Understanding Atrial Fibrillation

Atrial fibrillation is the most common sustained arrhythmia in clinical practice, and its management is now organised around a few clear principles.

A structured approach

The 2024 ESC guidelines organise care as AF-CARE:

• Comorbidity and risk factor management
• Avoid stroke and thromboembolism
• Reduce symptoms by rate and rhythm control
• Evaluation and dynamic reassessment

Stroke prevention

Stroke risk is assessed with CHA₂DS₂-VA, which no longer counts female sex as a risk factor. Direct oral anticoagulants are preferred over warfarin, except in patients with mechanical heart valves or moderate to severe mitral stenosis. Bleeding risk should be assessed to correct modifiable factors, not as a reason to withhold anticoagulation.

Anticoagulation decisions are based on stroke risk, not on whether the patient is in sinus rhythm.

Rhythm control, earlier

The EAST-AFNET 4 trial showed that early rhythm control, started within a year of diagnosis, reduced adverse cardiovascular outcomes. Catheter ablation is now a first-line option for selected patients with symptomatic paroxysmal atrial fibrillation.

Risk factors

Weight loss, blood pressure control, treatment of sleep apnoea and reducing alcohol all lower the burden of atrial fibrillation, and are part of treatment, not an afterthought.