University of Groningen 2020 ESC Guidelines for the diagnosis and ...

University of Groningen

2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS) Hindricks, Gerhard; Potpara, Tatjana; Dagres, Nikolaos; Arbelo, Elena; Bax, Jeroen J.; Blomstroem-Lundqvist, Carina; Boriani, Giuseppe; Castella, Manuel; Dan, Gheorghe-Andrei; Dilaveris, Polychronis E.

Published in: European Heart Journal

DOI: 10.1093/eurheartj/ehaa612

IMPORTANT NOTE: You are advised to consult the publisher's version (publisher's PDF) if you wish to cite from it. Please check the document version below. Document Version Publisher's PDF, also known as Version of record

Publication date: 2021

Link to publication in University of Groningen/UMCG research database

Citation for published version (APA): Hindricks, G., Potpara, T., Dagres, N., Arbelo, E., Bax, J. J., Blomstroem-Lundqvist, C., Boriani, G., Castella, M., Dan, G.-A., Dilaveris, P. E., Fauchier, L., Filippatos, G., Kalman, J. M., La Meir, M., Lane, D. A., Lebeau, J.-P., Lettino, M., Lip, G. Y. H., Pinto, F. J., ... Watkins, C. L. (2021). 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS). European Heart Journal, 42(5), 373-498.

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European Heart Journal (2020) 42, 373?498 doi:10.1093/eurheartj/ehaa612

ESC GUIDELINES

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2020 ESC Guidelines for the diagnosis and

management of atrial fibrillation developed in

collaboration with the European Association for

Cardio-Thoracic Surgery (EACTS)

The Task Force for the diagnosis and management of atrial fibrillation of the European Society of Cardiology (ESC)

Developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC

Authors/Task Force Members: Gerhard Hindricks* (Chairperson) (Germany), Tatjana Potpara* (Chairperson) (Serbia), Nikolaos Dagres (Germany), Elena Arbelo (Spain), Jeroen J. Bax (Netherlands), Carina Blomstro? m-Lundqvist (Sweden), Giuseppe Boriani (Italy), Manuel Castella1 (Spain), Gheorghe-Andrei Dan (Romania), Polychronis E. Dilaveris (Greece), Laurent Fauchier (France), Gerasimos Filippatos (Greece), Jonathan M. Kalman (Australia), Mark La Meir1 (Belgium), Deirdre A. Lane (United Kingdom), Jean-Pierre Lebeau (France),

* Corresponding authors: The two chairpersons contributed equally to the document. Gerhard Hindricks, University Clinic of Cardiology, Heart Center Leipzig, Department of Cardiology and Electrophysiology, Leipzig Heart Institute, Stru?mpellstr. 39, 04289 Leipzig, Germany. Tel: ?49 34 1865 1410, Fax: ?49 34 1865 1460, Email: gerhard.hindricks@helios-gesundheit.de Tatjana Potpara, School of Medicine, Belgrade University, dr Subotica 8, 11000 Belgrade, Serbia, and Cardiology Clinic, Clinical Centre of Serbia, Visegradska 26, 11000 Belgrade, Serbia. Tel: ?38 11 1361 6319, Email: tatjana.potpara@med.bg.ac.rs ESC Committee for Practice Guidelines (CPG) and National Cardiac Societies document reviewers, and Author/Task Force Member affiliations: listed in the Appendix. 1Representing the European Association for Cardio-Thoracic Surgery (EACTS) ESC entities having participated in the development of this document: Associations: Association for Acute CardioVascular Care (ACVC), Association of Cardiovascular Nursing & Allied Professions (ACNAP), European Association of Cardiovascular Imaging (EACVI), European Association of Preventive Cardiology (EAPC), European Association of Percutaneous Cardiovascular Interventions (EAPCI), European Heart Rhythm Association (EHRA), Heart Failure Association (HFA). Councils: Council on Stroke, Council on Valvular Heart Disease. Working Groups: Cardiac Cellular Electrophysiology, Cardiovascular Pharmacotherapy, Cardiovascular Surgery, e-Cardiology, Thrombosis. The content of these European Society of Cardiology (ESC) Guidelines has been published for personal and educational use only. No commercial use is authorized. No part of the ESC Guidelines may be translated or reproduced in any form without written permission from the ESC. Permission can be obtained upon submission of a written request to Oxford University Press, the publisher of the European Heart Journal and the party authorized to handle such permissions on behalf of the ESC (journals.permissions@). Disclaimer The ESC Guidelines represent the views of the ESC and were produced after careful consideration of the scientific and medical knowledge and the evidence available at the time of their publication. The ESC is not responsible in the event of any contradiction, discrepancy and/or ambiguity between the ESC Guidelines and any other official recommendations or guidelines issued by the relevant public health authorities, in particular in relation to good use of healthcare or therapeutic strategies. Health professionals are encouraged to take the ESC Guidelines fully into account when exercising their clinical judgment, as well as in the determination and the implementation of preventive, diagnostic or therapeutic medical strategies; however, the ESC Guidelines do not override, in any way whatsoever, the individual responsibility of health professionals to make appropriate and accurate decisions in consideration of each patient's health condition and in consultation with that patient and, where appropriate and/or necessary, the patient's caregiver. Nor do the ESC Guidelines exempt health professionals from taking into full and careful consideration the relevant official updated recommendations or guidelines issued by the competent public health authorities, in order to manage each patient's case in light of the scientifically accepted data pursuant to their respective ethical and professional obligations. It is also the health professional's responsibility to verify the applicable rules and regulations relating to drugs and medical devices at the time of prescription.

VC The European Society of Cardiology 2020. All rights reserved. For permissions please email: journals.permissions@.

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Maddalena Lettino (Italy), Gregory Y. H. Lip (United Kingdom), Fausto J. Pinto

(Portugal), G. Neil Thomas (United Kingdom), Marco Valgimigli (Switzerland), Isabelle C. Van Gelder (Netherlands), Bart P. Van Putte1 (Netherlands),

Caroline L. Watkins (United Kingdom)

Document Reviewers: Paulus Kirchhof (CPG Review Coordinator) (United Kingdom/Germany), Michael Ku? hne (CPG Review Coordinator) (Switzerland), Victor Aboyans (France), Anders Ahlsson1 (Sweden), Pawel Balsam (Poland), Johann Bauersachs (Germany), Stefano Benussi1 (Italy), Axel Brandes (Denmark), Frieder Braunschweig (Sweden), A. John Camm (United Kingdom), Davide Capodanno (Italy), Barbara Casadei (United Kingdom), David Conen (Canada), Harry J. G. M. Crijns (Netherlands), Victoria Delgado (Netherlands), Dobromir Dobrev (Germany), Heinz Drexel (Austria), Lars Eckardt (Germany), Donna Fitzsimons (United Kingdom), Thierry Folliguet (France), Chris P. Gale (United Kingdom), Bulent Gorenek (Turkey), Karl Georg Haeusler (Germany), Hein Heidbuchel (Belgium), Bernard Iung (France), Hugo A. Katus (Germany), Dipak Kotecha (United Kingdom), Ulf Landmesser (Germany), Christophe Leclercq (France), Basil S. Lewis (Israel), Julia Mascherbauer (Austria), Jose Luis Merino (Spain), Be? la Merkely (Hungary), Lluis Mont (Spain), Christian Mueller (Switzerland), Klaudia V. Nagy (Hungary), Jonas Oldgren (Sweden), Nikola Pavlovic (Croatia), Roberto F. E. Pedretti (Italy), Steffen E. Petersen (United Kingdom), Jonathan P. Piccini (United States of America), Bogdan A. Popescu (Romania), Helmut Pu? rerfellner (Austria), Dimitrios J. Richter (Greece), Marco Roffi (Switzerland), Andrea Rubboli (Italy), Daniel Scherr (Austria), Renate B. Schnabel (Germany), Iain A. Simpson (United Kingdom), Evgeny Shlyakhto (Russia), Moritz F. Sinner (Germany), Jan Steffel (Switzerland), Miguel Sousa-Uva (Portugal), Piotr Suwalski1 (Poland), Martin Svetlosak (Slovakia), Rhian M. Touyz (United Kingdom)

The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website guidelines

For the Supplementary Data which include background information and detailed discussion of the data that have provided the basis for the Guidelines see European Heart Journal online.

Click here to access the corresponding chapter in section 41- Atrial fibrillation

...................................................................................................................................................................................................

Keywords

Guidelines ? atrial fibrillation ? anticoagulation ? vitamin K antagonists ? non-vitamin K antagonist oral antico-

agulants ? left atrial appendage occlusion ? rate control ? rhythm control ? cardioversion ? antiarrhythmic

drugs ? catheter ablation ? pulmonary vein isolation ? left atrial ablation ? AF surgery ? upstream therapy

? ABC pathway ? screening ? stroke ? recommendations

Table of contents

1 Preamble . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 379 2 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 380

2.1 What is new in the 2020 Guidelines? . . . . . . . . . . . . . . . . . . . . . . . . . 381 3 Definition and diagnosis of atrial fibrillation . . . . . . . . . . . . . . . . . . . . . . . 385

3.1 Definition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 385 3.2 Diagnostic criteria for atrial fibrillation . . . . . . . . . . . . . . . . . . . . . . . 386 3.3 Diagnosis of atrial high-rate episodes/subclinical atrial fibrillation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 386 4 Epidemiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 386 4.1 Prediction of incident atrial fibrillation . . . . . . . . . . . . . . . . . . . . . . . . 388 4.2 Pathophysiology of atrial fibrillation . . . . . . . . . . . . . . . . . . . . . . . . . . 388 5 Clinical features of atrial fibrillation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 388 6 Atrial fibrillation subtypes, burden, and progression . . . . . . . . . . . . . . . 388 6.1 Classification of atrial fibrillation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 388

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6.2 Definition and assessment of atrial fibrillation burden . . . . . . . . . 391 6.3 Atrial fibrillation progression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 392 6.4 Atrial cardiomyopathy: definition, classification, clinical implications, and diagnostic assessment . . . . . . . . . . . . . . . . . . . . . . . . . . 392 7 Screening for atrial fibrillation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 392 7.1 Screening tools . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 392 7.2 Screening types and strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 394 7.3 Benefits from and risks of screening for atrial fibrillation . . . . . . . 394 7.4 Cost-effectiveness of screening for atrial fibrillation . . . . . . . . . . . 394 7.5 Screening in high-risk populations . . . . . . . . . . . . . . . . . . . . . . . . . . . 395

7.5.1 Elderly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 395 8 Diagnostic assessment in atrial fibrillation . . . . . . . . . . . . . . . . . . . . . . . . 395

8.1 Symptoms and quality of life . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 395 8.2 Substrate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 395 9 Integrated management of patients with atrial fibrillation . . . . . . . . . . 398

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9.1 Definitions and components of integrated management of atrial fibrillation patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 398 9.2 Multidisciplinary atrial fibrillation teams . . . . . . . . . . . . . . . . . . . . . . 398

9.2.1 Role of healthcare systems and budget constraints . . . . . . . 398 9.3 Patient involvement and shared decision making . . . . . . . . . . . . . . 398

9.3.1 Patient values and preferences . . . . . . . . . . . . . . . . . . . . . . . . . . 398 9.3.2 Patient education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 399 9.4 Healthcare professional education . . . . . . . . . . . . . . . . . . . . . . . . . . . 399 9.5 Adherence to treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 399 9.6 Technology tools supporting atrial fibrillation management . . . 399 9.7 Advantages of integrated management of atrial fibrillation patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 400 9.8 Measures (or approaches) for implementation of integrated management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 400 9.9 Treatment burden . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 400 9.10 Patient-reported outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 400 10 Patient management: the integrated ABC pathway . . . . . . . . . . . . . . 401 10.1 `A' ? Anticoagulation/Avoid stroke . . . . . . . . . . . . . . . . . . . . . . . . 401 10.1.1 Stroke risk assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 401 10.1.2 Bleeding risk assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 402 10.1.3 Absolute contraindications to oral anticoagulants . . . . . . . 404 10.1.4 Stroke prevention therapies . . . . . . . . . . . . . . . . . . . . . . . . . . . 404

10.1.4.1 Vitamin K antagonists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 404 10.1.4.2 Non-vitamin K antagonist oral anticoagulants . . . . . . . 405 10.1.4.3 Other antithrombotic drugs . . . . . . . . . . . . . . . . . . . . . . . 405 10.1.4.4 Combination therapy with oral anticoagulant and antiplatelet drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 406 10.1.4.5 Left atrial appendage occlusion and exclusion . . . . . . . 406

10.1.4.5.1 Left atrial appendage occlusion devices . . . . . . . . . 406 10.1.4.5.2 Surgical left atrial appendage occlusion or exclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 406 10.1.4.6 Long-term oral anticoagulation per atrial fibrillation burden . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 407 10.1.4.7 Long-term oral anticoagulation per symptom control strategy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 407 10.1.5 Management of anticoagulation-related bleeding risk . . . . 407 10.1.5.1 Strategies to minimize the risk of bleeding . . . . . . . . . . 407 10.1.5.2 High-risk groups . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 407 10.1.6 Decision-making to avoid stroke . . . . . . . . . . . . . . . . . . . . . . . 407 10.2 `B' ? Better symptom control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 409 10.2.1 Rate control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 409 10.2.1.1 Target/optimal ventricular rate range . . . . . . . . . . . . . . 409 10.2.1.2 Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 409 10.2.1.3 Acute rate control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 410 10.2.1.4 Atrioventricular node ablation and pacing . . . . . . . . . . 410 10.2.2 Rhythm control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 413 10.2.2.1 Indications for rhythm control . . . . . . . . . . . . . . . . . . . . . 413 10.2.2.2 Cardioversion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 414 10.2.2.2.1 Immediate cardioversion/elective cardioversion . . 414 10.2.2.2.2 Electrical cardioversion . . . . . . . . . . . . . . . . . . . . . . . 414 10.2.2.2.3 Pharmacological cardioversion (including `pill in the pocket') . . . . . . . . . . . . . . . . . . . . . . . . . . . . 414 10.2.2.2.4 Follow-up after cardioversion . . . . . . . . . . . . . . . . . 414 10.2.2.3 Atrial fibrillation catheter ablation . . . . . . . . . . . . . . . . . . 417 10.2.2.3.1 Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 417 10.2.2.3.2 Techniques and technologies . . . . . . . . . . . . . . . . . . 419 10.2.2.3.3 Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 419

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10.2.2.3.4 AF catheter ablation outcome and impact of modifiable risk factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 419 10.2.2.3.5 Follow-up after atrial fibrillation ablation . . . . . . . 420 10.2.2.3.7 Risk assessment for recurrence of AF post catheter ablation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 420 10.2.2.4 Surgery for atrial fibrillation . . . . . . . . . . . . . . . . . . . . . . . . 421 10.2.2.4.1 Concomitant surgery for atrial fibrillation: indications, outcome, complications . . . . . . . . . . . . . . . . . . . . . 422 10.2.2.4.2 Stand-alone surgery for atrial fibrillation: indications, outcome, complications . . . . . . . . . . . . . . . . . . . . . 422 10.2.2.5 Hybrid surgical/catheter ablation procedures . . . . . . . 422 10.2.2.6 Peri-procedural stroke risk management in patients undergoing rhythm control interventions . . . . . . . . . . 423 10.2.2.6.1 Management of stroke risk and oral anticoagulant therapy in atrial fibrillation patients undergoing cardioversion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 423 10.2.2.6.2 Management of stroke risk and oral anticoagulant therapy in atrial fibrillation patients undergoing atrial fibrillation catheter ablation . . . . . . . . . . . . 424 10.2.2.6.3 Postoperative anticoagulation after surgery for atrial fibrillation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 424 10.2.2.7 Long-term antiarrhythmic drug therapy for rhythm control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 424 10.2.2.7.1 Antiarrhythmic drugs . . . . . . . . . . . . . . . . . . . . . . . . . 424 10.3 `C ? Cardiovascular risk factors and concomitant diseases: detection and management . . . . . . . . . . . . . . . . . . . . . . . . . . . . 429 10.3.1 Lifestyle interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 429 10.3.1.1 Obesity and weight loss . . . . . . . . . . . . . . . . . . . . . . . . . . . 429 10.3.1.2 Alcohol and caffeine use . . . . . . . . . . . . . . . . . . . . . . . . . . . 430 10.3.1.3 Physical activity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 430 10.3.2 Specific cardiovascular risk factors/comorbidities . . . . . . . 430 10.3.2.1 Hypertension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 430 10.3.2.2 Heart failure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 430 10.3.2.3 Coronary artery disease . . . . . . . . . . . . . . . . . . . . . . . . . . . 430 10.3.2.4 Diabetes mellitus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 430 10.3.2.5 Sleep apnoea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 430 11 The ABC pathway in specific clinical settings/conditions/ patient populations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 431 11.1 Atrial fibrillation with haemodynamic instability . . . . . . . . . . . . . 431 11.2 First-diagnosed (new-onset) atrial fibrillation . . . . . . . . . . . . . . . . 431 11.3 Acute coronary syndromes, percutaneous coronary intervention, and chronic coronary syndromes in patients with atrial fibrillation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 432 11.4 Acute stroke or intracranial haemorrhage in patients with atrial fibrillation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 435 11.4.1 Patients with atrial fibrillation and acute ischaemic stroke or transient ischaemic attack . . . . . . . . . . . . . . . . . . . . . . . . . . 435 11.4.2 Cryptogenic stroke/embolic stroke with undetermined source . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 435 11.4.3 Post-stroke patients without known atrial fibrillation . . . . 436 11.4.4 Management of patients with atrial fibrillation postintracranial haemorrhage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 436 11.5 Active bleeding on anticoagulant therapy: management and reversal drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 438 11.6 Atrial fibrillation and heart failure . . . . . . . . . . . . . . . . . . . . . . . . . . . 439 11.7 Atrial fibrillation and valvular heart disease . . . . . . . . . . . . . . . . . . 439 11.8 Atrial fibrillation and chronic kidney disease . . . . . . . . . . . . . . . . . 440

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11.9 Atrial fibrillation and peripheral artery disease . . . . . . . . . . . . . . . 440 11.10 Atrial fibrillation and endocrine disorders . . . . . . . . . . . . . . . . . . 440 11.11 Atrial fibrillation and gastrointestinal disorders . . . . . . . . . . . . . 440 11.12 Atrial fibrillation and haematological disorders . . . . . . . . . . . . . 441 11.13 The elderly and frail with atrial fibrillation . . . . . . . . . . . . . . . . . . 441 11.14 Patients with cognitive impairment/dementia . . . . . . . . . . . . . . 441 11.15 Atrial fibrillation and congenital heart disease . . . . . . . . . . . . . . 441 11.16 Atrial fibrillation in inherited cardiomyopathies and primary arrhythmia syndromes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 442 11.17 Atrial fibrillation during pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . 442 11.18 Atrial fibrillation in professional athletes . . . . . . . . . . . . . . . . . . . 443 11.19 Postoperative atrial fibrillation . . . . . . . . . . . . . . . . . . . . . . . . . . . . 443

11.19.1 Prevention of postoperative AF . . . . . . . . . . . . . . . . . . . . . . . 444 11.19.2 Prevention of thrombo-embolic events . . . . . . . . . . . . . . . 444 12 Prevention of atrial fibrillation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 445 12.1 Primary prevention of atrial fibrillation . . . . . . . . . . . . . . . . . . . . . . 445 12.2 Secondary prevention of atrial fibrillation . . . . . . . . . . . . . . . . . . . 445 13 Sex-related differences in atrial fibrillation . . . . . . . . . . . . . . . . . . . . . . . 445 14 Implementation of the atrial fibrillation guidelines . . . . . . . . . . . . . . . . 446 15 Quality measures and clinical performance indicators in the management of atrial fibrillation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 446 16 Epidemiology, clinical implications, and management of atrial high-rate episodes/subclinical atrial fibrillation . . . . . . . . . . . . . . . . . . . . . . 446 17 Atrial fibrillation and other atrial tachyarrhythmias (atrial flutter and atrial tachycardias) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 449 18 Key messages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 449 19 Gaps in evidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 450 20 `What to do' and `what not to do' messages from the Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 452 21 Supplementary data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 456 22 Appendix . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 456 23 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 457

List of recommendations

New recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 381 Changes in the recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 383 Recommendations for diagnosis of AF . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 386 Recommendations for structured characterization of AF . . . . . . . . . . . 391 Recommendations for screening to detect AF . . . . . . . . . . . . . . . . . . . . . . 395 Recommendations for diagnostic evaluation of patients with AF . . . . 397 Recommendations about integrated AF management . . . . . . . . . . . . . . 401 Recommendations for the prevention of thrombo-embolic events in AF . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 408 Recommendations for ventricular rate control in patients with AF . . 412 Recommendations for rhythm control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 414 Recommendations for cardioversion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 417 Recommendations for rhythm control/catheter ablation of AF . . . . . . 421 Recommendations for surgical ablation of AF . . . . . . . . . . . . . . . . . . . . . . 422 Recommendations for stroke risk management peri-cardioversion . . 423 Recommendations for stroke risk management peri-catheter ablation . . 424 Recommendations for postoperative anticoagulation after AF surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 424 Recommendations for long-term antiarrhythmic drugs . . . . . . . . . . . . . 429 Recommendations for lifestyle interventions and management of risk factors and concomitant diseases in patients with AF . . . . . . . . . . . 431

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Recommendations for management of AF with haemodynamic instability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 431 Recommendations for patients with AF and an ACS, PCI, or CCS . . . 434 Recommendations for the search for AF in patients with cryptogenic stroke . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 436 Recommendations for secondary stroke prevention in AF patients after acute ischaemic stroke . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 437 Recommendations for stroke prevention in AF patients after intracranial haemorrhage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 437 Recommendations for the management of active bleeding on OAC . . . 439 Recommendations for patients with valvular heart disease and AF . . . 439 Recommendations for the management of AF in patients with congenital heart disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 442 Recommendations for the management of AF during pregnancy . . . . 443 Recommendations for sports activity in patients with AF . . . . . . . . . . . 443 Recommendations for postoperative AF . . . . . . . . . . . . . . . . . . . . . . . . . . . 445 Recommendations pertaining to sex-related differences in AF . . . . . . 446 Recommendations for quality measures in patients with AF . . . . . . . . . 446 Recommendations for management of patients with AHRE . . . . . . . . . 449

List of tables

Table 1 Classes of recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 379 Table 2 Levels of evidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 380 Table 3 Definition of atrial fibrillation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 385 Table 4 Classification of AF . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 390 Table 5 Sensitivity and specificity of various AF screening tools considering the 12-lead ECG as the gold standard . . . . . . . . . . . . . . . . . . 394 Table 6 EHRA symptom scale . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 396 Table 7 Stroke risk factors in patients with AF . . . . . . . . . . . . . . . . . . . . . . 402 Table 8 CHA2DS2-VASc score . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 403 Table 9 Risk factors for bleeding with OAC and antiplatelet therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 403 Table 10 Clinical risk factors in the HAS-BLED score . . . . . . . . . . . . . . . 404 Table 11 Dose selection criteria for NOACs . . . . . . . . . . . . . . . . . . . . . . . 405 Table 12 Antithrombotic therapy after left atrial appendage occlusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 406 Table 13 Drugs for rate control in AF . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 411 Table 14 Antiarrhythmic drugs used for restoration of sinus rhythm . . 416 Table 15 Goals of follow-up after cardioversion of AF . . . . . . . . . . . . . . 417 Table 16 Procedure-related complications in catheter ablation and thoracoscopic ablation of AF . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 419 Table 17 Key issues in follow-up after AF catheter ablation . . . . . . . . . 420 Table 18 Principles of antiarrhythmic drug therapy . . . . . . . . . . . . . . . . . 425 Table 19 Rules to initiate antiarrhythmic drugs for long-term rhythm control in AF . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 425 Table 20 AADs used for long-term maintenance of sinus rhythm in AF patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 426 Table 21 Non-antiarrhythmic drugs with antiarrhythmic properties (upstream therapy) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 428 Table 22 Summary of quality indicators for the diagnosis and management of AF . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 447

List of figures

Figure 1 Diagnosis of AHRE/subclinical AF . . . . . . . . . . . . . . . . . . . . . . . . . 386

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