Clinical Quick Reference — Management and Prevention
Key changes from the 2020 ESC AF Guidelines:
Comprehensive four-domain approach to integrated AF management:
Manage hypertension (target 120-129/70-79), heart failure, diabetes, obesity, sleep apnea; lifestyle interventions
CHA₂DS₂-VA risk assessment; initiate OAC in eligible patients; manage bleeding risk
Rate control (target <110 bpm resting); rhythm control; antiarrhythmic therapy; catheter ablation
Reassess every 6 months; echocardiography; patient-reported outcomes; dynamic reassessment
| Type | Definition |
|---|---|
| First-diagnosed AF | AF not previously recognized, regardless of symptom status or duration |
| Paroxysmal AF | AF episodes terminate spontaneously within 7 days (usually <48 h) |
| Persistent AF | AF episodes lasting >7 days, requiring cardioversion for termination |
| Long-standing persistent AF | Continuous AF lasting >12 months with rhythm control still attempted |
| Permanent AF | AF accepted, no further rhythm restoration attempted |
Clinical AF: Documented on ECG (≥1 episode) with ≥30 seconds of irregular rhythm without clear P waves, irregular RR intervals.
Device-detected subclinical AF: Asymptomatic episodes ≥5 minutes on continuous monitors. Requires professional ECG confirmation.
1 12-lead ECG confirmation essential to establish AF diagnosis and commence risk stratification.
1 CHA₂DS₂-VA ≥2 indicates elevated thromboembolism risk requiring oral anticoagulation.
IIa CHA₂DS₂-VA = 1 should be considered as indicator of elevated risk.
| Component | Points | Definition |
|---|---|---|
| C: CHF | 1 | HF symptoms/signs regardless of LVEF (HFrEF, HFmrEF, HFpEF) |
| H: Hypertension | 1 | BP >140/90 or on antihypertensive treatment |
| A: Age ≥75 | 2 | Age ≥75 years (independent risk factor) |
| D: Diabetes | 1 | Type 1 or 2; on medication or lifestyle |
| S: Prior stroke/TIA/TE | 2 | Prior stroke/TIA/arterial TE (weighted 2 points) |
| V: Vascular disease | 1 | CAD, MI, PCI, PVD, or aortic disease |
| A: Age 65-74 | 1 | Age 65-74 years |
1 OAC recommended in AF patients at elevated thromboembolism risk to prevent ischemic stroke and thromboembolism.
1 DOACs preferred over VKAs in eligible AF patients for stroke prevention.
| DOAC | Standard Dose | Dose Reduction Criteria | Reduced Dose |
|---|---|---|---|
| Apixaban | 5 mg BD | Age ≥80, BW ≤60 kg, Cr ≥133 μmol/L (≥2 of 3) | 2.5 mg BD |
| Dabigatran | 150 mg BD | Age ≥80, verapamil coadministration, GI concerns | 110 mg BD |
| Edoxaban | 60 mg OD | CrCl 15-50 mL/min, BW ≤60 kg, P-gp inhibitors | 30 mg OD |
| Rivaroxaban | 20 mg OD | CrCl 15-49 mL/min | 15 mg OD |
Reserved for mechanical heart valves or moderate-to-severe mitral stenosis. Target INR 2.0-3.0 with TTR >70%.
III Adding antiplatelet to OAC NOT recommended for primary stroke prevention; lacks efficacy, increases bleeding.
1 Assessment and management of modifiable bleeding risk factors recommended in all patients eligible for OAC.
Score ≥3 indicates higher bleeding risk requiring closer monitoring and management of modifiable factors.
| Factor | Points |
|---|---|
| Hypertension (SBP >160 mmHg) | 1 |
| Abnormal renal/liver function | 1-2 |
| Stroke history | 1 |
| Bleeding history or predisposition | 1 |
| Labile INR (if on VKA) | 1 |
| Elderly (age >65 years) | 1 |
| Drugs (NSAIDs, antiplatelet) | 1 |
| Alcohol excess (>8 drinks/week) | 1 |
1 Rate control target: resting HR <110 bpm (lenient control) recommended as initial therapy in acute setting, adjusting with rhythm control strategies or as sole treatment.
| Agent | Usual Dose | Use/Notes |
|---|---|---|
| Beta-blockers | Metoprolol 25-100 mg BD, Atenolol 25-100 mg OD | First-line; avoid if asthma, acute HF decompensation |
| Non-DHP CCBs | Verapamil 40-120 mg TDS, Diltiazem 60-360 mg OD | Alternative if beta-blocked contraindicated; caution in reduced LVEF |
| Digoxin | 0.0625-0.25 mg OD | Reserved for sedentary patients; narrow therapeutic window |
| Amiodarone | 200 mg OD | Last-line; broad extraadiac effects require monitoring |
1 Beta-blockers, diltiazem, or verapamil recommended as first-choice drugs in AF with LVEF >40%.
| Drug | Maintenance Dose | Key Contraindications |
|---|---|---|
| Amiodarone | 200 mg OD (or 100-200 mg BD acutely) | Risk of hypo/hyperthyroidism, pulmonary toxicity; QT prolongation |
| Dronedarone | 400 mg BD | Avoid in HFrEF, paroxysmal AF if LVEF <40% |
| Flecainide | 200-300 mg OD | Contraindicated in structural heart disease, severe CAD, Brugada |
| Propafenone | 450-600 mg OD or 150-300 mg TDS | Contraindicated in structural disease, severe LV dysfunction, CAD |
| Sotalol | 160-320 mg daily | QT prolongation risk; avoid if bradycardia, hypokalemia, renal impairment |
1 Amiodarone recommended for AF with HFrEF requiring long-term antiarrhythmic therapy.
1 Catheter ablation as first-line option should be considered in symptomatic paroxysmal AF to reduce symptoms, recurrence, and AF progression.
IIa Ablation in persistent AF may be considered after failed antiarrhythmic therapy or as initial strategy within shared decision-making.
1 SGLT2 inhibitors recommended for HF with AF regardless of LVEF to reduce hospitalization and cardiovascular death.
III AAD therapy NOT recommended with advanced conduction disturbances unless pacemaker provided.
DOAC dose adjustments critical based on renal function. Reassess at eGFR borderlines for appropriate anticoagulant selection.
1 Immediate electrical cardioversion for haemodynamic instability. Rate control with beta-blockers first-line. 1 LMWH or VKA (not first trimester) recommended for thromboembolism prevention.
1 Perioperative amiodarone recommended to prevent post-operative AF after cardiac surgery. IIa Long-term OAC after post-operative AF should be considered if elevated TE risk.
Evaluate for underlying structural disease. Discuss modifiable risk factors (alcohol, training intensity). Ablation consideration based on symptom severity.
1 BP control (target 120-129/70-79 mmHg) recommended to reduce AF recurrence and progression.
1 Weight loss recommended in overweight/obese AF patients (target ≥10% reduction) to reduce symptoms and AF burden.
1 Effective glycaemic control with diet/medications recommended. IIa SGLT2 inhibitors may be considered for AF prevention in diabetes patients.
IIb OSA management (CPAP) may be considered as part of comprehensive AF risk factor management.
1 Regular aerobic exercise (150-300 min/week moderate or 75-150 min/week vigorous intensity) recommended to improve fitness and reduce AF burden.
1 Avoid binge drinking; limit ≤3 standard drinks/week recommended for AF prevention and recurrence reduction.
Interactive tools to assist with AF risk stratification and clinical decision-making:
Assess thromboembolism risk to guide anticoagulation initiation
Identify modifiable bleeding risk factors for OAC management
Calculate QTc to monitor antiarrhythmic drug safety
Quantify AF symptom burden for treatment guidance
Estimate procedural risk and outcome probabilities
Predict incident AF risk in general populations
Identify patients likely to maintain sinus rhythm
Stratify major bleeding risk during anticoagulation therapy