Here are the key highlights of the latest guidelines and recommendations for the diagnosis and management of atrial fibrillation (AF), with implications for India.

Below listed are clinically useful, salient features of the new update from the 2020 European Society of Cardiology (ESC) and European Association of Cardio-Thoracic Surgery (EACTS).

The 4S-AF scheme

• Stroke risk
• Symptom severity
• The severity of AF burden – AF duration, the density of episodes
• Substrate severity – Comorbidities, cardiovascular risk factors

ABC pathway that guides the management

‘A’ - Anticoagulation/avoid stroke

‘B’ - Better symptom control

‘C’- Comorbidities/cardiovascular risk factor management

This pathway has shown to decrease re-hospitalisation, cardiovascular events and mortality.

CHA2DS2-VASc score

1. CHA2DS2-VASc clinical stroke risk score helps in identifying the risk status. Low risk (CHA2DS2-VASc score = 0 in men, or 1 in women) should not be administered antithrombotic therapy. Treatment with antiplatelet alone for stroke prevention in AF is not recommended (Class III).
2. For stroke prevention, patients with AF having CHA2DS2-VASc score ≥2 in men or ≥3 in women, oral anticoagulation (OAC) is indicated.
3. For patients having CHA2DS2-VASc score of 1 in men or 2 in women, treatment should be individualised based on clinical anticipated advantages.
4. A risk score-based bleeding risk assessment (HAS-BLED) is helpful in recognising patients at high risk of bleeding. They should frequently undergo a clinical follow-up. It is important to note that estimated bleeding risk without any absolute contraindications to OAC should not make the decision of avoiding OAC.
5. Oral anticoagulants (NOACs) with non-vitamin K antagonists are recommended in contrast to VKAs except in patients with mechanical heart valves or moderate-to-severe MS.
6. In the clinical scenario of AF, patient with ACS undergoing uncomplicated percutaneous coronary intervention, early termination (about 1 week) of aspirin and continuity of dual therapy with OAC and P2Y12 inhibitor (preferably clopidogrel) is prescribed for up to 12 months.
7. If the risk of stent thrombosis is more than the bleeding risk, triple therapy with aspirin, clopidogrel, and an OAC for longer than 1 week after an ACS should be continued with the total duration (≤1 month).
8. In patients prone to develop stroke with postoperative AF after non-cardiac surgery, long-term OAC therapy can be considered to prevent thromboembolic events (Class III).
9. AF-related symptoms are mostly controlled by rate control <110 bpm. Rhythm control can achieve AF symptoms as well as good quality of life. Although catheter ablation is a better alternative to anti-arrhythmic medicines for gaining sinus rhythm, its use has not demonstrated a decrease in stroke or mortality in AF patients with normal LV function. However, catheter ablation improves LV function in tachycardia-induced cardiomyopathy.
10. Lifestyle-related risk factors such as controlling hyperlipidemia, weight, diabetes, obstructive sleep apnoea, hypertension, and alcohol intake reduction and smoking cessation can effectively diminish AF episodes after ablation.

Implications for India

According to the Indian Heart Rhythm Society (IHRS), rheumatic heart disease (RHD) is the most frequent cause of AF in India. Stroke/thromboembolic incidents are the most feared complications of AF and the annual occurrence of such a case in non-valvular AF is 4% per year, particularly in comparison to 17 to 18% per year in patients with rheumatic AF.

Non-valvular AF is largely observed in elderly hypertensive patients. As a result of the increased substantial morbidity and mortality, the economic pressure on national resources has increased even further. There is an evident need to raise public awareness and the healthcare team about the burden and hazard of AF in the community. The present guidelines emphasise the early detection of AF in patients with risk factors, as well as prompt treatment of underlying symptoms and thromboembolic prophylaxis, which will minimise AF-related complications.