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10.5.7 Alcohol intake The premise that reducing alcohol intake can prevent AF is based on observational studies linking alcohol to an excess risk of incident AF in a dose-dependent manner (see Supplementary data online).1220–1222 In addition, a population cohort study of those with high alcohol consumption (>60 g/day for men and >40 g/day for women) found that abstinence from alcohol was associated with a lower incidence of AF compared with patients who continued heavy drinking.1223 11 Key messages (1) General management: optimal treatment according to the AF-CARE pathway, which includes: [C] Comorbidity and risk factor management; [A] Avoid stroke and thromboembolism; [R] Reduce symptoms by rate and rhythm control; and [E] Evaluation and dynamic reassessment. (2) Shared care: patient-centred AF management with joint decisionmaking and a multidisciplinary team. (3) Equal care: avoid health inequalities based on gender, ethnicity, disability, and socioeconomic factors. (4) Education: for patients, family members, caregivers, and healthcare professionals to aid shared decision-making. (5) Diagnosis: clinical AF requires confirmation on an ECG device to initiate risk stratification and AF management. (6) Initial evaluation: medical history, assessment of symptoms and their impact, blood tests, echocardiography/other imaging, patient-reported outcome measures, and risk factors for thromboembolism and bleeding. (7) Comorbidities and risk factors: thorough evaluation and management critical to all aspects of care for patients with AF to avoid recurrence and progression of AF, improve success of AF treatments, and prevent AF-related adverse outcomes. (8) Focus on conditions associated with AF: including hypertension, heart failure, diabetes mellitus, obesity, obstructive sleep apnoea, physical inactivity, and high alcohol intake. (9) Assessing the risk of thromboembolism: use locally validated risk tools or the CHA2DS2-VA score and assessment of other risk factors, with reassessment at periodic intervals to assist in decisions on anticoagulant prescription. (10) Oral anticoagulants: recommended for all eligible patients, except those at low risk of incident stroke or thromboembolism (CHA2DS2-VA = 1 anticoagulation should be considered; CHA2DS2-VA ≥2 anticoagulation recommended). (11) Choice of anticoagulant: DOACs (apixaban, dabigatran, edoxaban, and rivaroxaban) are preferred over VKAs (warfarin and others), except in patients with mechanical heart valves and mitral stenosis. (12) Dose/range of anticoagulant: use full standard doses for DOACs unless the patient meets specific dose-reduction criteria; for VKAs, keep INR generally 2.0–3.0, and in range for >70% of the time. (13) Switching anticoagulants: switch from a VKA to DOAC if risk of intracranial haemorrhage or poor control of INR levels. (14) Bleeding risk: modifiable bleeding risk factors should be managed to improve safety; bleeding risk scores should not be used to decide on starting or withdrawing anticoagulants. (15) Antiplatelet therapy: avoid combining anticoagulants and antipla- telet agents, unless the patient has an acute vascular event or needs interim treatment for procedures. (16) Rate control therapy: use beta-blockers (any ejection fraction), di- goxin (any ejection fraction), or diltiazem/verapamil (LVEF >40%) as initial therapy in the acute setting, an adjunct to rhythm control therapies, or as a sole treatment strategy to control heart rate and symptoms. (17) Rhythm control: consider in all suitable AF patients, explicitly discussing with patients all potential benefits and risks of cardioversion, antiarrhythmic drugs, and catheter or surgical ablation to reduce symptoms and morbidity. (18) Safety first: keep safety and anticoagulation in mind when considering rhythm control; e.g. delay cardioversion and provide at least 3 weeks of anticoagulation beforehand if AF duration >24 h, and consider toxicity and drug interactions for antiarrhythmic therapy. (19) Cardioversion: use electrical cardioversion in cases of haemodynamic instability; otherwise choose electrical or pharmacological cardioversion based on patient characteristics and preferences. (20) Indication for long-term rhythm control: the primary indication should be reduction in AF-related symptoms and improvement in quality of life; for selected patient groups, sinus rhythm maintenance can be pursued to reduce morbidity and mortality. (21) Success or failure of rhythm control: continue anticoagulation according to the patient’s individual risk of thromboembolism, irrespective of whether they are in AF or sinus rhythm. (22) Catheter ablation: consider as second-line option if antiarrhythmic drugs fail to control AF, or first-line option in patients with paroxysmal AF. (23) Endoscopic or hybrid ablation: consider if catheter ablation fails, or an alternative to catheter ablation in persistent AF despite antiarrhythmic drugs. (24) Atrial fibrillation ablation during cardiac surgery: perform in centres with experienced teams, especially for patients undergoing mitral valve surgery. (25) Dynamic evaluation: periodically reassess therapy and give atten- tion to new modifiable risk factors that could slow/reverse the progression of AF, increase quality of life, and prevent adverse outcomes. 12 Gaps in evidence The following bullet list gives the most important gaps in evidence where new clinical trials could substantially aid the patient pathway: Definition and clinical impact of AF • Paroxysmal AF is not one entity, and patterns of AF progression and regression are highly variable. It is uncertain what the relevance is for treatment strategies and management decisions. • Thirty seconds as definition for clinical AF needs validation and evaluation whether it is related to AF-related outcomes. • Definition, clinical features, diagnosis, and implementation for treatment choices of atrial cardiomyopathy in patients with AF is unsettled. • Diversity in AF presentation, underlying pathophysiological mechanisms, and associated comorbidities is incompletely understood with regard to differences in sex, gender, race/ethnicity, socioeconomic state, education, and differences between low-, moderate-, and highincome countries. • Personalized risk prediction for AF incidence, AF progression, and associated outcomes remains challenging. ESC Guidelines 3377 Downloaded from academic.oup.com/eurheartj/article/45/36/3314/7738779 by guest on 07 October 2026