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The experts of the writing and reviewing panels provided declaration of interest forms for all relationships that might be perceived as real or potential sources of conflicts of interest. Their declarations of interest were reviewed according to the ESC declaration of interest rules which can be found on the ESC website (http://www.escardio.org/guidelines) and have been compiled in a report published in a supplementary document with the guidelines. Funding for the development of ESC Guidelines is derived entirely from the ESC with no involvement of the healthcare industry. The ESC Clinical Practice Guidelines (CPG) Committee supervises and co-ordinates the preparation of new guidelines and is responsible for the approval process. In addition to review by the CPG Committee, ESC Guidelines undergo multiple rounds of double-blind peer review by external experts, including members from across the whole of the ESC region, all National Cardiac Societies of the ESC and from relevant ESC Subspecialty Communities. After appropriate revisions, the guidelines are signed off by all the experts in the task force. The finalized document is signed off by the CPG Committee for publication in the European Heart Journal. ESC Guidelines are based on analyses of published evidence, chiefly on clinical trials and meta-analyses of trials, but potentially including other types of studies. Evidence tables summarizing key information from relevant studies are generated early in the guideline development process to facilitate the formulation of recommendations, to enhance comprehension of recommendations after publication, and reinforce transparency in the guidelines development process. The tables are published in their own section of ESC Guidelines and reference specific recommendation tables. Off-label use of medication may be presented in this guideline if a sufficient level of evidence shows that it can be considered medically appropriate for a given condition. However, the final decisions concerning an individual patient must be made by the responsible health professional giving special consideration to: • The specific situation of the patient. Unless otherwise provided for by national regulations, off-label use of medication should be limited to situations where it is in the patient’s interest with regard to the quality, safety, and efficacy of care, and only after the patient has been informed and has provided consent. • Country-specific health regulations, indications by governmental drug regulatory agencies, and the ethical rules to which health professionals are subject, where applicable.

2 Introduction

Atrial fibrillation (AF) is one of the most commonly encountered heart conditions, with a broad impact on all health services across primary and secondary care. The prevalence of AF is expected to double in the next few decades as a consequence of the ageing population, an increasing burden of comorbidities, improved awareness, and new technologies for detection. The effects of AF are variable across individual patients; however, morbidity from AF remains highly concerning. Patients with AF can suffer from a variety of symptoms and poor quality of life. Stroke and heart failure as consequences of AF are now well appreciated by healthcare professionals, but AF is also linked to a range of other thromboembolic outcomes. These include subclinical cerebral damage (potentially leading to vascular dementia), and thromboembolism to every other organ, all of which contribute to the higher risk of mortality associated with AF. The typical drivers of AF onset and progression are a range of comorbidities and associated risk factors. To achieve optimal care for patients with AF, it is now widely accepted that these comorbidities and risk factors must be managed early and in a dynamic way. Failure to do so contributes to recurrent cycles of AF, treatment failure, poor patient outcomes, and a waste of healthcare resources. In this iteration of the European Society of Cardiology (ESC) practice guidelines on AF, the task force has consolidated and evolved past approaches to develop the AF-CARE framework (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). Comorbidities and risk factors is placed as the initial and central component of patient management. This should be considered first as it applies to all patients with AF, regardless of their thromboembolic risk factors or any symptoms that might warrant intervention. This is followed by considering how best to [A] avoid stroke and thromboembolism, and then the options available to reduce symptoms, and in some cases improve prognosis, through [R] rate and rhythm control. [E] Evaluation and reassessment should be individualized for every patient, with a dynamic approach that accounts for how AF and its associated conditions change over time.

Patient empowerment is critical in any long-term medical problem to achieve better outcomes, encourage adherence, and to seek timely guidance on changes in clinical status. A patient-centred, shared decision-making approach will facilitate the choice of management that suits each individual patient, particularly in AF where some therapies and interventions improve clinical outcomes, and others are focused on addressing symptoms and quality of life. Education and awareness are essential, not only for patients but also healthcare professionals in order to constrain the impact of AF on patients and healthcare services. With this in mind, the task force have created a range of patient pathways that cover the major aspects of AF-CARE. At present, these remain based on the time-orientated classification of AF (first-diagnosed, paroxysmal, persistent, and permanent), but ongoing research may allow for pathology-based classifications and a future of personalized medicine. Clinical practice guidelines can only cover common scenarios with an evidence base, and so there remains a need for healthcare professionals to care for patients within a local multidisciplinary team. While guidelineadherent care has repeatedly been shown to improve patient outcomes, the actual implementation of guidelines is often poor in many healthcare settings. This has been demonstrated in the ESC’s first randomized controlled trial (RCT), STEEER-AF (Stroke prevention and rhythm control Therapy: Evaluation of an Educational programme of the European Society of Cardiology in a cluster-Randomised trial in patients with Atrial Fibrillation), which has sought to improve guideline adherence in parallel to guideline production. The task force developing the 2024 AF Guidelines have made implementation a key goal by focusing on the underpinning evidence and using a consistent writing style for each recommendation (the intervention proposed, the population it should be applied to, and the potential value to the patient, followed by any exceptions). Tables 3 and 4 below outline new recommendations and those with important revisions. These initiatives have been designed to make the 2024 ESC Guidelines for the management of AF easier to read, follow, and implement, with the aim of improving the lives of patients with AF. A patient version of these guidelines is also available at http://www.escardio.org/Guidelines/ guidelines-for-patients.

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