Nationwide survey on the current clinical practice of the first atrial fibrillation episode

BACKGROUND Atrial fibrillation (AF) is a prevalent arrhythmia associated with increased risk of stroke, hospitalization, and progression to chronic forms. Early management of a first AF episode is essential to prevent recurrences and complications. OBJECTIVE To evaluate real-world practices among Italian cardiologists in the management of the first documented AF episode. METHODS Between January and October 2023, 706 cardiologists completed a nationwide online survey promoted by the ANMCO Arrhythmia Study Group. The questionnaire explored demographics, thromboembolic risk management, rhythm control strategies, and follow-up approaches. Descriptive and inferential analyses were performed. RESULTS Most respondents worked in public hospitals (437/706, 61.9%). Transthoracic echocardiography was the most frequently prescribed examination after a first AF episode (627/706, 88.9%), followed by electrical cardioversion (414/706, 58.6%) and TEE (178/706, 25.2%). For paroxysmal AF, anticoagulation guided by CHA₂DS₂-VASc ≥1 was prescribed by 575 cardiologists (81.4%), while 47 (6.7%) anticoagulated all patients and 84 (11.9%) did not prescribe any OAC. DOACs were preferred in 542 cases (76.8%). For persistent AF, anticoagulation was guided by CHA₂DS₂-VASc ≥1 in 354 (50.1%), whereas 321 (45.5%) prescribed OAC to all patients. DOACs were chosen in 636 cases (90.1%). Pharmacological cardioversion was the preferred initial strategy for paroxysmal AF (455/706, 64.4%), while electrical cardioversion was more frequently used as first-line treatment in persistent AF (300/706, 42.5%). Catheter ablation was rarely proposed after the first AF episode: only 53 respondents (7.5%) recommended it routinely, and 154 (21.8%) considered it only in patients with heart failure. Regarding the EAST-AFNET 4 trial, 268 cardiologists (38.0%) reported adopting an early rhythm-control strategy, whereas 220 (31.2%) were unaware of the study. CONCLUSIONS Management of the first AF episode in Italy is highly heterogeneous. While CHA₂DS₂-VASc-based anticoagulation and evidence-based rhythm control are generally applied, notable variability persists across healthcare settings, particularly concerning cardioversion strategies and limited adoption of early catheter ablation. Greater dissemination and implementation of guideline-based practices may improve uniformity of care.