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C Comorbidity and risk factor management

Hypertension

Diabetes mellitus

Blood pressure lowering treatment

(Class I) Patient-centred AF management with a multidisciplinary approach (Class IIa)

Education for patients, families and healthcare professionals (Class I)

Equality in healthcare provision (gender, ethnicity, socioeconomic) (Class I)

Heart failure Diuretics for congestion (Class I) Overweight

or obese Weight loss (target 10%)a

(Class I) Obstructive sleep

apnoea Management

of OSAa (Class IIb)

Appropriate HFrEF

medical therapy

(Class I) Bariatric surgery if rhythm controla

(Class IIb)

SGLT2 inhibitors

(Class 1) Alcohol

Reduce to •3 drinks per week

(Class I)

Effective glycaemic controla

(Class I) Exercise capacity

Tailored exercise programme

(Class I) Other risk factors/

comorbidities Identify and manage

aggressivelya

(Class I)

A Avoid stroke and thromboembolism

Risk of thromboembolism

Start oral anticoagulation

(Class I) Use locally-validated

risk score or CHA2DS2-VA

OAC if CHA2DS2-VA score = 2 or more

(Class I) Choice of anticoagulant Assess bleeding risk

OAC if CHA2DS2-VA

score = 1 (Class IIa) Use DOAC, except mechanical valve or

mitral stenosis

(Class I)

Target INR 2.0–3.0; (Class I) >70% INR range; (Class IIa) or switch to DOAC

(Class I) Assess and manage

all modifiable risk factors for bleeding

(Class I)

Do not use risk scores to withhold

anticoagulation

(Class III) Do not combine antiplatelets and OAC

for stroke prevention

(Class III)

Avoid antiplatelets beyond 12 months in OAC treated

CCS/PVD (Class III)

Temporal pattern of AF not relevant

(Class III) Antiplatelet therapy not an alternative

(Class III) Prevent bleeding

R Reduce symptoms by rate and rhythm control

E Evaluation and dynamic reassessment

See patient pathways for:

First-diagnosed AF Paroxysmal AF Persistent AF Permanent AF

Consider:

AF

C A R E

If  VKA:

Rate control drugs Ablate and pace Cardioversion Catheter ablation Endoscopic/hybrid ablation Surgical ablation Antiarrhythmic drugs

Re-evaluate when AF episodes or non-AF admissions

ECG, blood tests, cardiac imaging, ambulatory ECG,

other imaging

as needed Assess new and existing risk factors

and comorbidities

(Class I) Stratify risk for stroke and thromboembolism

(Class I) Check impact of AF

symptoms before and after treatment

(Class I) Assess and manage modifiable bleeding

risk factors (Class I) Continue OAC despite rhythm

control if risk of thromboembolism

(Class I)

Regular re-evaluation: 6 months after presentation, and then at least annually or based on clinical need

Figure 3 Central illustration. Patient pathway for AF-CARE (see Figures 4, 5, 6, and 7 for the [R] pathways for first-diagnosed, paroxysmal, persistent and permanent AF). AF, atrial fibrillation; AF-CARE, atrial fibrillation—[C] Comorbidity and risk factor management, [A] Avoid stroke and thromboembolism, [R] Reduce symptoms by rate and rhythm control, [E] Evaluation and dynamic reassessment; CCS, chronic coronary syndrome; CHA2DS2-VA, congestive heart failure, hypertension, age ≥75 years (2 points), diabetes mellitus, prior stroke/transient ischaemic attack/arterial thromboembolism (2 points), vascular disease, age 65–74 years; DOAC, direct oral anticoagulant; ECG, electrocardiogram; HFrEF, heart failure with reduced ejection fraction; INR, international normalized ratio of prothrombin time; OAC, oral anticoagulant; OSA, obstructive sleep apnoea; PVD, peripheral vascular disease; SGLT2, sodium-glucose cotransporter-2; VKA, vitamin K antagonist. aAs part of a comprehensive management of cardiometabolic risk factors.

ESC Guidelines                                                                                                                                                                                          3333

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