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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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Clinical Events (outcomes) affected by AF
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Conditions predisposing to, or encouraging progression of
AF
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Types of Atrial Fibrillation
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Clinical evaluation
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Structural abnormalities associated with AF
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EHRA score of AF- related symptoms
AF = atrial fibrillation; EHRA = European Heart Rhythm Association
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Natural time course of AF
AF = atrial fibrillation
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Diagnosis and initial management of AF
aClass of recommendation.bLevel of evidence.AF = atrial fibrillation; ECG = electrocardiogram; EHRA = European Heart Rhythm Association.
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Diagnosis and initial management of AF
aClass of recommendation.bLevel of evidence.AF = atrial fibrillation; ECG = electrocardiogram.
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Diagnosis and initial management of AF
aClass of recommendation.bLevel of evidence.AF = atrial fibrillation; ECG = electrocardiogram.
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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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CHADS2 score and stroke rate
*The adjusted stroke rate was derived from the multivariable analysis assuming no aspirin usage; these stroke rates arebased on data from a cohort of hospitalised AF patients, published in 2001, with low numbers in those with a CHADS2 scoreof 5 and 6 to allow an accurate judgement of the risk in these patients. Given that stroke rates are declining overall, actualstroke 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, cardiaccatheterization, cardiac magnetic resonance imaging, etc.); LV = left ventricular; TIA = transient ischaemic attack.
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Risk factor-based point-based scoring
system - CHA2DS2-VASc
*Prior myocardial infarction, peripheral artery disease, aortic plaque. Actual rates of stroke in contemporarycohorts may vary from these estimates.
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Adjusted stroke rate according
to CHA2DS2-VASc score
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Use of oral anticoagulation for
stroke 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 65–74 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 2.0–3.0 (target 2.5).
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The HAS-BLED bleeding risk score
*Hypertension is defined as systolic blood pressure > 160 mmHg.
INR = international normalized ratio.
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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.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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Drugs and doses for pharmacological
conversion of (recent-onset) AF
ACS = acute coronary syndrome; AF = atrial fibrillation; DCC = direct current cardioversion; i.v. = intravenous;N/A = not applicable; NYHA, New York Heart Association; p.o. = per os; QRS = QRS duration; QT = QT interval;T-U = abnormal repolarization (T-U) waves.
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DCC and pharmacological conversion
recent-onset AF
AF = atrial fibrillation; i.v. = intravenous.
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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
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Drugs for rate 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.
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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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AV node ablation in AF patients
aClass of recommendation. bLevel of evidence. AF = atrial fibrillation; AV = atrioventricular; CRT = cardiac resynchronizationtherapy; LV = left ventricular; LVEF = left ventricular ejection fraction; NYHA = New York Heart Association.
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Choice of pacemakers after
AV 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.
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Principles of antiarrhythmic drugtherapy to maintain sinus
rhythm1. 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 ratherthan eliminate recurrence of AF.
4. If one antiarrhythmic drug ‘fails’ a clinically acceptable responsemay be achieved with another agent.
5. Drug-induced proarrhythmia or extra-cardiac side-effects arefrequent.
6. Safety rather than efficacy considerations should primarily guidethe choice of antiarrhythmic agent.
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Suggested doses and main caveats for
commonly 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.
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Suggested doses and main caveats for commonly 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.
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Suggested doses and main caveats for commonly 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.
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Choice of antiarrhythmic for the patientwith no or minimal structural heart
disease
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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 prior4 weeks. Antiarrhythmic agents are listed in alphabetical order within each treatment box. ? = evidence for ‘upstream’ therapy for prevention of atrialremodelling still remains controversial.
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Choice of an antiarrhythmic drug
for AF control
aClass of recommendation. bLevel of evidence.AF = atrial fibrillation; AV = atrioventricular; LoE = level of evidence; NYHA = New York Heart Association.
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Choice of an antiarrhythmic drug
for AF control
aClass of recommendation. bLevel of evidence.AF = atrial fibrillation; AV = atrioventricular; LoE = level of evidence; NYHA = New York Heart Association.
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Choice of an antiarrhythmic drug
for AF control
aClass of recommendation. bLevel of evidence.
AF = atrial fibrillation; AV = atrioventricular; LoE = level of evidence; NYHA = New York Heart Association.
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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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Left atrial catheter ablation
aClass of recommendation. bLevel of evidence. AF = atrial fibrillation; i.v. = intravenous; LMWH = low molecular weightheparin; OAC = oral anticoagulant; UFH = unfractionated heparin.
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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.
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Surgical ablation of AF
aClass of recommendation.bLevel of evidence.
AF = atrial fibrillation.
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Primary prevention of AF
with “upstream” therapy
aClass of recommendation.bLevel of evidence.
ACEI = angiotensin-converting enzyme inhibitor; AF = atrial fibrillation; ARB = angiotensin receptor blocker.
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Secondary prevention of AF
with “upstream” therapy
aClass of recommendation.bLevel of evidence.
ACEI = angiotensin-converting enzyme inhibitor; AF = atrial fibrillation; ARB = angiotensin receptor blocker.
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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.
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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.
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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.
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www.escardio.org/guidelines European Heart Journal (2010) 31, 2369-2429
Atrial Fibrillation in athletes
aClass of recommendation. bLevel of evidence. AF = atrial fibrillation.
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www.escardio.org/guidelines European Heart Journal (2010) 31, 2369-2429
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.
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www.escardio.org/guidelines European Heart Journal (2010) 31, 2369-2429
Atrial Fibrillation inacute coronary
syndromes
aClass of recommendation. bLevel of evidence.
AF = atrial fibrillation, ACS = acute coronary syndrome; DCC = direct current cardioversion.
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www.escardio.org/guidelines European Heart Journal (2010) 31, 2369-2429
Atrial Fibrillation in :
aClass of recommendation.bLevel of evidence.
AF = atrial fibrillation, ECG = electrocardiogram.
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www.escardio.org/guidelines European Heart Journal (2010) 31, 2369-2429
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.
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www.escardio.org/guidelines European Heart Journal (2010) 31, 2369-2429
Atrial Fibrillation in pregnancy
aClass of recommendation.bLevel of evidence.
AF = atrial fibrillation; DCC = direct current cardioversion.
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www.escardio.org/guidelines European Heart Journal (2010) 31, 2369-2429
Post-operative Atrial Fibrillation
aClass of recommendation.bLevel of evidence.
AF = atrial fibrillation; DCC = direct current cardioversion.
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www.escardio.org/guidelines European Heart Journal (2010) 31, 2369-2429
Post-operative Atrial Fibrillation
aClass of recommendation. bLevel of evidence.
AF = atrial fibrillation; DCC = direct current cardioversion.
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www.escardio.org/guidelines European Heart Journal (2010) 31, 2369-2429
Atrial Fibrillation in hyperthyroidism
aClass of recommendation. bLevel of evidence. AF = atrial fibrillation.
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www.escardio.org/guidelines European Heart Journal (2010) 31, 2369-2429
AF in Wolff-Parkinson-White syndrome
aClass of recommendation. bLevel of evidence.AF = atrial fibrillation; AP = accessory pathway; ECG = electrocardiogram; SCD = sudden cardiac death..
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www.escardio.org/guidelines European Heart Journal (2010) 31, 2369-2429
AF in hypertrophic cardiomyopathy
aClass of recommendation. bLevel of evidence. AF = atrial fibrillation; DCC = direct current cardioversion;HCM = hypertrophic cardiomyopathy; INR = international normalized ratio.
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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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www.escardio.org/guidelines
European Heart Rhythm Association (EHRA);Endorsed by the European Association for Cardio-Thoracic Surgery (EACTS)
European Heart Journal (2010) 31, 2369-2429