Clinical Practice Guideline: Preventive Measures and Treatment Options for Atrial Fibrillation

Abstract

Background: With approximately 1.6 million people affected in Germany, atrial fibrillation (AF) is the most common arrhythmia. The management of AF, from prevention to treatment, including anticoagulation, is therefore of major clinical importance in terms of these patients' quality of life and their mortality.

Methods: This first German clinical practice guideline on AF was developed in accordance with the Regelwerk Leitlinien (rules for guidelines) of the Association of the Scientific Medical Societies in Germany (Arbeitsgemeinschaft der Wissenschaftlichen Medizi - nischen Fachgesellschaften e. V., AWMF). The available evidence on all relevant issues was retrieved by a systematic literature search and evaluated with the participation of many medical specialty societies.

Results: AF is classified on clinical grounds as paroxysmal, persis - tent, longstanding persistent, or permanent. It is associated with a 1.5- to 2-fold increase in mortality and a 4- to 5-fold increase in the risk of stroke. Nonetheless, general screening for AF is not currently recommended, as the data on this question are conflicting. Lifestyle interventions and the reduction of risk factors lessen the frequency of AF. Female sex is only a minor risk factor; the CHA2DS2-VA-Score is recommended to assess the risk of thromboembolic events. If it is 2 or higher, oral anticoagulation (OAC) is indicated, of a type that should be decided on an individual basis. In patients with cardiovascular risk factors, early rhythm control has been shown to reduce prognostically relevant cardio - vascular endpoints (3.9 versus 5.0 per 100 patientyears). Multiple studies have shown that catheter ablation is superior to drug-based antiarrhythmic therapy in patients with paroxysmal symptomatic AF as well as in those with heart failure and AF.

Conclusion: It is hoped that the recommendations contained in this guideline will lead to intensified measures for the prevention of AF, resulting in a lower prevalence of AF and its adverse sequelae. The available evidence supports the evaluation of the indications for OAC, early rhythm control, and the use of catheter ablation, especially in patients with paroxysmal AF or heart failure.

Figure 1

Overview of the main recommendations given in this guideline for AF, including the management of accompanying conditions, detection and diagnostic work-up, stroke prevention, and specific treatment with either rhythm or rate control AF, atrial fibrillation; CHA₂DS₂-VA, a score for determining the risk of stroke in a patient with atrial fibrillation; EKG, electrocardiogram

Figure 2

Overview of recommendations in the guideline concerning the indications for rhythm control in patients with paroxysmal and persistent atrial fibrillation, which vary depending on the potential underlying disease. Green: rhythm control should be performed; yellow: rhythm control may be performed; rhythm control is not recommended. AF, atrial fibrillation

Figure 3

Overview of the options for antiarrhythmic treatment to achieve rhythm control in patients with paroxysmal or persistent atrial fibrillation. *¹Consideration on an individual basis taking into account the AWMF recommendations, the risks and benefits, and the patient’s wishes. NYHA I/II refers to the New York Heart Association classification of heart failure. Patients with NYHA I have no limitation of physical performance, while those with NYHA II have a mild slight limitation. *² Long-term treatment with amiodarone should be avoided if possible. CHD, coronary heart disease; HFpEF, heart failure with preserved ejection fraction; HFrEF, heart failure with reduced left ventricular ejection fraction; LVEF, left ventricular ejection fraction; PVI, pulmonary vein isolation; TDP, torsade de pointes (a specific type of ventricular tachycardia)

Figure 4

Simplified flowchart of staged strategies for appropriate rate control with moderate and strict stages and, if necessary, AV node ablation combined with pacemaker therapy AF, atrial fibrillation; BiV, biventricular stimulation/cardiac resynchronization; CSP, conduction system pacing; HR, heart rate; LV-EF, left ventricular ejection fraction; SM + AVN, pacemaker therapy plus AV node ablation