Show 2 more Patients with acute ischemic stroke: As per ESC 2021 guidelines: Initiate long-term oral anticoagulation (with a preference for direct oral coagulants over vitamin K antagonists in direct oral coagulant-eligible patients) for secondary prevention of stroke in patients with AF and an ischemic stroke or TIA, in the absence of strict contraindications to OACs. A Do not administer very early anticoagulation (< 48 hours) using UFH, LMWH, or vitamin K antagonists in patients with AF presenting with acute ischemic stroke. D As per NHFA 2018 guidelines: Do not initiate anticoagulants in the first few days after an ischemic stroke because of the risk of hemorrhage or hemorrhagic transformation of infarction. D Consider delaying the initiation of OACs for 2 weeks, but making the decision before discharge, in patients with ischemic stroke. C Patients with acute coronary syndromes: administer anticoagulation for patients with acute coronary syndrome and AF at increased risk of systemic thromboembolism (based on CHA2DS2- VASc risk score of 2), unless the bleeding risk exceeds the expected benefit. B Show 2 more Patients with valvular heart disease: As per ESC 2021 guidelines, do not use direct OACs in patients with AF and: https://web.pathway.md/diseases/recZrV7qZIxyavdK7 14/20 6/23/23, 3:15 AM Atrial fibrillation Pathway prosthetic mechanical valve D moderate-to-severe mitral stenosis. D As per AHA 2019 guidelines: Administer warfarin in patients with AF who have mechanical heart valves. B Avoid administering the direct thrombin inhibitor dabigatran in patients with AF and a mechanical heart valve. D Patients with coronary/arterial vascular disease: use a direct OAC in preference to warfarin when oral anticoagulation is indicated in the presence of coronary or arterial vascular disease. B Show 2 more Patients with congenital heart disease: consider initiating OACs in all adult patients with intracardiac repair, cyanosis, Fontan palliation, or systemic right ventricle and a history of AF. C Show 5 more Patients with chronic kidney disease: As per AHA 2019 guidelines, avoid administering the direct thrombin inhibitor dabigatran or the factor Xa inhibitors rivaroxaban or edoxaban in patients with AF and end-stage CKD or on dialysis, because of the lack of evidence from clinical trials that benefit exceeds risk. D Show 2 more As per NHFA 2018 guidelines: Individualize the decision to use anticoagulants in patients with AF and severe CKD because there are no prospective data showing benefit in this population. B Administer warfarin if a patient with AF with severe CKD requires anticoagulant therapy. B Pregnant patients (rate control): Administer selective -blockers for rate control in pregnant patients with AF. B Consider administering digoxin or verapamil for rate control in pregnant patients with AF if - blockers fail. C Pregnant patients (cardioversion): perform immediate electrical cardioversion in pregnant patients with AF and hemodynamic instability or pre-excited AF. B Show 2 more Pregnant patients (maintenance therapy): consider administering flecainide, propafenone, or sotalol for the prevention of AF if atrioventricular nodal-blocking drugs fail. C Pregnant patients (anticoagulation): administer therapeutic anticoagulation with heparin or vitamin K antagonist according to the stage of pregnancy in pregnant patients with AF. B 10. Patient education General counseling: As per ESC 2021 guidelines: To optimize shared decision-making about specific treatment options in consideration: https://web.pathway.md/diseases/recZrV7qZIxyavdK7 15/20 6/23/23, 3:15 AM Atrial fibrillation Pathway inform patients about the advantages/limitations and benefit/risks associated with treatment options discuss the potential burden of the treatment and include the patient's perception of treatment burden in the treatment decision. B Counsel patients and strongly emphasize about the importance of adherence and persistence to treatment with direct anticoagulants both before and after cardioversion. B As per NHFA 2018 guidelines: Provide targeted education throughout the continuum of management in patients with AF. A Take into consideration patients' beliefs, values, and preferences in the shared decision- making, with a goal of empowering patients to undertake self-management. B 11. Follow-up and surveillance Serial clinical assessment: obtain regular clinical surveillance for emergent cardiomyopathy or overt HF during long-term follow-up in patients with AF, because HF may develop even in the presence of apparently adequate ventricular rate control. B Monitoring of treatment response: As per ESC 2021 guidelines, collect patient-reported outcomes routinely to measure treatment success and improve patient care. B As per NHFA 2018 guidelines, obtain regular monitoring of treatment adherence and persistence in all patients prescribed pharmacotherapy for the management of AF, including core rhythm control and anticoagulation therapies. Use accessible and patient-centered strategies to support treatment adherence and persistence. B 12. Quality improvement Quality of care: As per ESC 2021 guidelines, consider introducing tools to measure quality of care and identifying opportunities for improved treatment quality and patient outcome. C Show 2 more As per NHFA 2018 guidelines, ensure using eHealth tools and resources by patients and health professionals, to support the integrated management of AF. A References 1. Brieger D, Amerena J, Attia JR et al. National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand: Australian clinical guidelines for the diagnosis and management of atrial fibrillation 2018. Med J Aust. 2018 Oct 15;209 8 356 362. Open https://web.pathway.md/diseases/recZrV7qZIxyavdK7 16/20 6/23/23, 3:15 AM Atrial fibrillation Pathway 2. Gerhard Hindricks, Tatjana Potpara, Nikolaos Dagres et al. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio- Thoracic Surgery EACTS The Task Force for the diagnosis and management of atrial fibrillation of the European Society of Cardiology ESC Developed with the special contribution of the European Heart Rhythm Association EHRA of the ESC. 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