2016 ESC GUIDELINES FOR THE

MANAGEMENT ATRIAL FIBRILLATION

WHAT’S NEW

Akmal Mufriadi Hanif

Cardiology Division of Internal Medicine Department
Medical Faculty of Andalas University
OUTLINES

HOPECARDIS 2017 2
 OUTLINES

I. INTRODUCTION

II. WHAT THE 2016 ESC GUIDELINE SAYS?

WHAT’S A NEW ?

III. SUMMARY

HOPECARDIS 2017 3
 OUTLINES

I. INTRODUCTION

II. WHAT THE 2016 ESC GUIDELINE SAYS?

WHAT’S A NEW?

III. SUMMARY

HOPECARDIS 2017 4
 INTRODUCTION

• The most common sustained

Atrial arrhythmia.
• Disorganized, rapid & irregular atrial
fibrillation activation.
(AF) • Irregular ventricular response to atrial
activation.

• Remodelling of atrial structure

AF & ion channel function
Mechanism
• Electrophysiological changes.

HOPECARDIS 2017 5
 independently associated
INTRODUCTION with 2x risk of all cause
mortality in women and
1.5x in men

AF : one of the major

causes of stroke, heart 1/4 middle-aged
failure, sudden death & will develop AF
other CV morbidity (Europe & US)

3% in adults
≥ 20 y.o
33.5 million
(2010)

HOPECARDIS 2017 6
FIVE DOMAINS OF AF MANAGEMENT
Acute rate &
• Drugs
rhythm control
Managing • Lifestyle changes, treatment of
precipitating factors underlying CVD conditions

• Oral anticoagulant in patients at

Assess stroke risk risk for stroke

Assess heart rate • Rate control therapy

• Antiarrythmic drugs, cardioversion,

Assess symptom catheter ablation, AF surgery
HOPECARDIS 2017 7
 OUTLINES

I. INTRODUCTION

II. WHAT THE 2016 ESC GUIDELINE SAYS?

WHAT’S A NEW ?

III. SUMMARY

HOPECARDIS 2017 8
Recommendation in AF patients

Recommendation for screening

Recommendation for diagnosis

Recommendation for AF general

management

Recommendation for stroke

prevention
HOPECARDIS 2017 9
RECOMMENDATION FOR SCREENING

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2012 Guideline 2016 Guideline
Screening
Pulse taking followed by Pulse taking or ECG in patients > 65 y.o
ECG, in patients ≥ 65 y.o I-B
ECG recording followed by continous ECG, at
least 72 hours (TIA or stroke patients)
I-B
ECG monitoring before therapy ( in AHRE
patients) IIa-B
Long-term non invasive ECG monitors or
implanted loop recorders in stroke patients
IIa-B
Systematic ECG in >75 y.o or high stroke risk.
IIb-B
HOPECARDIS 2017 11
RECOMMENDATION FOR DIAGNOSIS

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2012 Guideline 2016 Guideline
Diagnosis
ECG documentation to establish
diagnosis I-B
A full cardiovasculer evaluation and
assesment of concomittant condition
for all patients I-B
Transthoracic echocardiography for all
patients I-C
Long-term ECG monitoring in selected
patients IIa-C
HOPECARDIS 2017 13
RECOMMENDATION FOR
ATRIAL FIBRILLATION MANAGEMENT

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2012 Guideline 2016 Guideline
EHRA symptom scale
NONE Modified EHRA symptom scale for
clinical practice and research
I-C

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2012 Guideline 2016 Guideline
AF + Valvular Heart Disease
NONE Early mitral valve surgery for severe
MR and preserved LV function
IIa-C
Mitral valvulotomy for asymptomatic
patients with severe MS & suitable
valve IIa-C

HOPECARDIS 2017 16
2012 Guideline 2016 Guideline
AF + Respiratory diseases
NONE Correction of hypoxaemia and
acidosis IIa-C

Interrogation for clinical signs of OSA

IIa-B

OSA treatment should be optimized

IIa-B

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2012 Guideline 2016 Guideline
AF + Kidney Disease
NONE Assessment of creatinine clearance
I-A

Patients with OAC, at least assess

yearly renal function
IIa-B

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RECOMMENDATION FOR
ATRIAL FIBRILLATION MANAGEMENT

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2012 Guideline 2016 Guideline
Prediction of Stroke and Bleeding Risk
CHA2DS2-VASc The CHA2DS2-VASc score for stroke risk
score for stroke prediction
IIa-C
risk prediction
Bleeding risk scores to identify modifiable
risk factors for major bleeding.
IIa-B
Biomarkers (high-sensitivity troponin and
natriuretic peptide) to refine stroke and
bleeding risk IIa-B
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2012 Guideline 2016 Guideline
Stroke Prevention
Antithrombotic for all AF patients OAC for all male with a CHA2DS2-VASc
except low risk or contraindication score > 2 ; 1 I-A II a - B
The choice antithrombotic based Oral anticoagulation, for female with a
upon risk of thromboembolism and CHA2DS2-VASc score ≥ 3 ; 2
bleeding I-A II a - B
CHA2DS2-VASc score of 0, no VKA (INR 2.0–3.0 or higher) for patients
antithrombotic with moderate-to-severe MS or
mechanical heart valves. I- B
CHA2DS2-VASc score ≥ 2 ; NOAC is recommended in preference to
OAC (I – A) a VKA I-A
CHA2DS2-VASc score of 1 ; Patients with VKA, keep time in
OAC (IIa – A) therapeutic range (TTR) as high as
possible and closely monitored. I-A
Female < 65 y.o, lone AF, CHA2DS2- Patients with VKA, considered for NOAC
VASc score of 1 : no antithrombotic treatment II b - A
HOPECARDIS 2017 21
 2012 Guideline
Antithrombotic for all AF
patients except low risk or
contraindication
The choice antithrombotic
based upon risk of
thromboembolism and
bleeding
CHA2DS2-VASc score of 0, no
antithrombotic
2016 Guideline
Stroke Prevention
Patients with VKA, TTR should
be kept as high as possible &
closely monitored.
I-A
Patients with VKA may be
considered for NOAC treatment
IIb-A
Avoid combinations of OAC &
platelet inhibitors III-B
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2012 Guideline
Dabigatran 150 mg b.i.d is prefer
than 110 mg except for age ≥ 80,
using of interacting drugs, HAS-
BLED score ≥ 3, CrCl 30 – 49 ml/min
Rivaroxaban dose 20 mg o.d id
prefer than 15 mg o.d. Latter dose
reccomend for HAS-BLED ≥ 3, CrCl
30 – 49 ml/min
2016 Guideline
Stroke Prevention
Anticoagulant or antiplatelet
therapy is not recommended for
stroke prevention (without
another risk factor)
III-B
Antiplatelet monotherapy is not
recommended for stroke
prevention III-A

NOACs are NOT RECOMMENDED

in patients with mechanical
heart valves III-B/C
HOPECARDIS 2017 23
 Recommendation for AF Management

Stroke Prevention
AVOID combinations of oral anticoagulants & platelet III – B
inhibitors

Anticoagulant or antiplatelet therapy is NOT III – B

RECOMMENDED for stroke prevention without risk factor

Antiplatelet monotherapy is NOT RECOMMENDED for III – A

stroke prevention

NOACs are NOT RECOMMENDED in patients with III –

mechanical heart valves B/C
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2012 Guideline 2016 Guideline

Occlusion or Exclusion of the Left Atrial Appendage

Interventional, percutaneous LAA
closure may be considered in
patients with high stroke risk and
contraindications for long term
oral anticoagulant
After surgical occlusion or
exclusion of the LAA, continue
anticoagulation in at-risk
patients
I-B

LAA occlusion for stroke

prevention IIb-B
Surgical excision of LAA may be
considered undergoing openheart
Surgical occlusion or exclusion of
surgery the LAA undergoing cardiac /
thoracoscopic surgery
IIb-B
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2012 Guideline 2016 Guideline
Combination Therapy with Oral Anticoagulants and Antiplatelets

None After elective coronary stenting,

combination aspirin, clopidogrel and an
oral anticoagulant for 1 month
IIa-B

After an ACS with stent implantation,

combination aspirin, clopidogrel and an
oral anticoagulant for 1–6 months
IIa-C

After an ACS without stent IIa-C

implantation, oral anticoagulant and
aspirin or clopidogrel for 12 months
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 Combination Therapy with Oral Anticoagulants
and Antiplatelets
After coronary stenting ; aspirin + clopidogrel + IIa – B

OAC (1 month)

After ACS + stent implantation ; aspirin + IIa – C

clopidogrel + OAC (1–6 months)

After ACS without stent implantation : OAC + IIa – C

aspirin/clopidogrel (12 months)

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Antithrombotic after PCI in AF
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2012 Guideline 2016 Guideline
Rate Control Therapy
NO EXPLANATION Beta-blockers, digoxin, diltiazem, or verapamil in patients
with LVEF ≥ 40%. I-B
Beta-blockers and/or digoxin in patients with LVEF <40%.I-B
Combination therapy if a single agent does not achieve the
necessary heart rate target. IIa-C
In patients with haemodynamic instability or severely
depressed LVEF, amiodarone for acute control of heart rate.IIb-B
In patients with permanent AF, antiarrhythmic drugs should
not routinely be used for rate control. III-A
A resting heart rate of <110 bpm as the initial heart rate
target IIa-B
Rhythm rather than rate control strategies as the preferred
in preexcited AF and AF during pregnancy. IIa-C
AV node ablation in patients unresponsive or intolerant to
intensive rate and rhythm control therapy IIa-B
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 Rate Control
Beta-blockers, digoxin, diltiazem, or verapamil ; LVEF ≥ I–B
40%.
Beta-blockers and/or digoxin ; LVEF <40%. I–B
Combination therapy if a single agent doesn’t achieve IIa – C
heart rate target.
In haemodynamic instability or severely depressed LVEF ; IIb – B
amiodarone (acute heart rate control)
In permanent AF; antiarrhythmic shouldn’t routinely be III – A
used
A resting heart rate of <110 bpm (initial target) IIa – B
Rhythm control as the preferred in preexcited AF & AF IIa – C
during pregnancy.
AV node ablation in patients unresponsive or intolerant to IIa – B
intensive rate & rhythm control therapyHOPECARDIS 2017 30
2012 Guideline 2016 Guideline
Rhythm Control Therapy
Indicated for symptom improvement I-B
NONE

Management of CV risk factors and avoidance of

AF triggers IIa-B
Electrical cardioversion in acute haemodynamic
instability I-B
Cardioversion in symptomatic persistent or long-
I-B
standing AF
Pre-treatment with amiodarone, flecainide, IIa-B
No or minimal structural ibutilide, or propafenone before electrical
heart disease ; IV
flecainide, propafenone,
cardioversion
ibutilide, or vernakalant In patients with no history of ischaemic or IIa-B
for cardioversion
structural heart disease, flecainide,
propafenone, or vernakalant for cardioversion
Indicated for symptom improvement I-A
31
HOPECARDIS 2017
 Rhythm Control Therapy
Indicated for symptom improvement I–B

Management of cardiovascular risk factors and avoidance IIa – B

of AF triggers
Electrical cardioversion in acute haemodynamic instability I–B

Cardioversion in symptomatic persistent or long-standing I–B

AF
Pre-treatment with amiodarone, flecainide, ibutilide, or IIa – B
propafenone to enhance success of electrical cardioversion
and prevent recurrent AF.
No history of ischaemic or structural heart disease ; I–A
flecainide, propafenone, or vernakalant
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2012 Guideline
Occlusion or Exclusion of the Left Atrial Appendage
AF ≤ 7 days, with moderate structural heart
disease, (without hypotension, NYHA III/IV,
ACS < 30 days) vernakalant may be
considered
Vernakalant IV may be considered for
cardioversion of postoperative cardiac
surgery ≤ 3 days
2016 Guideline
In patients with no history of ischaemic or
structural heart disease, ibutilide for
cardioversion IIa-B
In recent-onset AF and no significant
structural or ischaemic heart disease, use
single oral dose of flecainide or
propafenone (the ‘pill in the pocket’
IIa-B
approach)
In patients with ischaemic and/or structural
heart disease, amiodarone for cardioversion
I-A
Vernakalant as an alternative to amiodarone in
patients without hypotension, severe heart
failure or severe structural heart disease
(especially aortic stenosis). IIb-B
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No history of ischaemic or structural heart disease ; IIa – B
ibutilide
Recent-onset AF and no significant structural or IIa – B
ischaemic heart disease ; single oral dose of flecainide or
propafenone.
In patients with ischaemic and/or structural heart I–A
disease ; amiodarone
Vernakalant as an alternative to amiodarone (no IIb – B
hypotension, severe heart failure or severe structural
heart disease (especially aortic stenosis)).

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2012 Guideline 2016 Guideline
Stroke prevention in patients designated for cardioversion
NONE Anticoagulation as soon as possible
IIa-B
Anticoagulation for a minimum of 3 weeks before
cardioversion I-B
TOE to exclude cardiac thrombus
I-B
Early cardioversion without TOE in AF <48 hours IIa-B
Stroke High risk ; long-term anticoagulant after
I-B
cardioversion. No risk factors ; anticoagulation for 4 weeks
Thrombus (+) ; anticoagulation at least 3 weeks.
I-C
Repeat TOE to ensure thrombus resolution before
cardioversion. IIa-C
Dronedarone, flecainide, propafenone, or sotalol for
prevention of recurrent symptomatic AF (normal left
I-A
ventricular function and left ventricular hypertrophy).
35
HOPECARDIS 2017
2012 Guideline 2016 Guideline
Stroke prevention in patients designated for cardioversion
Dronedarone for prevention of
Drodenarone for recurrent AF (I – A) recurrent symptomatic AF in patients
with stable CAD, and without HF I-A
Drodenarone not recomended for Amiodarone for prevention of
permanent AF recurrent symptomatic AF in HF
patients I-B
Short term (4 weeks) antiarrythmic ECG recording during the initiation of
therapy after cardioversion for AAD
selected patient IIa-B
AAD therapy is not recommended in
patients with prolonged QT interval or
those with significant sinoatrial node
disease or AV node dysfunction III-C
HOPECARDIS 2017
36
2012 Guideline 2016 Guideline
Stroke prevention in patients designated for cardioversion
Continuation of AAD therapy after AF ablation
IIa-B
ACE-Is, ARBs and beta-blockers for prevention of
new-onset AF in heart failure patients IIa-A

ACE-Is and ARBs for prevention of new-onset AF

in hypertension patients IIa-B

Pre treatment ACE-Is or ARBs in patients with

IIb-B
recurrent AF undergoing electrical cardioversion

ACE-Is or ARBs are not recommended for the

III-B
secondary prevention of paroxysmal AF
HOPECARDIS 2017 37
 OUTLINES

I. INTRODUCTION

II. WHAT THE 2016 ESC GUIDELINE SAYS?

WHAT’S A NEW ?

III. SUMMARY

HOPECARDIS 2017 38
Ten Commandments of 2016 ESC
Guideline for AF management
Use ECG to screening & monitoring AF

Comprehensive AF care management,

include underlying or comorbidities.

Initiate anticoagulant in AF patient with stroke risk

Assess stroke risk using CHAD2S-Vasc score

Assess and minimize bleeding risk

HOPECARDIS 2017 39
 Use combination anticoagulant &
antiplatelets after ACS or PCI depend on
recurrent coronary events and bleeding risk.

Use rate control to reduce initially

ventricular rate (target < 110
beats/minutes) in acute condition

Use rhythm control to improve symptom or

cardioversion & considered safety profile of
the agent
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 Use effective anticoagulant before
cardioversion (minimum 3 weeks before
and 4 weeks after)

Use long term rhythm control to maintain

sinus rhythm after cardioversion

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HOPECARDIS 2017 42
Antithrombotic after ACS in AF patients
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Long term rate control in AF
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Acute heart rate control in AF
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Rhythm control in AF recent onset
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Long term rhythm control in AF patient
HOPECARDIS 2017 47
 Recommendation for Screening
Recommendations CoR & LoE

Pulse taking or ECG in patients >65 years of age I–B

ECG recording followed by continuous monitoring (at I–B
least 72 hours) in TIA or ischemic stroke patients

ECG monitoring in AHRE patients before therapy. IIa – B

Long-term ECG monitors or implanted loop recorders IIa – B
to document silent AF in stroke patients

Systematic ECG to detect AF in patients aged >75 IIb – B

years, or high stroke risk.

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 Recommendation for diagnosis
CoR & LoE
Recommendations
ECG documentation to establish diagnosis I–B

A full cardiovasculer evaluation and assesment I–C

of concomittant condition for all patients

Transthoracic echocardiography for all patients I–C

Long-term ECG monitoring in selected patients IIa – C

HOPECARDIS 2017 49
 Recommendation for AF Management

Modified EHRA symptom scale is I–C

recommended in clinical pracice and research

HOPECARDIS 2017 50
 Recommendation for AF Management
AF + Valvular Heart Disease CoR & LoE

Early mitral valve surgery severe MR & IIa – C

preserved LV function
Mitral valvulotomy for asymptomatic patients IIa – C
with severe MS & suitable valve anatomy

AF + respiratory diseases
Correction of hypoxaemia & acidosis IIa – C
Interrogation for clinical signs of OSA IIa – B
OSA treatment should be optimized IIa – B
HOPECARDIS 2017 51
 Recommendation for AF Management

AF + kidney disease
Assess serum creatinine or creatinine clearance I–A

Patients with anticoagulationt, at least assess yearly IIa – B

renal function

Prediction of Stroke and Bleeding Risk

CHA2DS2-VASc score for stroke risk prediction I–A
Assess bleeding risk scores to identify risk factors for IIa – B
major bleeding.

Biomarkers to refine stroke & bleeding risk IIb – B

HOPECARDIS 2017 52
 Recommendation for AF Management
Stroke Prevention
OAC for all male with a CHA2DS2-VASc score ≥ 2 ; I – A IIa-B

OAC for all female with a CHA2DS2-VASc score ≥ 3 ; 2 I – A IIa-B

VKA (INR 2.0–3.0 or higher) for patients with I–B

moderate-to-severe MS or mechanical heart valves.

NOAC is recommended in preference to a VKA I–A

Patients with VKA, keep time in therapeutic range I–A

(TTR) as high as possible and closely monitored.

Patients with VKA, considered for NOAC treatment IIb – A

HOPECARDIS 2017 53
Recommendation for AF Management

Occlusion or Exclusion of the Left Atrial Appendage

After LAA surgical, continue OAC in at-risk patients I–B

LAA occlusion for stroke prevention IIb – B

LAA surgical undergoing cardiac / thoracoscopic IIb – B

surgery

HOPECARDIS 2017 54
 Recommendation for AF Management

Secondary Stroke Prevention

Heparin / LMWH immediately after an ischaemic III – A
stroke

TIA / stroke while on OAC, assessed & optimized IIa – C

adherence therapy.
Moderate to severe ischaemic stroke while on IIa – C
OAC, interrupted OAC for 3–12 days

Aspirin for prevention until the initiation / IIa – B

resumption of OAC HOPECARDIS 2017 55
 Management of Bleeding
Blood pressure control IIa – B

When dabigatran is used, reduced dose (110 mg twice daily) IIb – B

in patients >75 years

High-risk of GI bleeding, a VKA or other NOAC preparation IIa – B

preferred over dabigatran (2x150 mg), rivaroxaban (1x20
mg), or edoxaban (1x60 mg).

Avoid alcohol excess IIa – C

Genetic testing before VKA therapy NOT RECOMMENDED. III – B

Reinitiation of OAC after a bleeding event IIa – B

Severe active bleeding events, interrupt OAC therapy until I–C
the cause of bleeding is resolved. HOPECARDIS 2017 56
HOPECARDIS 2017 57
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HOPECARDIS 2017 60
Initiation or continuation of anticoagulation in atrial
fibrillation patients after a stroke or TIA

HOPECARDIS 2017 61
HOPECARDIS 2017 62
Management of active bleeding in AF
patients receiving OAC
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Priorities in the Management of AF
The Patient Care Pathway

Risk factors

Rhythm Control

Stroke prevention

Rate Control
HOPECARDIS 2017 64
2012 Guideline 2016 Guideline
Secondary Stroke Prevention
Heparin or LMWH immediately after an
NONE ischaemic stroke (III – A)
III-A
TIA or stroke while on anticoagulation,
reassessed adherence therapy & optimized
IIa-C
Moderate to severe ischaemic stroke while on
anticoagulation, anticoagulation should be
interrupted for 3–12 days IIa-C
In AF patients who suffer a stroke, aspirin for
prevention of secondary stroke until the
initiation or resumption of oral anticoagulation.
IIa-B
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2012 Guideline 2016 Guideline
Secondary Stroke Prevention
NONE Systemic thrombolysis with rtPA is not
recommended if the INR is above 1.7
III-C
NOACs in preference to VKAs or aspirin
with a previous stroke I-B

After TIA or stroke, combination therapy

of OAC and an antiplatelet is not
III-B
recommended.
After intracranial haemorrhage, OAC
REINITIATED after 4–8 weeks IIb-B
HOPECARDIS 2017 66
2012 Guideline 2016 Guideline
Management of Bleeding
NONE Blood pressure control IIa-B
When dabigatran is used, a reduced dose (110 mg
twice daily) in patients >75 years IIb-B
High-risk of GI bleeding, a VKA or other NOAC
preparation preferred over dabigatran 150 mg
twice daily, rivaroxaban 20 mg once daily, orIIa-B
edoxaban 60 mg once daily.
Avoid alcohol excess IIa-C
Genetic testing before the initiation of VKA
therapy is not recommended. III-B
Reinitiation of OAC after a bleeding event IIa-B

Severe active bleeding events, interrupt OAC

I-C
therapy until the cause of bleeding is resolved.
HOPECARDIS 2017 67
 Recommendation for AF Management
Secondary Stroke Prevention
Systemic thrombolysis with rtPA is NOT RECOMMENDED III – C
if the INR < 1.7

NOACs in PREFERENCE to VKAs / aspirin I–B

After TIA / stroke, combination OAC & antiplatelet is NOT III – B

RECOMMENDED.

After intracranial haemorrhage, OAC REINITIATED after IIb – B

4–8 weeks
HOPECARDIS 2017 68
Dronedarone, flecainide, propafenone, or sotalol I – A
for recurrent AF prevention (normal LV function
and LVH).
Dronedarone for recurrent AF prevention in stable I – A
CAD without HF
Amiodarone for recurrent Afprevention in HF I–B
ECG recording during the initiation of AAD IIa –
B
Prolonged QT interval / significant SA node III –
disease / AV node dysfunction : No AAD C
HOPECARDIS 2017 69
Continuation of AAD therapy after AF IIa –
ablation B
ACE-Is, ARBs & BB for AF prevention in HF IIa – A
ACE-Is & ARBs for AF prevention in IIa – B
hypertension
Pre treatment ACE-Is or ARBs in patients IIb – B
with recurrent AF undergoing electrical
cardioversion
ACE-Is or ARBs aren’t recommended for the III – B
secondary prevention of paroxysmal AF
(without underlying disease) HOPECARDIS 2017 70
Stroke prevention in patients designated for cardioversion
Anticoagulation as soon as possible IIa – B
Anticoagulation for a minimum of 3 weeks before cardioversion I–B
Transoesophageal echocardiography (TOE) to exclude cardiac thrombus I–B
Cardioversion without TOE if AF <48 hours IIa – B
Patients with risk for stroke, long-term OAC after cardioversion. In patients I–B
without stroke risk factors, OAC for 4 weeks after cardioversion.
When thrombus is identified, anticoagulation at least 3 weeks. I–C
A repeat TOE to ensure thrombus resolution before cardioversion. IIa – C

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Major mechanisms of atrial fibrillation
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HOPECARDIS 2017 74
Timeline of atrial fibrillation management trials

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