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What's new in the 2016 ESC Guidelines on atrial fibrillation?

On 27 August 2016, the European Society of Cardiology (ESC) Guidelines for the management of atrial fibrillation (AF) were presented and published in the current issue of the European Heart Journal. Extensive new evidence underpinning the major components of AF management required a complete re-write of the existing guidelines, including concomitant cardiovascular conditions, anticoagulation, rate control, and rhythm control (Figure 1). Written in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS), and endorsed by the European Stroke Organisation (ESO), here we highlight some of the new aspects of the 2016 guidelines. These new guidelines reflect the increasing need to integrate and coordinate care of AF patients, reflected by the multidisciplinary input into the task force that included expert cardiologists and electrophysiologists, stroke neurologists, AF nurses, and cardiac surgeons. Integration ranges from screening and initial management, which can be done in many different healthcare settings, to complex decisions in patients needing advanced anticoagulation or rhythm control therapy. Knowledge about the epidemiology of AF has progressed substantially, and the enormous impact of this rapidly growing group of patients (over 2% of typical European populations) highlights the need for both opportunistic and targeted intensive ECG screening for AF (for example, in patients over the age of 65 or those with stroke or transient ischemic attack; I B recommendations). Although classification into first diagnosed AF, paroxysmal, persistent, longstanding persistent and permanent AF has not changed, advances in our understanding of the pathophysiology of this condition mean that in the future, mechanistic and treatment-specific types of AF may supersede the current classification to enable personalized cardiovascular medicine for AF patients. Diagnosis of AF continues to require formal ECG documentation (I B), and in addition to clinical evaluation, this Task Force now recommends the use of transthoracic echocardiography in all AF patients to guide management (I C), assessing concomitant cardiovascular diseases (such as hypertension, valvular disease, and heart failure), but also to guide the use of anticoagulants, the choice of rate controlling agent, and rhythm control therapy. This recommendation also reflects the common co-existence of heart failure and AF. Oral anticoagulation remains a major treatment component in AF patients, and apart from patients at the lowest risk of stroke (women and men without any clinical risk factors), most others will receive a net clinical benefit from anticoagulation (I A). The issue of anticoagulation in patients with a single risk factor (CHA2DS2-VASc score of 2 for women and 1 for men) is less well supported by data, but again many patients are likely to benefit, considering individual characteristics and patient preferences (IIa B). Importantly, stroke prevention should be considered irrespective of current heart rhythm; in