The 2024 European Society of Cardiology Atrial Fibrillation Guidelines: A Moving Goalpost

Atrial Fibrillation"Cucullus non facit monachum" (the cowl does not make the monk) -old proverb When new international guidelines are published, clinicians expect to see a paradigm shift, new answers to challenging clinical issues, revisions to previous recommendations in light of new evidence and concise, practical management algorithms.Several aspects of AF management have changed since the publication of the previous European Society of Cardiology (ESC) guidelines for AF 4 years ago. 1 These include novel patient screening recommendations, stroke prevention strategies for patients with subclinical AF, anticoagulation guidance for special situations (e.g.extreme body weight, severe renal failure, dialysis and a history of intracerebral haemorrhage), increased recognition of genetic factors and the role of artificial intelligence and machine learning in the management of AF.Like their predecessor, the current guidelines are described as being "patient-centred", as they should be, and their foundational concept is encapsulated in the acronym CARE: • Comorbidity and risk factor management; • Avoid stroke and thromboembolism; • Reduce symptoms by rate and rhythm control; and • Evaluation and dynamic reassessment.2Is this a new and revolutionary approach, or does it herald the emergence of a new management paradigm?The answer is simply "no".The 2020 ESC guidelines for the management of AF had already introduced a structured approach to AF management under the acronym ABC:• Anticoagulation/Avoid stroke; • Better symptom control; and • Cardiovascular and comorbidity optimisation.The integrated ABC approach was tested in several studies and found to be associated with a reduction in all-cause mortality, cardiovascular mortality, ischaemic stroke and major bleeding compared with usual care.3,4 One study based on the ABC algorithm was presented at the ESC 2024 congress alongside the new guideline (Figure 1).