 AF, atrial fibrillation. aClass of recommendation. bLevel of evidence. | Recommendation Table 16 — Recommendations for electrical cardioversion of AF (see also Evidence Table 16) |
| p.43 | I | A | Intravenous flecainide or propafenone is recommended when pharmacological cardioversion of recent-onset AF is desired, excluding patients with severe left ventricular hypertrophy, HFrEF, or coronary artery disease.562–566 | Recommendation Table 17 — Recommendations for pharmacological cardioversion of AF (see also Evidence Table 17) |
| p.43 | I | A | Intravenous vernakalant is recommended when pharmacological cardioversion of recent-onset AF is desired, excluding patients with recent ACS, HFrEF, or severe aortic stenosis.562–568 | Recommendation Table 17 — Recommendations for pharmacological cardioversion of AF (see also Evidence Table 17) |
| p.43 | I | A | Intravenous amiodarone is recommended when cardioversion of AF in patients with severe left ventricular hypertrophy, HFrEF, or coronary artery disease is desired, accepting there may be a delay in cardioversion.473,569,570 | Recommendation Table 17 — Recommendations for pharmacological cardioversion of AF (see also Evidence Table 17) |
| p.43 | IIa | B | A single self-administered oral dose of flecainide or propafenone (pill-in-the-pocket) should be © ESC 2024 considered for patient-led cardioversion in selected patients with infrequent paroxysmal AF, after efficacy and safety assessment and excluding those with severe left ventricular hypertrophy, HFrEF, or coronary artery disease.560,571–573 | Recommendation Table 17 — Recommendations for pharmacological cardioversion of AF (see also Evidence Table 17) |
| p.43 | III | C | Pharmacological cardioversion is not recommended for patients with sinus node dysfunction, atrioventricular conduction disturbances, or prolonged QTc (>500 ms), unless risks for proarrhythmia and bradycardia have been considered. | Recommendation Table 17 — Recommendations for pharmacological cardioversion of AF (see also Evidence Table 17) |
| p.45 | I | A | Amiodarone is recommended in patients with AF and HFrEF requiring long-term antiarrhythmic drug therapy to prevent recurrence and progression of AF, with careful consideration and monitoring for extracardiac toxicity.577,585–587 | Recommendation Table 18 — Recommendations for antiarrhythmic drugs for long-term maintenance of sinus rhythm (see also Evidence Table 18) |
| p.45 | I | A | Dronedarone is recommended in patients with AF requiring long-term rhythm control, including those with HFmrEF, HFpEF, ischaemic heart disease, or valvular disease to prevent recurrence and progression of AF.512,577,588,589 | Recommendation Table 18 — Recommendations for antiarrhythmic drugs for long-term maintenance of sinus rhythm (see also Evidence Table 18) |
| p.45 | I | A | Flecainide or propafenone is recommended in patients with AF requiring long-term rhythm control to prevent recurrence and progression of AF, excluding those with impaired left ventricular systolic function, severe left ventricular hypertrophy, or coronary artery disease.526,577,585,590 | Recommendation Table 18 — Recommendations for antiarrhythmic drugs for long-term maintenance of sinus rhythm (see also Evidence Table 18) |
| p.45 | IIa | C | Concomitant use of a beta-blocker, diltiazem, or verapamil should be considered in AF patients treated with flecainide or propafenone, to prevent 1:1 conduction if their rhythm is transformed to atrial flutter. | Recommendation Table 18 — Recommendations for antiarrhythmic drugs for long-term maintenance of sinus rhythm (see also Evidence Table 18) |
| p.45 | IIb | A | Sotalol may be considered in patients with AF requiring long-term rhythm control with normal LVEF or coronary artery disease to prevent recurrence and progression of AF, but requires close monitoring of QT interval, serum potassium levels, renal function, and other proarrhythmia risk factors.585,587 | |
| p.45 | III | C | Antiarrhythmic drug therapy is not recommended in patients with advanced conduction disturbances unless antibradycardia pacing is provided. | |
| p.46 | I | C | Shared decision-making Shared decision-making is recommended when considering catheter ablation for AF, taking into account procedural risks, likely benefits, and risk factors for AF recurrence.128,210,503,646 | Recommendation Table 19 — Recommendations for catheter ablation of AF (see also Evidence Table 19) |
| p.46 | I | A | Catheter ablation is recommended in patients with paroxysmal or persistent AF resistant or intolerant to antiarrhythmic drug therapy to reduce symptoms, recurrence, and progression of AF.3,15,503,505,506,508 First-line rhythm control therapy | Recommendation Table 19 — Recommendations for catheter ablation of AF (see also Evidence Table 19) |
| p.46 | I | A | Catheter ablation is recommended as a first-line option within a shared decision-making rhythm control strategy in patients with paroxysmal AF, to reduce symptoms, recurrence, and progression of AF.16,591–594 | Recommendation Table 19 — Recommendations for catheter ablation of AF (see also Evidence Table 19) |
| p.46 | IIb | C | Catheter ablation may be considered as a first-line option within a shared decision-making rhythm control strategy in selected patients with persistent AF to reduce symptoms, recurrence, and progression of AF. | Recommendation Table 19 — Recommendations for catheter ablation of AF (see also Evidence Table 19) |
| p.46 | I | B | Patients with heart failure AF catheter ablation is recommended in patients with AF and HFrEF with high probability of tachycardia-induced cardiomyopathy to reverse left ventricular dysfunction.604,611 | |
| p.46 | IIa | B | AF catheter ablation should be considered in selected AF patients with HFrEF to reduce HF hospitalization and prolong survival.4,513,514,604,610,612 | |
| p.46 | IIa | C | AF catheter ablation should be considered in patients with AF-related bradycardia or sinus pauses on AF termination to improve symptoms and avoid pacemaker implantation.595–598 Recurrence after catheter ablation | |
| p.46 | IIa | B | 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 PVI or after failed initial PVI, to reduce symptoms, recurrence, and progression of AF.643–645 | |
| p.47 | I | C | Initiation of oral anticoagulation is recommended at least 3 weeks prior to catheter-based ablation in AF patients at elevated thromboembolic risk, to prevent peri-procedural ischaemic stroke and thromboembolism.554,647 | Recommendation Table 20 — Recommendations for anticoagulation in patients undergoing catheter ablation (see also Evidence Table 20) |
| p.47 | I | A | Uninterrupted oral anticoagulation is recommended in patients undergoing AF catheter ablation to prevent peri-procedural ischaemic stroke and thromboembolism.664,665 | Recommendation Table 20 — Recommendations for anticoagulation in patients undergoing catheter ablation (see also Evidence Table 20) |
| p.47 | I | C | Continuation of oral anticoagulation is recommended for at least 2 months after AF ablation in all patients, irrespective of rhythm outcome or CHA2DS2-VA score, to reduce the risk of peri-procedural ischaemic stroke and thromboembolism.554,663 | Recommendation Table 20 — Recommendations for anticoagulation in patients undergoing catheter ablation (see also Evidence Table 20) |
| p.47 | I | C | Continuation of oral anticoagulation is recommended after AF ablation according to the patient’s CHA2DS2-VA score, and not the perceived success of the ablation procedure, to prevent ischaemic stroke and thromboembolism.554 | Recommendation Table 20 — Recommendations for anticoagulation in patients undergoing catheter ablation (see also Evidence Table 20) |
| p.47 | IIa | B | Cardiac imaging should be considered prior to catheter ablation of AF in patients at high risk of ischaemic stroke and thromboembolism despite taking oral anticoagulation to exclude thrombus.649,650 | Recommendation Table 20 — Recommendations for anticoagulation in patients undergoing catheter ablation (see also Evidence Table 20) |
| p.47 | I | C | © ESC 2024 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 LAA exclusion, to prevent ischaemic stroke and thromboembolism. | Recommendation Table 21 — Recommendations for endoscopic and hybrid AF ablation (see also Evidence Table 21) |
| p.48 | IIa | A | persistent AF refractory to AAD therapy to prevent symptoms, recurrence, and progression of AF, within a shared decision-making rhythm control team of electrophysiologists and surgeons.667–671,674 | Recommendation Table 22 — Recommendations for AF ablation during cardiac surgery (see also Evidence Table 22) |
| p.48 | IIb | B | Endoscopic and hybrid ablation procedures may be considered in patients with symptomatic paroxysmal AF refractory to AAD therapy and failed percutaneous catheter ablation strategy to prevent symptoms, recurrence, and progression of AF, within a shared decision-making rhythm control team of electrophysiologists and surgeons.668,669 | Recommendation Table 22 — Recommendations for AF ablation during cardiac surgery (see also Evidence Table 22) |
| p.48 | I | A | Concomitant surgical ablation is recommended in patients undergoing mitral valve surgery and AF suitable for a rhythm control strategy to prevent symptoms and recurrence of AF, with shared decision-making supported by an experienced team of electrophysiologists and arrhythmia surgeons.683– 685,701 | Recommendation Table 22 — Recommendations for AF ablation during cardiac surgery (see also Evidence Table 22) |
| p.48 | I | C | © ESC 2024 Intraprocedural imaging for detection of left atrial thrombus in patients undergoing surgical ablation is recommended to guide surgical strategy, independent of oral anticoagulant use, to prevent peri-procedural ischaemic stroke and thromboembolism. | Recommendation Table 22 — Recommendations for AF ablation during cardiac surgery (see also Evidence Table 22) |
| p.48 | IIa | B | Concomitant surgical ablation should be considered in patients undergoing non-mitral valve cardiac surgery and AF suitable for a rhythm control strategy to prevent symptoms and recurrence of AF, with shared decision-making supported by an experienced team of electrophysiologists and arrhythmia surgeons.701,703–707 AF, atrial fibrillation. aClass of recommendation. bLevel of evidence. | Recommendation Table 22 — Recommendations for AF ablation during cardiac surgery (see also Evidence Table 22) |
| p.51 | IIa | B | Evaluating quality of care and identifying opportunities for improved treatment of AF should be considered by practitioners and institutions to improve patient experiences.49–55 AF, atrial fibrillation. aClass of recommendation. bLevel of evidence. | Recommendation Table 23 — Recommendations to improve patient experience (see also Evidence Table 23) |
| p.53 | I | A | indication for concomitant antiplatelet therapy For combinations with antiplatelet therapy, a DOAC is recommended in eligible patients in preference to a VKA to mitigate bleeding risk and prevent thromboembolism.764,766 | Recommendation Table 24 — Recommendations for patients with acute coronary syndromes or undergoing percutaneous intervention (see also Evidence Table 24) |
| p.53 | IIa | B | Rivaroxaban 15 mg once daily should be considered in preference to rivaroxaban 20 mg once daily when combined with antiplatelet therapy in patients where concerns about bleeding risk prevail over concerns about stent thrombosis or ischaemic stroke.765 | Recommendation Table 24 — Recommendations for patients with acute coronary syndromes or undergoing percutaneous intervention (see also Evidence Table 24) |
| p.53 | IIa | B | Dabigatran 110 mg twice daily should be considered in preference to dabigatran 150 mg twice daily when combined with antiplatelet therapy in patients where concerns about bleeding risk prevail over concerns about stent thrombosis or ischaemic stroke.766 | Recommendation Table 24 — Recommendations for patients with acute coronary syndromes or undergoing percutaneous intervention (see also Evidence Table 24) |
| p.53 | IIa | C | Carefully regulated VKA dosing with a target INR of 2.0–2.5 and TTR >70% should be considered when combined with antiplatelet therapy in AF patients to mitigate bleeding risk. Recommendations for AF patients with ACS | Recommendation Table 24 — Recommendations for patients with acute coronary syndromes or undergoing percutaneous intervention (see also Evidence Table 24) |
| p.53 | I | A | Early cessation (≤1 week) of aspirin and continuation of an oral anticoagulant (preferably DOAC) with a P2Y12 inhibitor (preferably clopidogrel) for up to 12 months is recommended in AF patients with ACS undergoing an uncomplicated PCI to avoid major bleeding, if the risk of thrombosis is low or bleeding risk is high.764–767 | Recommendation Table 24 — Recommendations for patients with acute coronary syndromes or undergoing percutaneous intervention (see also Evidence Table 24) |
| p.53 | IIa | C | Triple therapy with aspirin, clopidogrel, and oral anticoagulation for longer than 1 week after an ACS should be considered in patients with AF when ischaemic risk outweighs the bleeding risk, with the total duration (≤1 month) decided according to assessment of these risks and clear documentation of the discharge treatment plan.776 | Recommendation Table 24 — Recommendations for patients with acute coronary syndromes or undergoing percutaneous intervention (see also Evidence Table 24) |
| p.53 | I | A | After uncomplicated PCI, early cessation (≤1 week) of aspirin and continuation of an oral anticoagulant and a P2Y12 inhibitor (preferably clopidogrel) for up to 6 months is recommended to avoid major bleeding, if ischaemic risk is low.763–766,776,780 | |
| p.53 | IIa | B | Triple therapy with aspirin, clopidogrel, and an oral anticoagulant for longer than 1 week should be considered after PCI when the risk of stent thrombosis outweighs the bleeding risk, with the total duration (≤1 month) decided according to assessment of these risks and clear documentation.776 | |
| p.53 | III | B | anticoagulation, due to lack of efficacy and to avoid major bleeding.353,781,782 | Recommendation Table 24 — Recommendations for patients with acute coronary syndromes or undergoing percutaneous intervention (see also Evidence Table 24) |
| p.55 | IIa | C | Long-term oral anticoagulation should be considered in suitable patients with trigger-induced AF at elevated thromboembolic risk to prevent ischaemic stroke and systemic thromboembolism.13,800,806,807,815 AF, atrial fibrillation. aClass of recommendation. bLevel of evidence. | Recommendation Table 25 — Recommendations for trigger-induced AF (see also Evidence Table 25) |
| p.55 | I | A | Peri-operative amiodarone therapy is recommended where drug therapy is desired to prevent post-operative AF after cardiac surgery.838,839,850,851 | Recommendation Table 26 — Recommendations for management of post-operative AF (see also Evidence Table 26) |
| p.55 | IIa | B | Concomitant posterior peri-cardiotomy should be considered in patients undergoing cardiac surgery to prevent post-operative AF.845,846 | Recommendation Table 26 — Recommendations for management of post-operative AF (see also Evidence Table 26) |
| p.55 | IIa | B | Long-term oral anticoagulation should be considered in patients with post-operative AF after cardiac and non-cardiac surgery at elevated thromboembolic risk, to prevent ischaemic stroke and thromboembolism.811,852–854 | Recommendation Table 26 — Recommendations for management of post-operative AF (see also Evidence Table 26) |
| p.55 | III | B | Routine use of beta-blockers is not recommended in patients undergoing non-cardiac surgery for the prevention of post-operative AF.836,855 AF, atrial fibrillation. aClass of recommendation. bLevel of evidence. | Recommendation Table 26 — Recommendations for management of post-operative AF (see also Evidence Table 26) |
| p.56 | I | B | Prolonged monitoring for AF is recommended in patients with ESUS to inform on AF treatment decisions.861–863 | Recommendation Table 27 — Recommendations for patients with embolic stroke of unknown source (see also Evidence Table 27) |
| p.56 | III | A | Initiation of oral anticoagulation in ESUS patients without documented AF is not recommended due to lack of efficacy in preventing ischaemic stroke and thromboembolism.875,876 AF, atrial fibrillation; ESUS, embolic stroke of undetermined source. aClass of recommendation. bLevel of evidence. | Recommendation Table 27 — Recommendations for patients with embolic stroke of unknown source (see also Evidence Table 27) |
| p.56 | I | C | © ESC 2024 Immediate electrical cardioversion is recommended in patients with AF during pregnancy and haemodynamic instability or pre-excited AF to improve maternal and foetal outcomes.885,891–893 | Recommendation Table 28 — Recommendations for patients with AF during pregnancy (see also Evidence Table 28) |
| p.56 | I | C | Therapeutic anticoagulation with LMWHs or VKAs (except VKAs for the first trimester or beyond Week 36) is recommended for pregnant patients with AF at elevated thromboembolic risk to prevent ischaemic stroke and thromboembolism.885 | Recommendation Table 28 — Recommendations for patients with AF during pregnancy (see also Evidence Table 28) |
| p.56 | I | C | Beta-1 selective blockers are recommended for heart rate control of AF in pregnancy to reduce symptoms and improve maternal and foetal outcomes, excluding atenolol.888 | Recommendation Table 28 — Recommendations for patients with AF during pregnancy (see also Evidence Table 28) |
| p.56 | IIa | C | Electrical cardioversion should be considered for persistent AF in pregnant women with HCM to improve maternal and foetal outcomes.885,894 | Recommendation Table 28 — Recommendations for patients with AF during pregnancy (see also Evidence Table 28) |
| p.56 | IIa | C | Digoxin should be considered for heart rate control of AF in pregnancy, if beta-blockers are ineffective or not tolerated, to reduce symptoms and improve maternal and foetal outcomes.885 | Recommendation Table 28 — Recommendations for patients with AF during pregnancy (see also Evidence Table 28) |
| p.56 | IIb | C | Intravenous ibutilide or flecainide may be considered for termination of AF in stable pregnant patients with a structurally normal heart to improve maternal and foetal outcomes.895,896 | Recommendation Table 28 — Recommendations for patients with AF during pregnancy (see also Evidence Table 28) |
| p.56 | IIb | C | Flecainide or propafenone may be considered for longer-term rhythm control in pregnancy, if rate controlling drugs are ineffective or not tolerated, to reduce symptoms and improve maternal and foetal outcomes.885 | Recommendation Table 28 — Recommendations for patients with AF during pregnancy (see also Evidence Table 28) |
| p.57 | IIa | C | Oral anticoagulation should be considered in all adult congenital heart disease patients with AF/AFL and intracardiac repair, cyanosis, Fontan palliation, or systemic right ventricle to prevent ischaemic stroke and thromboembolism, regardless of other thromboembolic risk factors.897 AF, atrial fibrillation; AFL, atrial flutter. aClass of recommendation. bLevel of evidence. | Recommendation Table 29 — Recommendations for patients with AF and congenital heart disease (see also Evidence Table 29) |
| p.58 | I | B | Oral anticoagulation is recommended in patients with atrial flutter at elevated thromboembolic risk to prevent ischaemic stroke and thromboembolism.86,1032 AF, atrial fibrillation; AFL, atrial flutter. aClass of recommendation. bLevel of evidence. | Recommendation Table 30 — Recommendations for prevention of thromboembolism in atrial flutter (see also Evidence Table 30) |
| p.61 | I | B | Review of an ECG (12-lead, single, or multiple leads) by a physician is recommended to provide a definite diagnosis of AF and commence appropriate management.1091,1121–1123,1125 | Recommendation Table 31 — Recommendations for screening for AF (see also Evidence Table 31) |
| p.61 | I | C | Routine heart rhythm assessment during healthcare contact is recommended in all individuals aged ≥65 years for earlier detection of AF. | Recommendation Table 31 — Recommendations for screening for AF (see also Evidence Table 31) |
| p.61 | IIa | B | Population-based screening for AF using a prolonged non-invasive ECG-based approach should be considered in individuals aged ≥75 years, or ≥65 years with additional CHA2DS2-VA risk factors to ensure earlier detection of AF.6,1135–1137 | Recommendation Table 31 — Recommendations for screening for AF (see also Evidence Table 31) |
| p.63 | I | B | Appropriate medical HF therapy is recommended in individuals with HFrEF to prevent AF.133,136,1208–1211 | Recommendation Table 32 — Recommendations for primary prevention of AF (see also Evidence Table 32) |
| p.63 | IIa | B | Weight reduction should be considered in obese individuals to prevent AF.1212,1227–1231 | Recommendation Table 32 — Recommendations for primary prevention of AF (see also Evidence Table 32) |
| p.63 | I | B | Maintaining optimal blood pressure is recommended in the general population to prevent AF, with ACE inhibitors or ARBs as first-line therapy.1205–1207 | Recommendation Table 32 — Recommendations for primary prevention of AF (see also Evidence Table 32) |
| p.63 | I | B | Maintaining normal weight (BMI 20–25 kg/m2) is recommended for the general population to prevent AF.208,1212,1213 | Recommendation Table 32 — Recommendations for primary prevention of AF (see also Evidence Table 32) |
| p.63 | I | B | Maintaining an active lifestyle is recommended to prevent AF, with the equivalent of 150–300 min per week of moderate intensity or 75–150 min per week of vigorous intensity aerobic physical activity.1214–1219 | Recommendation Table 32 — Recommendations for primary prevention of AF (see also Evidence Table 32) |
| p.63 | I | B | Avoidance of binge drinking and alcohol excess is recommended in the general population to prevent AF.1220–1223 | Recommendation Table 32 — Recommendations for primary prevention of AF (see also Evidence Table 32) |
| p.63 | IIa | B | Metformin or SGLT2 inhibitors should be considered for individuals needing pharmacological management of diabetes mellitus to prevent AF.1210,1211,1224–1226 | Recommendation Table 32 — Recommendations for primary prevention of AF (see also Evidence Table 32) |
| p.66 | I | A | commence risk stratification and treatment. | Table 17 lists all Class I and Class III recommendations from the text alongside their level of evidence. |
| p.66 | I | B | decision-making and guide treatment choices. | Table 17 lists all Class I and Class III recommendations from the text alongside their level of evidence. |
| p.66 | I | C | A transthoracic echocardiogram is recommended in patients with an AF diagnosis where this will guide treatment decisions. | Table 17 lists all Class I and Class III recommendations from the text alongside their level of evidence. |
| p.66 | I | C | decision-making, facilitating open discussion of both the benefit and risk associated with each treatment option. | Table 17 lists all Class I and Class III recommendations from the text alongside their level of evidence. |
| p.66 | I | C | ethnicity, and socioeconomic status, to ensure equality in healthcare provision and improve outcomes. | Table 17 lists all Class I and Class III recommendations from the text alongside their level of evidence. |
| p.66 | I | B | Identification and management of risk factors and comorbidities is recommended as an integral part of AF care. | Table 17 lists all Class I and Class III recommendations from the text alongside their level of evidence. |
| p.66 | I | B | prevent adverse cardiovascular events. | Table 17 lists all Class I and Class III recommendations from the text alongside their level of evidence. |
| p.66 | I | C | Diuretics are recommended in patients with AF, HF, and congestion to alleviate symptoms and facilitate better AF management. | Table 17 lists all Class I and Class III recommendations from the text alongside their level of evidence. |
| p.66 | I | B | Appropriate medical therapy for HF is recommended in AF patients with HF and impaired LVEF to reduce symptoms and/or HF hospitalization and prevent AF recurrence. | Table 17 lists all Class I and Class III recommendations from the text alongside their level of evidence. |
| p.66 | I | A | Sodium-glucose cotransporter-2 inhibitors are recommended for patients with HF and AF regardless of left ventricular ejection fraction to reduce the risk of HF hospitalization and cardiovascular death. | Table 17 lists all Class I and Class III recommendations from the text alongside their level of evidence. |
| p.66 | I | C | Effective glycaemic control is recommended as part of comprehensive risk factor management in individuals with diabetes mellitus and AF, to reduce burden, recurrence, and progression of AF. | Table 17 lists all Class I and Class III recommendations from the text alongside their level of evidence. |
| p.66 | I | B | 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% or more reduction in body weight. | Table 17 lists all Class I and Class III recommendations from the text alongside their level of evidence. |
| p.66 | I | B | A tailored exercise programme is recommended in individuals with paroxysmal or persistent AF to improve cardiorespiratory fitness and reduce AF recurrence. | Table 17 lists all Class I and Class III recommendations from the text alongside their level of evidence. |
| p.66 | I | B | 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. | Table 17 lists all Class I and Class III recommendations from the text alongside their level of evidence. |
| p.66 | III | B | When screening for obstructive sleep apnoea in individuals with AF, using only symptom-based questionnaires is not recommended. | Table 17 lists all Class I and Class III recommendations from the text alongside their level of evidence. |
| p.66 | I | A | thromboembolism. | Table 17 lists all Class I and Class III recommendations from the text alongside their level of evidence. |
| p.66 | I | C | anticoagulation. | Table 17 lists all Class I and Class III recommendations from the text alongside their level of evidence. |
| p.66 | I | B | CHA2DS2-VA score, to prevent ischaemic stroke and thromboembolism. | Table 17 lists all Class I and Class III recommendations from the text alongside their level of evidence. |
| p.66 | I | B | started in appropriate patients. | Table 17 lists all Class I and Class III recommendations from the text alongside their level of evidence. |
| p.66 | III | A | thromboembolism. | Table 17 lists all Class I and Class III recommendations from the text alongside their level of evidence. |
| p.66 | III | B | anticoagulation. | Table 17 lists all Class I and Class III recommendations from the text alongside their level of evidence. |
| p.67 | I | A | Direct oral anticoagulants are recommended in preference to VKAs to prevent ischaemic stroke and thromboembolism, except in patients with mechanical heart valves or moderate-to-severe mitral stenosis. | |
| p.67 | I | B | A target INR of 2.0–3.0 is recommended for patients with AF prescribed a VKA for stroke prevention to ensure safety and effectiveness. | |
| p.67 | I | B | (TTR <70%) to prevent thromboembolism and intracranial haemorrhage. | |
| p.67 | III | B | avoidable thromboembolic events. | |
| p.67 | III | B | thromboembolism. | |
| p.67 | III | B | Adding antiplatelet treatment to anticoagulation is not recommended in patients with AF to prevent recurrent embolic stroke. | |
| p.67 | III | B | Switching from one DOAC to another, or from a DOAC to a VKA, without a clear indication is not recommended in patients with AF to prevent recurrent embolic stroke. | |
| p.67 | I | B | Surgical closure of the left atrial appendage is recommended as an adjunct to oral anticoagulation in patients with AF undergoing cardiac surgery to prevent ischaemic stroke and thromboembolism. | |
| p.67 | I | B | shared decision-making to ensure safety and prevent bleeding. | |
| p.67 | III | B | under-use of anticoagulation. | |
| p.67 | I | C | the cause of bleeding is identified and resolved. | |
| p.67 | I | B | a sole treatment strategy to control heart rate and reduce symptoms. | |
| p.67 | I | B | rate and reduce symptoms. | |
| p.67 | I | B | Beta-blockers and/or digoxin are recommended in patients with AF and LVEF ≤40% to control heart rate and reduce symptoms. | |
| p.67 | I | C | Electrical cardioversion is recommended in AF patients with acute or worsening haemodynamic instability to improve immediate patient outcomes. | |
| p.67 | I | B | Therapeutic oral anticoagulation for at least 3 weeks (adherence to DOACs or INR ≥2.0 for VKAs) is recommended before scheduled cardioversion of AF and atrial flutter to prevent procedure-related thromboembolism. | |
| p.67 | I | B | Transoesophageal echocardiography is recommended if 3 weeks of therapeutic oral anticoagulation has not been provided, for exclusion of cardiac thrombus to enable early cardioversion. | |
| p.67 | I | B | Oral anticoagulation is recommended to continue for at least 4 weeks in all patients after cardioversion and long-term in patients with thromboembolic risk factor(s) irrespective of whether sinus rhythm is achieved, to prevent thromboembolism. | |
| p.67 | III | C | Early cardioversion is not recommended without appropriate anticoagulation or transoesophageal echocardiography if AF duration is longer than 24 h, or there is scope to wait for spontaneous cardioversion. | |
| p.67 | I | A | Intravenous flecainide or propafenone is recommended when pharmacological cardioversion of recent-onset AF is desired, excluding patients with severe left ventricular hypertrophy, HFrEF, or coronary artery disease. | |
| p.67 | I | A | Intravenous vernakalant is recommended when pharmacological cardioversion of recent-onset AF is desired, excluding patients with recent ACS, HFrEF, or severe aortic stenosis. | |
| p.67 | I | A | Intravenous amiodarone is recommended when cardioversion of AF in patients with severe left ventricular hypertrophy, HFrEF, or coronary artery disease is desired, accepting there may be a delay in cardioversion. | |
| p.67 | III | C | Pharmacological cardioversion is not recommended for patients with sinus node dysfunction, atrioventricular conduction disturbances, or prolonged QTc (>500 ms), unless risks for proarrhythmia and bradycardia have been considered. | |
| p.68 | I | A | Amiodarone is recommended in patients with AF and HFrEF requiring long-term antiarrhythmic drug therapy to prevent recurrence and progression of AF, with careful consideration and monitoring for extracardiac toxicity. | |
| p.68 | I | A | Dronedarone is recommended in patients with AF requiring long-term rhythm control, including those with HFmrEF, HFpEF, ischaemic heart disease, or valvular disease to prevent recurrence and progression of AF. | |
| p.68 | I | A | Flecainide or propafenone is recommended in patients with AF requiring long-term rhythm control to prevent recurrence and progression of AF, excluding those with impaired left ventricular systolic function, severe left ventricular hypertrophy, or coronary artery disease. | |
| p.68 | III | C | Antiarrhythmic drug therapy is not recommended in patients with advanced conduction disturbances unless antibradycardia pacing is provided. | |
| p.68 | I | C | risk factors for AF recurrence. | |
| p.68 | I | A | reduce symptoms, recurrence, and progression of AF. | |
| p.68 | I | A | paroxysmal AF, to reduce symptoms, recurrence, and progression of AF. | |
| p.68 | I | B | Atrial fibrillation catheter ablation is recommended in patients with AF and HFrEF with high probability of tachycardia-induced cardiomyopathy to reverse left ventricular dysfunction. | |
| p.68 | I | C | Initiation of oral anticoagulation is recommended at least 3 weeks prior to catheter-based ablation in AF patients at elevated thromboembolic risk, to prevent peri-procedural ischaemic stroke and thromboembolism. | |
| p.68 | I | A | Uninterrupted oral anticoagulation is recommended in patients undergoing AF catheter ablation to prevent peri-procedural ischaemic stroke and thromboembolism. | |
| p.68 | I | C | Continuation of oral anticoagulation is recommended for at least 2 months after AF ablation in all patients, irrespective of rhythm outcome or CHA2DS2-VA score, to reduce the risk of peri-procedural ischaemic stroke and thromboembolism. | |
| p.68 | I | C | Continuation of oral anticoagulation is recommended after AF ablation according to the patient’s CHA2DS2-VA score, and not the perceived success of the ablation procedure, to prevent ischaemic stroke and thromboembolism. | |
| p.68 | I | C | or hybrid AF ablation, independent of rhythm outcome or LAA exclusion, to prevent ischaemic stroke and thromboembolism. | |
| p.68 | I | C | Intraprocedural imaging for detection of left atrial thrombus in patients undergoing surgical ablation is recommended to guide surgical strategy, independent of oral anticoagulant use, to prevent peri-procedural ischaemic stroke and thromboembolism. | |
| p.68 | I | A | and prevent thromboembolism. | |
| p.68 | I | A | clopidogrel) for up to 6 months is recommended to avoid major bleeding, if ischaemic risk is low. | |
| p.69 | III | B | Antiplatelet therapy beyond 12 months is not recommended in stable patients with chronic coronary or vascular disease treated with oral anticoagulation, due to lack of efficacy and to avoid major bleeding. | |
| p.69 | I | A | Peri-operative amiodarone therapy is recommended where drug therapy is desired to prevent post-operative AF after cardiac surgery. | |
| p.69 | III | B | Routine use of beta-blockers is not recommended in patients undergoing non-cardiac surgery for the prevention of post-operative AF. | |
| p.69 | I | B | Prolonged monitoring for AF is recommended in patients with ESUS to inform on AF treatment decisions. | |
| p.69 | III | A | ischaemic stroke and thromboembolism. | |
| p.69 | I | C | to improve maternal and foetal outcomes. | |
| p.69 | I | C | patients with AF at elevated thromboembolic risk to prevent ischaemic stroke and thromboembolism. | |
| p.69 | I | C | outcomes, excluding atenolol. | |
| p.69 | I | B | thromboembolism. | |
| p.69 | I | B | Review of an ECG (12-lead, single, or multiple leads) by a physician is recommended to provide a definite diagnosis of AF and commence appropriate management. | |
| p.69 | I | C | Routine heart rhythm assessment during healthcare contact is recommended in all individuals aged ≥65 years for earlier detection of AF. | |
| p.69 | I | B | Appropriate medical HF therapy is recommended in individuals with HFrEF to prevent AF. | |
| p.69 | I | B | Maintaining normal weight (BMI 20–25 kg/m2) is recommended for the general population to prevent AF. | |
| p.69 | I | B | Maintaining an active lifestyle is recommended to prevent AF, with the equivalent of 150–300 min per week of moderate intensity or 75– 150 min per week of vigorous intensity aerobic physical activity. | |
| p.69 | I | B | Avoidance of binge drinking and alcohol excess is recommended in the general population to prevent AF. |