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New European Society of Cardiology Guidelines Provide Leading-Edge Atrial Fibrillation Treatment Guidance

New ESC guidelines provide detailed guidance for afib treatment, stroke prevention, and unique circumstances

The European Society of Cardiology’s Guidelines for the Management of Atrial Fibrillation offer recommendations for patient care and treatment in a wide variety of scenarios. So if you have unusual circumstances, you may find important answers here. Since the American Heart Association, American College of Cardiology, and European Society of Cardiology last released their joint atrial fibrillation treatment guidelines in 2006, the new ESC guidelines can be seen as the “standard of care” because they incorporate findings from recent medical research and reflect the better understanding of the mechanisms of afib. Much of this information applies regardless of where you live.

The guidelines include a wealth of valuable discussions related to all aspects of treatment for those with atrial fibrillation and should provide patients with an understanding of their current treatment and future options, as well as addressing the unique needs of specific populations within the afib community. Here is the information that you will find in the guidelines, and the locations where you'll find it:

  • discussion of the prevalence of cardiovascular and other conditions that are commonly associated with atrial fibrillation, such as hypertension, valvular heart disease, cardiomyopathies, congenital heart defects, obesity, diabetes, chronic obstructive pulmonary disease (COPD), and sleep apnea (pgs. 6–7)
  • information about the mechanisms of atrial fibrillation, including genetic predisposition (pgs. 7–8)
  • extensive discussion of avoiding stroke risk through use of antithrombotics (anticoagulant and antiplatelet medications), including the myriad of combinations of these medications and what is best for a variety of situations, such as when undergoing cardioversion, surgery, or stent placement, or having a heart attack or heart disease, and even how to manage these medications when strokes do occur. In addition, a new drug for stroke prevention, dabigatran, is also included, and there is a very brief discussion of catheter-based left atrial appendage occlusion devices (pgs. 11–24)
  • detailed discussions of medications for rate control and rhythm control, including in what cases certain drugs should not be used (such as with underlying heart disease). Some of the newer drugs are included, such as vernakalant for converting recent-onset afib and dronedarone for maintaining sinus rhythm (pgs. 24–38)
  • explanations of catheter ablation and surgical ablation, when they are appropriate, and risks and success rates (pgs. 38–44)
  • information about various upstream therapies that may deter the development of afib, decrease episodes, or delay the progression from paroxysmal to persistent afib by preventing remodeling due to inflammation, high blood pressure, or heart failure — this includes the use of aldosterone antagonists, statins, angiotensin-converting enzyme inhibitors (ACEIs), angiotensin receptor blockers (ARBs), and polyunsaturated (Omega-3) fatty acids (pgs. 44–47)
  • discussion of specific populations, such as those who are athletes, elderly, pregnant, or who have diabetes, pulmonary disease, or a wide variety of heart issues or disease (pgs. 47–55)

Here are some important and interesting facts from the ESC Guidelines for those with afib along with the pages where you can find out more:

  • "Patients with paroxysmal AF should be regarded as having a stroke risk similar to those with persistent or permanent AF, in the presence of risk factors." (pg. 13)
  • "Patients aged < 60 years, with ‘lone AF’, i.e. no clinical history or echocardiographic [EKG] evidence of cardiovascular disease, carry a very low cumulative stroke risk, estimated to be 1.3% over 15 years. The probability of stroke in young patients with lone AF appears to increase with advancing age or development of hypertension, emphasizing the importance of re-assessment of risk factors for stroke over time." (pg. 13)
  • "Age as a risk factor is not a ‘yes/no’ phenomenon, and stroke risk in AF starts to rise from age 65, although it is clear that AF patients aged ≥75 years (even with no other associated risk factors) have a significant stroke risk and derive benefit from VKA [anticoagulants] over aspirin." (pg. 13)
  • "As patients with AF get older, the relative efficacy of antiplatelet therapy to prevent ischaemic [clot] stroke decreases, whereas it does not change for VKAs [anticoagulants]. Thus, the absolute benefit of VKAs for stroke prevention increases as AF patients get older." (pg. 13)
  • "The presence of atherosclerotic vascular disease [plaque or blockage in the arteries] may contribute to stroke risk. An increased risk of stroke and thrombo-embolism [clots] with previous myocardial infarction [heart attack] is present in most (but not all) studies. Also, AF confers a poor prognosis in patients with peripheral artery disease (PAD), and the presence of complex aortic plaque on the descending aorta on TOE (transesophogeal echocardiography) is an independent risk factor for stroke and thrombo-embolism." (pg. 13)
  • "Gender analyses from population studies, cohort studies, trial cohorts, and surveys also suggest higher thrombo-embolism [clot] rates in female subjects." (pg. 13)
  • "Aspirin had less effect in people older than 75 years and did not prevent severe or recurrent strokes." (pg. 15)
  • "Pharmacologically, near-complete platelet inhibition is achieved with aspirin 75 mg. Furthermore, low-dose aspirin (<100 mg) is safer than higher doses (such as 300 mg), given that bleeding rates with higher doses of aspirin are significant. Thus, if aspirin is used, it is reasonable to use doses in the lower end of the allowed range (75–100 mg daily)." (pg. 15)
  • "Given that AF commonly co-exists with vascular [heart] disease, the modest benefit seen for aspirin in AF is likely to be related to its effects on vascular disease. More recent cardiovascular primary prevention trials in non-AF cohorts have not shown a significant benefit from aspirin in reducing risk of cardiovascular events." (pg. 15)
  • "The Birmingham Atrial Fibrillation Treatment of the Aged (BAFTA) study showed that VKA [anticoagulant] (target INR 2–3) was superior to aspirin 75 mg daily in reducing the primary endpoint of fatal or disabling stroke (ischaemic [clot] or haemorrhagic [bleed]), intracranial haemorrhage, or clinically significant arterial embolism by 52%, with no difference in the risk of major haemorrhage between warfarin and aspirin." (pg. 15)
  • As a result of these statistics, where there are options that include aspirin, the new guidelines recommend the alternative to aspirin, with either oral anticoagulants or nothing being the preferred course instead of aspirin. (pg. 16)
  • "It is reasonable to assume that the major bleeding risk with aspirin is similar to that with VKA [anticoagulant], especially in elderly individuals. The fear of falls may be overstated, as a patient may need to fall ~300 times per year for the risk of intracranial haemorrhage [bleed] to outweigh the benefit of OAC [oral anticoagulants] in stroke prevention." (pg. 17)
  • "Cohort studies suggest a 2-fold increase in stroke risk at INR 1.5–2.0 and, therefore, an INR <2.0 is not recommended." (pg. 18)
  • "The preventive effect of statins on AF is thought to be the net benefit derived from improvement of lipid [cholesterol] metabolism and prevention of process of atherosclerosis, anti-inflammatory and antioxidant actions... But while there is evidence for benefits of statins on AF, the evidence is insufficient for the guidelines to contain any recommendations.” (pg. 46)
  • "In experiments, PUFAs [polyunsaturated fatty acids] reduced atrial electrical remodeling and attenuated structural changes in the atria." However, like statins, there is limited evidence, which is insufficient for the guidelines to contain any recommendations. (pg. 47)
  • "There are increasing data showing that AF is 2–10 times more prevalent in active or former competitive athletes and those performing intense recreational endurance sports. The reasons for this association are probably both functional (increased sympathetic activity, volume load during exercise, vagotonia at rest) and structural (atrial hypertrophy and dilatation)." Because medications can be problematic for athletes, and some, such as beta-blockers, may even be prohibited, non-pharmacological options, such as catheter ablation, are often considered. However, drugs may still need to be continued after a successful ablation. (pgs. 48–49)
  • In pregnancy, atrial fibrillation is rare unless it was pre-existing. Many drugs, including beta blockers and warfarin, cross the placenta and have adverse effects, and should be avoided, if possible, during the first trimester. Some case reports showed no harm from cardioversion. Heparin has been used during pregnancy without adverse effects. (pgs. 51–52)
  • "AF is the most common complication after cardiac surgery (30% after coronary artery bypass graft (CABG), 40% after valve surgery, and 50% after combined CABG/valve surgery)." Beta-blockers, sotalol, and amiodarone have shown favorable results in preventing afib after cardiac surgery. Statins and intravenous magnesium have also shown positive results. Corticosteroids have been explored with some patients due to their anti-inflammatory effects, but have potential adverse effects. (pgs. 52–53)
  • In those with hypertrophic cardiomyopathy (HCM), "the decision to implant a cardioverter-defibrillator in patients with AF should be undertaken with caution since it is associated with a higher risk of inappropriate shocks, especially in the first year following implantation." (pg. 55)

If any of the facts above apply to you, you can find out more in the ESC Guidelines at the pages listed with each fact.

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Last Modified November 1, 2010

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