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8/13/2019 Guidelines Afib Slides 2010
1/71
www.escardio.org/guidelines
European Heart Journal 2010
European Heart Rhythm Association (EHRA);
Endorsed by the European Association for Cardio-Thoracic Surgery (EACTS)
ESC Guidelines 2010
on the management of
Atrial Fibrillation
European Heart Journal (2010) 31, 2369-2429
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Classes of recommendations
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Levels of evidence
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Types of Atrial Fibrillation
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EHRA score of AF-related symptoms
AF = atrial fibrillation; EHRA = European Heart Rhythm Association
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The management cascade for patients with AF
ACEI = angiotensin-converting enzyme inhibitor; AF = atrial fibrillation; ARB = angiotensin receptor blocker;
PUFA = polyunsaturated fatty acid; TE = thrombo-embolism.
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CHADS2score and stroke rate
*The adjusted stroke rate was derived from the multivariable analysis assuming no aspirin usage; these stroke rates are
based on data from a cohort of hospitalised AF patients, published in 2001, with low numbers in those with a CHADS2score
of 5 and 6 to allow an accurate judgement of the risk in these patients. Given that stroke rates are declining overall, actual
stroke rates in contemporary non-hospitalised cohorts may also vary from these estimates. Adapted from Gage BF et al.
AF = atrial fibrillation; CHADS2= cardiac failure, hypertension, age, diabetes, stroke (doubled).
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Risk factors for stroke andthrombo-embolism in non-valvular AF
AF= atrial fibrillation; EF = ejection fraction (as documented by echocardiography, radionuclide ventriculography, cardiac
catheterization, cardiac magnetic resonance imaging, etc.); LV = left ventricular; TIA = transient ischaemic attack.
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Risk factor-based point-based scoringsystem - CHA2DS2-VASc
*Prior myocardial infarction, peripheral artery disease, aortic plaque. Actual rates of stroke in contemporary
cohorts may vary from these estimates.
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Adjusted stroke rate accordingto CHA2DS2-VASc score
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Use of oral anticoagulation forstroke prevention in AF
AF = atrial fibrillation; OAC = oral anticoagulant; TIA = transient ischaemic attack.
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Approach to thromboprophylaxis in AF
AF = atrial fibrillation; CHA2DS2-VASc = cardiac failure, hypertension, age 75 (doubled), diabetes, stroke (doubled)-
vascular disease, age 6574 and sex category (female); INR = international normalized ratio; OAC = oral anticoagulation,
such as a vitamin K antagonist (VKA) adjusted to an intensity range of INR 2.03.0 (target 2.5).
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Cardioversion, TOE and anticoagulation
AF = atrial fibrillation; DCC = direct current cardioversion; LA = left atrium; LAA = left atrial appendage; OAC = oral anticoagulant;
SR= sinus rhythm; TOE= transoesophageal echocardiography.
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Prevention of thromboembolism in AF
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Prevention of thromboembolism in AF
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aClass of recommendation. bLevel of evidence. AF = atrial fibrillation; CHADS2 = cardiac failure, hypertension, age, diabetes, stroke (doubled);INR = international normalized ratio; LMWH = low molecular weight heparin; OAC = oral anticoagulant; TIA = transient ischaemic attack; VKA = vitamin K antagonist.
Prevention of thromboembolism in AF
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Pharmacological cardioversion of AF
aClass of recommendation. bLevel of evidence.
AF = atrial fibrillation; LoE = level of evidence; i.v. = intravenous.
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DC cardioversion for AF
aClass of recommendation. bLevel of evidence.
AF = atrial fibrillation; DCC = direct current cardioversion.
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General Management of the AF Patient
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Choice of rate and rhythm control strategies
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Rate and rhythm control of AF
aClass of recommendation. bLevel of evidence.
AF = atrial fibrillation; EHRA = European Heart Rhythm Association.
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Optimal level of heart rate control
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Rate control of atrial fibrillation
The choice of drugs depends on life style and underlying disease
Drugs for
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Drugs forrate control
ER = extended release formulations; N/A = not
applicable. Only in patients with non-permanent
atrial fibrillation.
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Acute rate control in AF
aClass of recommendation. bLevel of evidence.
AF = atrial fibrillation; i.v. = intravenous.
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Long-term rate control in AF
aClass of recommendation. bLevel of evidence.
AF = atrial fibrillation; bmp = beats per minute; LV = left ventricular; NYHA = New York Heart Association.
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Long-term rate control in AF
aClass of recommendation. bLevel of evidence.
AF = atrial fibrillation; bmp = beats per minute; LV = left ventricular; NYHA = New York Heart Association.
Choice of antiarrhythmic for the patient
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Choice of antiarrhythmic for the patientwith no or minimal structural heart disease
Choice of antiarrhythmic drug
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Choice of antiarrhythmic drugaccording to underlying pathology
ACEI = angiotensin-converting enzyme inhibitor; ARB = angiotensin receptor blocker; CAD = coronary artery disease; CHF = congestive heart failure;
HT = hypertension; LVH = left ventricular hypertrophy; NYHA = New York Heart Association; unstable = cardiac decompensation within the prior
4 weeks. Antiarrhythmic agents are listed in alphabetical order within each treatment box. ? = evidence for upstream therapy for prevention of atrial
remodelling still remains controversial.
Choice between ablation and antiarrhythmic drug therapy
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Choice between ablation and antiarrhythmic drug therapyfor patients with and without structural heart disease
More extensive LA ablation may be needed; *usually PVI is appropriate.
AF = atrial fibrillation; CAD = coronary artery disease; CHF = congestive heart failure; HT = hypertension; LVH = left ventricular hypertrophy;
NYHA = New York Heart Association; PVI = pulmonary vein isolation. Antiarrhythmic agents are listed in alphabetical order within each treatment box.
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AV node ablation in AF patients
aClass of recommendation. bLevel of evidence.
AF = atrial fibrillation; AV = atrioventricular; CRT = cardiac resynchronization therapy; LV = left ventricular;
LVEF = left ventricular ejection fraction; NYHA = New York Heart Association.
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Choice of pacemakers after
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Choice of pacemakers afterAV node ablation
aClass of recommendation. bLevel of evidence.
AF = atrial fibrillation; AV = atrioventricular; CRT = cardiac resynchronization therapy; LV = left ventricular;
LVEF = left ventricular ejection fraction; NYHA = New York Heart Association.
Principles of antiarrhythmic drug
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Principles of antiarrhythmic drugtherapy to maintain sinus rhythm
1. Treatment is motivated by attempts to reduce AF-related
symptoms.
2. Efficacy of antiarrhythmic drugs to maintain sinus rhythm is modest.
3. Clinically successful antiarrhythmic drug therapy may reduce rather
than eliminate recurrence of AF.
4. If one antiarrhythmic drug fails a clinically acceptable response
may be achieved with another agent.
5. Drug-induced proarrhythmia or extra-cardiac side-effects are
frequent.
6. Safety rather than efficacy considerations should primarily guidethe choice of antiarrhythmic agent.
Suggested doses and main caveats for
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Suggested doses and main caveats forcommonly used antiarrhythmic drugs
AF = atrial fibrillation; AV = atrioventricular; bpm = beats per minute; CYP = cytochrome P; ECG = electrocardiogram;
LV = left ventricular; NYHA = New York Heart Association.
Suggested doses and main caveats for
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Suggested doses and main caveats forcommonly used antiarrhythmic drugs(Contd)
AF = atrial fibrillation; AV = atrioventricular; bpm = beats per minute; CYP = cytochrome P; ECG = electrocardiogram;
LV = left ventricular; NYHA = New York Heart Association.
Suggested doses and main caveats for
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Suggested doses and main caveats forcommonly used antiarrhythmic drugs(Contd)
AF = atrial fibrillation; AV = atrioventricular; bpm = beats per minute; CYP = cytochrome P; ECG = electrocardiogram;
LV = left ventricular; NYHA = New York Heart Association.
Choice of antiarrhythmic for the patient
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Choice of antiarrhythmic for the patientwith no or minimal structural heart disease
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Choice of an antiarrhythmic drug
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Choice of an antiarrhythmic drugfor AF control
aClass of recommendation. bLevel of evidence.
AF = atrial fibrillation; AV = atrioventricular; LoE = level of evidence; NYHA = New York Heart Association.
Choice of an antiarrhythmic drug
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Choice of an antiarrhythmic drugfor AF control
aClass of recommendation. bLevel of evidence.
AF = atrial fibrillation; AV = atrioventricular; LoE = level of evidence; NYHA = New York Heart Association.
Choice of an antiarrhythmic drug
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Choice of an antiarrhythmic drugfor AF control
aClass of recommendation.
bLevel of evidence.
AF = atrial fibrillation; AV = atrioventricular; LoE = level of evidence; NYHA = New York Heart Association.
Choice between ablation and antiarrhythmic drug therapy
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Choice between ablation and antiarrhythmic drug therapy
for patients with and without structural heart disease
More extensive LA ablation may be needed; *usually PVI is appropriate.
AF = atrial fibrillation; CAD = coronary artery disease; CHF = congestive heart failure; HT = hypertension; LVH = left ventricular hypertrophy;
NYHA = New York Heart Association; PVI = pulmonary vein isolation. Antiarrhythmic agents are listed in alphabetical order within each treatment box.
Left atrial catheter ablation
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Left atrial catheter ablation
aClass of recommendation. bLevel of evidence. AF = atrial fibrillation; i.v. = intravenous; LMWH = low molecular weight
heparin; OAC = oral anticoagulant; UFH = unfractionated heparin.
Left atrial catheter ablation
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Left atrial catheter ablation
aClass of recommendation.bLevel of evidence.
AF = atrial fibrillation; i.v. = intravenous; LMWH = low molecular weight heparin; OAC = oral anticoagulant;
UFH = unfractionated heparin.
Surgical ablation of AF
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Surgical ablation of AF
aClass of recommendation.
bLevel of evidence.
AF = atrial fibrillation.
Primary prevention of AF
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y pwith upstream therapy
aClass of recommendation.
bLevel of evidence.
ACEI = angiotensin-converting enzyme inhibitor; AF = atrial fibrillation; ARB = angiotensin receptor blocker.
Secondary prevention of AF
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y pwith upstream therapy
aClass of recommendation.
bLevel of evidence.
ACEI = angiotensin-converting enzyme inhibitor; AF = atrial fibrillation; ARB = angiotensin receptor blocker.
Rate control during AF with heart failure
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Rate control during AF with heart failure
aClass of recommendation.
bLevel of evidence.
AF = atrial fibrillation; AP = accessory pathway; LVEF = left ventricular ejection fraction.
Rate control during AF with heart failure
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Rate control during AF with heart failure
aClass of recommendation.
bLevel of evidence.
AF = atrial fibrillation; AV = atrioventricular; CRT = cardiac resynchronization therapy;
LVEF = left ventricular ejection fraction; NYHA = New York Heart Association.
Rhythm control of AF in heart failure
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Rhythm control of AF in heart failure
aClass of recommendation. bLevel of evidence.
AF = atrial fibrillation; DCC = direct current cardioversion; NYHA = New York Heart Association.
Atrial Fibrillation in athletes
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Atrial Fibrillation in athletes
aClass of recommendation. bLevel of evidence. AF = atrial fibrillation.
Atrial Fibrillation in valvular heart disease
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Atrial Fibrillation in valvular heart disease
aClass of recommendation. bLevel of evidence.
AF = atrial fibrillation; INR = international normalized ratio; LA = left atrial; LV = left ventricular.
Atrial Fibrillation in
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acute coronary syndromes
aClass of recommendation. bLevel of evidence.
AF = atrial fibrillation, ACS = acute coronary syndrome; DCC = direct current cardioversion.
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Atrial Fibrillation in pregnancy
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Atrial Fibrillation in pregnancy
aClass of recommendation. bLevel of evidence.
AF = atrial fibrillation; DCC = direct current cardioversion; LMWH = low molecular weight heparin;
UFH = unfractionated heparin; VKA = vitamin K antagonist.
Atrial Fibrillation in pregnancy
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Atrial Fibrillation in pregnancy
aClass of recommendation.
bLevel of evidence.
AF = atrial fibrillation; DCC = direct current cardioversion.
Post-operative Atrial Fibrillation
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Post-operative Atrial Fibrillation
aClass of recommendation.
bLevel of evidence.
AF = atrial fibrillation; DCC = direct current cardioversion.
Post-operative Atrial Fibrillation
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Post-operative Atrial Fibrillation
aClass of recommendation. bLevel of evidence.
AF = atrial fibrillation; DCC = direct current cardioversion.
Atrial Fibrillation in hyperthyroidism
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Atrial Fibrillation in hyperthyroidism
aClass of recommendation. bLevel of evidence. AF = atrial fibrillation.
AF in Wolff-Parkinson-White syndrome
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AF in Wolff Parkinson White syndrome
aClass of recommendation. bLevel of evidence.
AF = atrial fibrillation; AP = accessory pathway; ECG = electrocardiogram; SCD = sudden cardiac death..
AF in hypertrophic cardiomyopathy
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AF in hypertrophic cardiomyopathy
aClass of recommendation. bLevel of evidence. AF = atrial fibrillation; DCC = direct current cardioversion;
HCM = hypertrophic cardiomyopathy; INR = international normalized ratio.
Atrial Fribillation in pulmonary disease
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Atrial Fribillation in pulmonary disease
aClass of recommendation. bLevel of evidence.
AF = atrial fibrillation; DCC = direct current cardioversion.
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European Heart Rhythm Association (EHRA);
Endorsed by the European Association for Cardio-Thoracic Surgery (EACTS)