The 2024 ESC Guidelines for the management of atrial fibrillation, developed in collaboration with the European Association of Cardio-Thoracic Surgery (EACTS), contain a number of new approaches and treatment-specific recommendations to help manage the surging numbers of patients with AF worldwide.
"Atrial fibrillation (AF) is one of the most commonly encountered heart conditions, with a broad impact on all health services across primary, secondary and tertiary care," says Guidelines Chair Professor Isabelle C. Van Gelder, University Medical Centre Groningen, Groningen, The Netherlands. "The prevalence of AF is expected to double by 2050 as a consequence of the ageing population, an increasing burden of comorbidities, improved awareness, and new technologies for detection."
"The impact of AF is variable across individual patients; however, morbidity from AF remains highly concerning," adds Guidelines Chair Professor Dipak Kotecha, University of Birmingham, UK. "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 death associated with AF."
The 2024 guidelines stress the importance of optimal care according to the new AF-CARE pathway, which has been designed to ensure that each and every patient with AF can benefit from recent scientific advances: [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.
The new guidelines also stress the importance of shared decision making on treatments and care, including both patients and a multidisciplinary team. Education of patients, family members and healthcare professionals are emphasised to ensure that all are empowered to make the right treatment choice for each patient. There is also a focus on equal care, stressing the importance of avoiding health inequalities based on gender, ethnicity, disability, and socioeconomic factors.
"The comorbidities sections in these new guidelines highlight that AF cannot be viewed in isolation. Thorough evaluation and management of comorbidities and risk factors are critical to all aspects of care for patients with AF to avoid recurrence and progression of AF, improve success of treatments, and prevent AF-related adverse outcomes," explains Professor Van Gelder. "There should be an increased focus on the range of conditions and lifestyle factors where there is growing evidence of impact on AF and patient care".
The new guidelines also focus on recent clinical trials and research studies that can change the routine management of patients with AF for the better. "The guideline task force has carefully evaluated the current evidence-base, with patient pathways that can help to achieve better implementation of recommendations to improve patient wellbeing," says Professor Kotecha. The key new features are: (1) broader application of appropriate anticoagulant therapy, and using the CHA2DS2-VA score (without gender) to assist in decision-making; (2) a 'safety-first' approach throughout, for example by delaying cardioversion if AF duration exceeds 24 hours, or considering fully any potential side effects of antiarrhythmic drugs; and (3) integrating rate and rhythm control, with shared-decision making on referral for catheter and surgical ablation.
The authors conclude by making clear that dynamic evaluation and reassessment is needed for patients with AF. They say: "Healthcare teams in primary and secondary care need to periodically reassess therapy and give attention to new modifiable risk factors that could slow or reverse the progression of AF, increase quality of life, and prevent adverse outcomes." A patient version of the guidelines will be released simultaneously, co-written by the patient and public representatives on the taskforce.
