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. 2024 Mar 30;26(4):euae070.
doi: 10.1093/europace/euae070.

Longer and better lives for patients with atrial fibrillation: the 9th AFNET/EHRA consensus conference

Dominik Linz  1   2 , Jason G Andrade  3   4 , Elena Arbelo  5   6   7   8 , Giuseppe Boriani  9 , Guenter Breithardt  10   11 , A John Camm  12 , Valeria Caso  13 , Jens Cosedis Nielsen  14 , Mirko De Melis  15 , Tom De Potter  16 , Wolfgang Dichtl  17 , Søren Zoega Diederichsen  18 , Dobromir Dobrev  19 , Nicolas Doll  20 , David Duncker  21 , Elke Dworatzek  22 , Lars Eckardt  11   23 , Christoph Eisert  24 , Larissa Fabritz  11   25   26   27 , Michal Farkowski  28 , David Filgueiras-Rama  7   29   30 , Andreas Goette  11   31 , Eduard Guasch  6   7   32 , Guido Hack  33 , Stéphane Hatem  34 , Karl Georg Haeusler  11   35 , Jeff S Healey  36   37 , Hein Heidbuechel  38 , Ziad Hijazi  38   39   40 , Lucas H Hofmeister  41 , Leif Hove-Madsen  7   42   43 , Thomas Huebner  24 , Stefan Kääb  8   44   45 , Dipak Kotecha  27   46 , Katarzyna Malaczynska-Rajpold  47   48 , José Luis Merino  49 , Andreas Metzner  50 , Lluís Mont  5   6   7 , Ghulam Andre Ng  51   52 , Michael Oeff  11   53 , Abdul Shokor Parwani  54 , Helmut Puererfellner  55 , Ursula Ravens  11   56 , Michiel Rienstra  57 , Prashanthan Sanders  58 , Daniel Scherr  59 , Renate Schnabel  11   26   50 , Ulrich Schotten  11   60 , Christian Sohns  61 , Gerhard Steinbeck  11   62 , Daniel Steven  11   63 , Tobias Toennis  26   50 , Stylianos Tzeis  64 , Isabelle C van Gelder  57 , Roderick H van Leerdam  65 , Kevin Vernooy  1 , Manish Wadhwa  66 , Reza Wakili  11   67   68 , Stephan Willems  11   26   69 , Henning Witt  22 , Stef Zeemering  60 , Paulus Kirchhof  11   26   27   50
Affiliations

Longer and better lives for patients with atrial fibrillation: the 9th AFNET/EHRA consensus conference

Dominik Linz et al. Europace. .

Abstract

Aims: Recent trial data demonstrate beneficial effects of active rhythm management in patients with atrial fibrillation (AF) and support the concept that a low arrhythmia burden is associated with a low risk of AF-related complications. The aim of this document is to summarize the key outcomes of the 9th AFNET/EHRA Consensus Conference of the Atrial Fibrillation NETwork (AFNET) and the European Heart Rhythm Association (EHRA).

Methods and results: Eighty-three international experts met in Münster for 2 days in September 2023. Key findings are as follows: (i) Active rhythm management should be part of the default initial treatment for all suitable patients with AF. (ii) Patients with device-detected AF have a low burden of AF and a low risk of stroke. Anticoagulation prevents some strokes and also increases major but non-lethal bleeding. (iii) More research is needed to improve stroke risk prediction in patients with AF, especially in those with a low AF burden. Biomolecules, genetics, and imaging can support this. (iv) The presence of AF should trigger systematic workup and comprehensive treatment of concomitant cardiovascular conditions. (v) Machine learning algorithms have been used to improve detection or likely development of AF. Cooperation between clinicians and data scientists is needed to leverage the potential of data science applications for patients with AF.

Conclusions: Patients with AF and a low arrhythmia burden have a lower risk of stroke and other cardiovascular events than those with a high arrhythmia burden. Combining active rhythm control, anticoagulation, rate control, and therapy of concomitant cardiovascular conditions can improve the lives of patients with AF.

Keywords: AFNET; Anticoagulation; Artificial intelligence; Atrial cardiomyopathy; Atrial fibrillation; Biomarkers; Bleeding; Catheter ablation; Cognitive function; Consensus statement; Cost; Dementia; EHRA; Guidelines; Heart failure; Integrated care; Outcomes; Quality of care; Research; Research priorities; Rhythm management; Screening; Stroke; Technology.

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Conflict of interest statement

Conflict of interest The 9th AFNET/EHRA consensus conference was partially supported by the European Union MAESTRIA project (grant agreement 965286) to AFNET. The following participants and authors are employees of companies active in cardiovascular health as indicated in their affiliations: M.D.M., E.D., C.E., G.H., L.H.H., T.H., R.H.v.L., M.W., and H.W. P.K. was partially supported by the European Union AFFECT-AF (grant agreement 847770) and MAESTRIA (grant agreement 965286), German Center for Cardiovascular Research supported by the German Ministry of Education and Research (DZHK, grant numbers DZHK FKZ 81X2800182, 81Z0710116, and 81Z0710110), German Research Foundation (Ki 509167694), and Leducq Foundation. He receives research support for basic, translational, and clinical research projects from several drug and device companies active in AF and has received honoraria from several such companies in the past, but not in the last 3 years. He is listed as an inventor on two issued patents held by the University of Hamburg (Atrial Fibrillation Therapy WO 2015140571, Markers for Atrial Fibrillation WO 2016012783). J.G.A. was partially supported by the Canadian Arrhythmia Network and the Michael Smith Foundation for Health Research, Baylis Medical. He receives consulting fees/honoraria from Bayer, BMS/Pfizer Alliance, Servier, and Medtronic Inc. E.A. receives consulting fees/honoraria from Biosense Webster and Bayer. G.B. receives consulting fees/honoraria from Bayer, BMS, Boston Scientific, Daiichi Sankyo, Sanofi, and Janssen. A.J.C. receives consulting fees/honoraria from Bayer, Pfizer/BMS, Daiichi Sankyo, Menarini, Sanofi, Boston Scientific, Biosense Webster, Abbott, Acesion Pharma, Huya Bio, and Milestone. V.C. receives consulting fees/honoraria from Bayer, Boehringer Ingelheim, and Ever Pharma (paid to the institution of employment). W.D. receives consulting fees/honoraria from Reata and research grants from MicroPort, Boston Scientific, and Abbott. S.Z.D. receives consulting fees from BMS/Pfizer, Cortrium, and Acesion Pharma and speaker fees from MS/Pfizer and Bayer. He is listed as a medical advisor for Vital Beats. Dobromir D. receives consulting fees/honoraria from Elsevier, Springer Healthcare Ltd, and Daiichi Sankyo and research grants as follows: four NIH grants (partially) from Baylor College of Medicine, Houston; one NIH grant from UC Davis, one NIH grant from the University of Minnesota, and one EU-Project H2020. David D. receives consulting fees/honoraria from Abbott, Astra Zeneca, Biotronik, Boehringer Ingelheim, Boston Scientific, BMS/Pfizer, CVRx, Medtronic, MicroPort, and Zoll and research grants from Roche, CVRx, and Zoll. L.E. has received lecture fees from various companies in AF in the past but none related to the present work. L.F. receives consulting fees/honoraria from Roche (paid to the institution of employment). She is currently employed at the UKE and previously at the University of Birmingham. She was partially supported by the European Union AFFECT-EU (grant agreement 847770), MAESTRIA (grant agreement 965286), CATCH ME (grant agreement 633196), and the British Heart Foundation (AA/18/2/3218). D.F.-R. receives research grants from Abbott. He is listed as an inventor on two issued patents: EP3636147A1 (method for the identification of cardiac fibrillation drivers and/or the footprint of rotational activations) and PCT/EP2022/071364 (system and method of assessment of electromechanical remodelling). A.G. receives consulting fees/honoraria from Daiichi Sankyo, Bayer, BMS/Pfizer, Medtronic, Abbott, and Boston Scientific and was partially supported by the European Union MAESTRIA (grant agreement 965286). K.G.H. receives consulting fees/honoraria from Abbott, Alexion, Amarin, Astra Zeneca, Bayer Healthcare, Biotronik, Boehringer Ingelheim, Boston Scientific, BMS/Pfizer, Daiichi Sankyo, Edwards Lifesciences, Medtronic, Novaris, Portola, Premier Research, Sanofi, SUN Pharma, and W. L. Gore and Associates. J.S.H. receives speaking fees from BMS/Pfizer, Bayer, Servier, and Boston Scientific and consulting fees from Bayer and Boston Scientific. He receives research grants from BMS/Pfizer, Servier, Novartis, Boston Scientific, and Medtronic. H.H. receives lecture and consulting fees from Bayer, Biotronik, BMS/Pfizer, Daiichi Sankyo, Milestone Pharmaceuticals, Centrix India, C.T.I. Germany, ESC, Medscape, and Springer Healthcare Ltd. He receives research grants (paid to the institution of employment, University of Antwerp and/or University of Hasselt) from Abbott, Bayer, Biosense Webster, Boston Scientific, Daiichi Sankyo, Fibricheck/Qompium, Medtronic, and BMS/Pfizer. Z.H. receives consulting fees/honoraria from Boehringer Ingelheim, BMS/Pfizer, and Roche Diagnostics. He was partially supported by The Swedish Society for Medical Research (S17-0133), Hjärt-Lungfonden (The Swedish Heart-Lung Foundation, 20200722), and the institution he is currently employed at (Uppsala University Hospital). L.H.-M. receives research grants from the Spanish Ministry of Science and Innovation (PID2020-116927RB-C21) and Fondo Europeo de Desarrollo Regional (FEDER). D.K. receives consulting fees/honoraria from Bayer, Amomed, and Protherics Medicines Development. He receives research grants from the National Institute for Health Research (NIHR CDF-2015-08-074 RAE-AF; NIHR130280 DaRe2THINK; NIHR13274 D2T-NeuroVascular; and NIHR203326 Biomedical Research Centre), the British Heart Foundation (PG/17/55/33087, AA/182/3218, and FS/CDRF/21/21032), the EU/EFPIA Innovative Medicines Initiative (BigData@Heart 116074), EU Horizon and UKRI (HYPERMARKER 101095480) UK National Health Service—Data for R&D-Subnational Secure Data Environment programme, UK Department for Business, Energy Industrial Strategy Regulators Pioneer Fund, the Cook & Wolstenholme Charitable Trust, and the European Society of Cardiology supported by educational grants from Boehringer Ingelheim, BMS/Pfizer, Alliance, Bayer, Daiichi Sankyo, Boston Scientific, the NIHR/University of Oxford Biomedical Research Centre, and the British Hear Foundation, the University of Birmingham Accelerator Award (STEEER-AF). J.L.M. receives consulting fees/honoraria from Biotronik, Medtronic, MicroPort, and Milestone Pharmaceuticals. A.M. receives consulting fees/honoraria from Medtronic, Biosense Webster, and Boston Scientific and lecture fees from Medtronic, Boston Scientific, Biosense Webster, BMS, and Bayer. L.M. receives consulting fees/honoraria from Abbott, Medtronic, Boston Scientific, and Johnson & Johnson. G.A.N. receives lecture fees from AliveCor, consultant fees from Biosense Webster, and research grants from Abbott and Biosense Webster. H.P. receives consulting fees/honoraria from Abbott, Boston Scientific, Biosense Webster, Medtronic, Daiichi Sankyo, Bayer, and Pfizer. P.S. receives consulting fees/honoraria from Medtronic, Boston Scientific, Abbott, CathRx, and PaceMate (paid to the institution of employment). He is currently employed at the University of Adelaide, which receives research grants from Medtronic, Boston Scientific, and Becton-Dickenson. R.B.S. receives consulting fees/honoraria from BMS/Pfizer. She was partially supported by the European Union Horizon 2020 research and innovation programme (grant agreement 648131 and 847770), German Center for Cardiovascular Research supported by the German Ministry of Education and Research (DZHK, grant numbers 81Z1710103 and 81Z0710114), German Ministry of Research and Education (BMBF 01ZX1408A), ERACoSysMed3 (031L0239), Wolfgang Seefried project funding German Heart Foundation. U.S. receives consulting fees/honoraria from University Svizzerra Italiana, Stanford, and Johnson & Johnson and research grants from the European Union, Dutch Heart Foundation, Roche, and EP Solution. He is a shareholder of YourRhythmics B.V. T.T. receives consulting fees/honoraria from Boston Scientific and Medtronic. I.C.v.G. receives consulting fees/honoraria from Bayer (paid to the institution of employment). She is currently employed at the University of Groningen. K.V. receives consulting fees/honoraria from Abbott, Philips, Medtronic, Biosense Webster, and Boston Scientific and research grants from Medtronic and Biosense Webster. R.W. receives consulting fees/honoraria from Boehringer Ingelheim, BMS/Pfizer, Daiichi Sankyo, Boston Scientific, Biotronik, Abiomed, and Zoll and a research grant from Boston Scientific, BMS/Pfizer, and Abiomed. S.W. receives consulting fees/honoraria from Boehringer Ingelheim, Boston Scientific, Abbott, and Bayer Vital and a research grant from Boston Scientific. All remaining authors (G.B., J.C.N., T.D.P., N.D., M.F., E.G., S.H., S.K., D.L., K.M.-R., M.O., A.S.P., U.R., M.R., D.S., C.S., G.S., D.S., S.T., R.H.v.L., and S.Z.) have declared no conflicts of interest.

Figures

Graphical Abstract
Graphical Abstract
Figure 1
Figure 1
Timeline of landmark trials in atrial fibrillation management on active rhythm management (left) and stroke prevention (right) from 2000 until today. The studies are colour-coded based on their size (from light to dark: <1000, 1000–10 000, and >10 000 participants), and ongoing studies are shown in orange. AAD, antiarrhythmic drugs; AF, atrial fibrillation; CA, catheter ablation; CV, cardiovascular; ECV, electrical cardioversion; ED, emergency department; HFrEF, heart failure with reduced ejection fraction; HFpEF, heart failure with preserved ejection fraction; Htx, heart transplantation; LAAO, left atrial appendage occlusion; OMT, optimal medical treatment; NOACs, novel oral anticoagulant drugs; PVI, pulmonary vein isolation; VKA, vitamin K antagonist.
Figure 2
Figure 2
Candidates for early rhythm control to improve outcome. Colours represent the quality and availability of data (from dark for best quality and availability of data to light for the worst quality and availability of data). AF, atrial fibrillation; AiCM, arrhythmia induced cardiomyopathy; HFrEF, heart failure with reduced ejection fraction; HFpEF/HFmrEF, heart failure with preserved or mid-range ejection fraction; RF, risk factors.
Figure 3
Figure 3
Device-detected compared with electrocardiogram-diagnosed atrial fibrillation in relation to atrial fibrillation progression (which can take several months to years) from very low to very high burden. Electrocardiogram documentation can be achieved using single-lead electrocardiograms or 6- to 12-lead electrocardiograms using accepted definitions of atrial fibrillation. Electrocardiogram documentation of atrial fibrillation is a simple, clinically operable method to identify patients with a high arrhythmia burden. AF, atrial fibrillation; ECG, electrocardiogram.
Figure 4
Figure 4
Refined risk assessment resulting in improved stroke risk prediction compared with traditional risk schemas. A longitudinal re-assessment of stroke risk may trigger adjustment of therapy (intensified therapies or de-escalation of therapy). AF, atrial fibrillation; ECG, electrocardiogram.
Figure 5
Figure 5
A risk factor and comorbidity management clinic according to the ‘Adelaide’ model: the risk factor and comorbidity management clinic is separated from the atrial fibrillation clinic and has a single healthcare professional who (i) initiates risk factor modification, (ii) identifies risk factors according to HEAD 2 TOES, (iii) sets achievable goals, and (iv) monitors progress towards habitual change. AF, atrial fibrillation; BMI, body mass index.
Figure 6
Figure 6
Various groups of artificial intelligence techniques using different data sources, their dominant features and outputs, and potential applications. AF, atrial fibrillation; CV, cardiovascular; CNN, convolutional neural network; ECG, electrocardiogram.
See this image and copyright information in PMC

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