The ‘10 commandments’ for the 2024 European Society of Cardiology guidelines on atrial fibrillation

The 2024 European Society of Cardiology guidelines for the management of atrial fibrillation (AF) were developed in collaboration with the European Association for Cardio-Thoracic Surgery by a multidisciplinary team including patient representatives.1 These ‘10 commandments’ summarize the full guideline (Figure 1). Treat all patients with AF according to the AF-CARE framework to enhance patient-centred care and reduce adverse outcomes, including shared decision-making with patients within a multi-disciplinary team for: [C] Comorbidity and risk factor management [A] Avoid stroke and thromboembolism [R] Reduce symptoms by rate and rhythm control [E] Evaluation and dynamic reassessment Provide anticoagulation to patients at risk of ischaemic stroke or thromboembolism, preferably a direct oral anticoagulant and use locally validated risk scores or the simplified CHA2DS2-VA score (same thresholds for women and men).2 Do not use bleeding risk scores to decide on starting or withdrawing anticoagulants; instead, address all modifiable bleeding risk factors to improve safety. Consider long-term oral anticoagulation in trigger-induced AF (for example sepsis), according to the perceived individual risk of stroke or thromboembolism.3 Consider oral anticoagulation in device-detected subclinical AF for patients with high stroke risk and low bleeding risk, acknowledging the high chance of progression to clinical AF (6%–9% per year), and also the bleeding risk accompanying anticoagulation.4 For patients with AF undergoing cardiac surgery, left atrial appendage exclusion can prevent thromboembolism as an adjunct to anticoagulation.5 Catheter ablation in suitable patients with paroxysmal AF can be used as a first-line rhythm control option to alleviate symptoms, reduce AF recurrence, and delay progression of AF.6,7 Rhythm control in selected patients with AF can improve prognosis: within 12 months of an AF diagnosis and a high risk of thromboembolism8 and with heart failure and reduced ejection fraction either due to tachycardia or in selected patients where rhythm control is expected to reduce heart failure hospitalization and mortality.1 Cardioversion of AF requires appropriate anticoagulation or transoesophageal echocardiography if AF duration is longer than 24 h; consider safety first and the scope to wait for spontaneous cardioversion. Regular re-evaluation is critical, with routine heart rhythm assessment during healthcare contact for all individuals aged ≥65 years to facilitate earlier detection of AF,1 and population-based non-invasive ECG screening for those with risk factors for thromboembolism.9 Central patient pathways for AF-CARE from the 2024 European Society of Cardiology/European Association for Cardio-Thoracic Surgery guideline for the management of atrial fibrillation.1 See full guideline for rhythm control pathways. AF, atrial fibrillation; AF-CARE, atrial fibrillation—[C] comorbidity and risk factor management, [A] avoid stroke and thromboembolism, [R] reduce symptoms by rate and rhythm control, [E] evaluation and dynamic reassessment; CCS, chronic coronary syndrome; CHA2DS2-VA, congestive heart failure, hypertension, age ≥75 years (2 points), diabetes mellitus, prior stroke/transient ischaemic attack/arterial thromboembolism (2 points), vascular disease, age 65–74 years; DOAC, direct oral anticoagulant; ECG, electrocardiogram; HFrEF, heart failure with reduced ejection fraction; INR, international normalized ratio of prothrombin time; OAC, oral anticoagulant; OSA, obstructive sleep apnoea; PVD, peripheral vascular disease; SGLT2, sodium-glucose cotransporter-2; VKA, vitamin K antagonist. aAs part of a comprehensive management of cardiometabolic risk factors All authors declare no disclosure of interest for this contribution.