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• Insights into psychosocial and environmental factors and risk of AF and adverse outcomes in AF are understudied.

Patient-centred, multidisciplinary AF management • The benefit of additional education directed to patients, to family members, and to healthcare professionals in order to optimize shared decision-making still needs to be proved. • Access to patient-centred management according to the AF-CARE principles to ensure equality in healthcare provision and improve outcomes warrants evidence. • The place of remote monitoring and telemedicine for identification and follow-up of patients with AF, or its subgroups is non-established, though widely applied.

[C] Comorbidity and risk factor management • Methods to achieve consistent and reproducible weight loss in patients with AF requires substantial improvement. Despite some evidence demonstrating the benefits of weight loss, widespread adoption has been limited by the need for reproducible strategies. • The importance of sleep apnoea syndrome and its treatment on AF-related outcomes remains to be elucidated.

[A] Avoid stroke and thromboembolism • Data are lacking on how to treat patients with low risk of stroke (with a CHA2DS2-VA score of 0 or 1), as these patients were excluded from large RCTs. • Not enough evidence is available for OAC in elderly patients, frail polypharmacy patients, those with cognitive impairment/dementia, recent bleeding, previous ICH, severe end-stage renal failure, liver impairment, cancer, or severe obesity. • In elderly patients, routinely switching VKAs to DOACs is associated with increased bleeding risk; however, the reasons why this happens are unclear. • The selection of which patients with asymptomatic device-detected subclinical AF benefit from OAC therapy needs to be defined. • There is a lack of evidence whether and when to (re)start anticoagulation after intracranial haemorrhage. • There is lack of evidence about optimal anticoagulation in patients with ischaemic stroke or left atrial thrombus while being treated with OAC. • There is uncertainty about the place of LAA closure and how to manage antithrombotic post-procedural management when LAAO is performed. • Balance of thromboembolism and bleeding is unclear in patients with AF and incidental cerebral artery aneurysms identified on brain MRI.

[R] Reduce symptoms by rate and rhythm control • In some patients, AF can be benign in terms of symptoms and outcomes. In which patients rhythm control is not needed warrants investigation. • Application of antiarrhythmic drugs has been hampered by poor effectiveness and side effects; however, new antiarrhythmic drugs are needed to increase the therapeutic arsenal for AF patients. • The amount of AF reduction obtained by rhythm control to improve outcomes is unknown. • Large catheter ablation studies showed no improved outcome of patients with AF. Some small studies in specific subpopulations have observed an improved outcome. This warrants further investigation to provide each patient with AF with personalized treatment goals. • Uncertainty exists on the time of duration of AF and risk of stroke when performing a cardioversion. • The value of diagnostic cardioversion for persistent AF in steering management of AF is unknown. • Decisions on continuation of OAC are completely based on stroke risk scores and irrespective of having (episodes) of AF; whether this holds for patients undergoing successful catheter ablation is uncertain. • Large variability in ablation strategies and techniques exist for patients with persistent AF, or after first failed catheter ablation for paroxysmal AF. The optimal catheter ablation strategy and techniques, however, are unknown. • Sham-controlled intervention studies are lacking to determine the effects on AF symptoms, quality of life, and PROMS, accounting for the placebo effect that is associated with interventions.

The AF-CARE pathway in specific clinical settings

• The optimal duration of triple therapy in patients with AF at high risk of recurrent coronary events after acute coronary syndrome is unclear. • The role of the coronary vessel involved and whether this should impact on the duration of combined OAC and antiplatelet treatment needs further study. • The role of antiplatelet therapy in patients with AF and peripheral artery disease on OAC is uncertain. • The use of DOACs in patients with congenital heart disease, particularly in patients with complex corrected congenital defects, is poorly studied. • Improved risk stratification for stroke in patients with AF and cancer, or with post-operative or trigger-induced AF is needed to inform on OAC treatment decisions.

Screening and prevention of AF

• There are a lack of adequately powered randomized controlled studies on ischaemic stroke rate in patients screened for AF, both in the primary prevention setting and in secondary prevention (poststroke), and its cost-effectiveness. • Population selection that might benefit the most from screening, the optimal duration of screening, and the burden of AF that might increase the risk for patients with screening-detected AF are uncertain. • Evaluation of strategies to support longer-term use of technologies for AF detection are awaited. • The role of photoplethysmography technology for AF screening in an effort to assess AF burden and reduce stroke is still unclear. • How new consumer devices and wearable technology can be used for diagnostic and monitoring purposes in routine clinical practice needs to be clarified. Downloaded from academic.oup.com/eurheartj/article/45/36/3314/7738779 by guest on 07 October 2026