Guideline sources The following summarized guidelines for the evaluation and management of atrial fibrillation are prepared by our editorial team based on guidelines from the Society for Cardiovascular Angiography and Interventions (SCAI/HRS 2023), the European Society of Cardiology (ESC/EACTS/EHRA 2021), the American Heart Association (AHA/HRS/ACC 2019), the National Heart Foundation of Australia (NHFA 2018), the Canadian Cardiovascular Society (CCS 2018; 2014), the U.S. Preventive Services Task Force (USPSTF 2018), and the Society of Thoracic Surgeons (STS 2017). 1 2 3 4 5 6 7 8 9 9 10 11 12 Definition AF is a cardiac arrhythmia characterized by a diffuse and abnormal pattern of electrical activity in the atria of the heart. 9 E id i l https://web.pathway.md/diseases/recZrV7qZIxyavdK7 1/20 6/23/23, 3:15 AM Atrial fibrillation Pathway Epidemiology The development of AF is related to structural and electrophysiological abnormalities resulting from comorbid conditions (including hypertension, diabetes mellitus, obesity, obstructive sleep apnea, myocardial infarction, HF), genetics, sex, and other factors. 11 Pathophysiology The prevalence of AF in the United States ranges is estimated at 700-775 cases per 100,000 persons. 10 Disease course In patients with AF, rapid and irregular atrial contractions lead to tachyarrhythmias, which lead to symptoms of palpitations, dyspnea, and an increased risk of HF; as well as stasis of blood in the LA appendage, which increases the risk of stroke and systemic embolism. 12 Prognosis and risk of recurrence AF is estimated to cause 15% of all strokes and is associated with a 5-fold increased risk of stroke and a 2-fold risk for all-cause mortality, respectively. 9 Calculator Calculator Calculator Anticoagulation and risk factors CHA DS VASc score for stroke CHADS s Guidelines 1. Screening and diagnosis Indications for screening: As per ESC 2021 guidelines, consider offering systematic ECG screening to detect AF in individuals 75 years of age, or in patients at high risk of stroke. C Show 4 more As per NHFA 2018 guidelines, obtain opportunistic point-of-care screening for AF in the clinic or community in individuals 65 years of age. B Show 2 more As per USPSTF 2018 guidelines, insufficient evidence to assess the balance of benefits and harms of screening for AF with ECG. I Indications for testing: As per ESC 2021 guidelines: https://web.pathway.md/diseases/recZrV7qZIxyavdK7 2/20 6/23/23, 3:15 AM Atrial fibrillation Pathway Obtain short-term ECG recording for at least the first 24 hours, followed by continuous ECG monitoring for at least 72 hours whenever possible, to monitor for AF in patients with acute ischemic stroke or TIA without previously known AF. B Consider obtaining long-term noninvasive ECG monitoring or placing insertable cardiac monitors for additional monitoring for AF in selected patients with stroke without previously known AF. C As per AHA 2019 guidelines, consider implantation of a cardiac monitor to optimize detection of silent AF in patients with cryptogenic stroke in whom external ambulatory monitoring is inconclusive. C As per CCS 2014 guidelines: Obtain continuous ECG monitoring for at least 24 hours to screen for paroxysmal AF in patients with acute ischemic stroke or TIA potentially eligible for OAC therapy. B Consider obtaining additional ambulatory monitoring (beyond 24 hours) in selected older patients with an acute, non-lacunar, embolic stroke of undetermined source and suspected (but unproven) AF potentially eligible for OAC therapy. C Diagnostic criteria: make the diagnosis of AF based on a standard 12-lead ECG recording or a single-lead ECG tracing of 30 seconds showing heart rhythm with no discernible repeating P waves and irregular RR intervals (when atrioventricular conduction is not impaired). B 2. Classification and risk stratification Structured characterization: consider obtaining structured characterization of AF including clinical assessment of stroke risk, symptom status, burden of AF, and evaluation of substrate in all patients with AF, to streamline the assessment of patients with AF at different healthcare levels, inform treatment decision-making, and facilitate optimal management. C Stroke risk assessment: As per ESC 2021 guidelines, use the CHA2DS2-VASc clinical stroke risk score assessment to initially identify patients at low risk of stroke (CHA2DS2-VASc score of 0 in males and 1 in females). A Show 2 more As per AHA 2019 guidelines: Administer OACs for patients with AF and an elevated CHA2DS2-VASc score of 2 in males or 3 in females. A Use the CHA2DS2-VASc score for assessment of stroke risk in patients with AF, except with moderate-to-severe mitral stenosis or a mechanical heart valve. B As per NHFA 2018 guidelines, use the CHA2DS2-VA score - the sexless CHA2DS2-VASc score - for predicting stroke risk in patients with AF. B As per CCS 2014 guidelines, stratify all patients with AF or atrial flutter, whether paroxysmal or persistent, using a predictive index for stroke risk. A Bleeding risk assessment: https://web.pathway.md/diseases/recZrV7qZIxyavdK7 3/20 6/23/23, 3:15 AM Atrial fibrillation Pathway As per ESC 2021 guidelines, obtain a formal structured risk-score-based bleeding risk assessment to help identify non-modifiable and address modifiable bleeding risk factors in all patients with AF, and to identify patients potentially at high risk of bleeding requiring early and more frequent clinical review and follow-up. B Show 2 more As per NHFA 2018 guidelines, initiate anticoagulant therapy after addressing bleeding and if the stroke risk is believed to exceed the risk of further bleeding. B Show 2 more 3. Diagnostic investigations Clinical assessment: Evaluate AF-related symptoms (including fatigue, tiredness, exertional shortness of breath, palpitations, and chest pain) and quantify the patient symptom status using the modified European Heart Rhythm Association symptom scale before and after initiation of treatment. B Evaluate AF-related symptoms before and after cardioversion of persistent AF to aid rhythm control treatment decisions. B Echocardiography: As per AHA 2019 guidelines, consider obtaining TEE before cardioversion in patients with AF of 48 hours or of unknown duration not received anticoagulation for the preceding 3 weeks. C As per CCS 2018 guidelines, consider obtaining TEE to exclude cardiac thrombus before cardioversion as an alternative to at least 3 weeks of anticoagulation. C As per NHFA 2018 guidelines, obtain TTE in all patients with newly diagnosed AF. B Laboratory testing: As per AHA 2019 guidelines: Determine the INR among patients treated with warfarin at least weekly during initiation of anticoagulant therapy and at least monthly when anticoagulation is stable. A Evaluate renal and hepatic function before initiation of a novel OAC and reevaluate at least annually. B As per NHFA 2018 guidelines, obtain TSH testing in patients with newly diagnosed AF but delay in acutely ill patients. B Evaluation for sleep apnea: obtain polysomnography for the screening of sleep apnea in patients with recurrent symptomatic AF. B 4. Medical management General principles: As per ESC 2021 guidelines, offer an integrated management with a structured multidisciplinary approach including healthcare professionals, patients, and their family/carers in all patients with https://web.pathway.md/diseases/recZrV7qZIxyavdK7 4/20 6/23/23, 3:15 AM Atrial fibrillation Pathway AF to improve clinical outcomes. B Show 4 more As per CCS 2018 guidelines: Implement systematic and strict guideline-adherent management of traditional modifiable cardiovascular risk factors and/or conditions associated with AF, to reduce cardiovascular events. A Consider targeting modifiable risk markers and conditions associated with AF should be applied to prevent recurrence of the arrhythmia and/or decrease its symptom burden. C As per NHFA 2018 guidelines, adopt an integrated care approach aiming to provide patient- centered comprehensive treatment delivered by a multidisciplinary team. A Show 4 more As per STS 2017 guidelines, consider offering multidisciplinary heart team assessment, treatment planning, and long-term follow-up to optimize patient outcomes in the treatment of AF. B Rate control: As per ESC 2021 guidelines, consider setting a resting HR of < 110 bpm (lenient rate control) as the initial HR target for rate control therapy. C Show 4 more As per AHA 2019 guidelines: Consider administration of nondihydropyridine calcium antagonists to slow a rapid ventricular response in patients with acute coronary syndrome and AF only in the absence of significant HF or hemodynamic instability. C Consider administering amiodarone or digoxin to slow a rapid ventricular response in patients with acute coronary syndrome and AF associated with severe LV dysfunction and HF or hemodynamic instability. C As per NHFA 2018 guidelines, administer -blockers or nondihydropyridine CCBs for acute control of ventricular rate in hemodynamically stable patients with AF, although caution is needed if given IV. B Show 7 more Rhythm control (general indications): Administer rhythm control therapy for symptom and quality of life improvement in symptomatic patients with AF. A Perform cardioversion of AF (either pharmacological or electrical) in symptomatic patients with persistent AF as part of rhythm control therapy. B Rhythm control, pharmacological cardioversion: As per EACTS/EHRA/ESC 2021 guidelines, administer pharmacological cardioversion of AF only in a hemodynamically stable patient, after consideration of the thromboembolic risk. B Show 5 more As per NHFA 2018 guidelines, consider administering IV amiodarone for delayed conversion to sinus rhythm in patients with AF and structural heart disease, including patients with HF and https://web.pathway.md/diseases/recZrV7qZIxyavdK7 5/20 6/23/23, 3:15 AM Atrial fibrillation Pathway coronary artery disease. B Rhythm control, maintenance therapy: As per EACTS/EHRA/ESC 2021 guidelines, administer amiodarone for long-term rhythm control in all patients with AF, including those with HFrEF. Consider administering other antiarrhythmic drugs first whenever possible, owing to its extracardiac toxicity. A Show 6 more As per NHFA 2018 guidelines, consider administering -blockers for the maintenance of sinus rhythm in patients with AF. C Show 6 more Anticoagulation, general indications: As per EACTS/EHRA/ESC 2021 guidelines, initiate OACs for stroke prevention in patients with AF and CHA2DS2-VASc score of 2 in males and 3 in females. A Show 4 more As per HRS/ACC/AHA 2019 guidelines, select anticoagulant therapy based on the risk of thromboembolism, irrespective of whether the AF pattern is paroxysmal, persistent, or permanent. B Show 2 more As per HRS/ACC/AHA 2019 guidelines: Consider prescribing an OAC to reduce thromboembolic stroke risk for patients with AF (except with moderate-to-severe mitral stenosis or a mechanical heart valve) and a CHA2DS2-VASc score of 1 in males and 2 in females. C Consider omitting anticoagulant therapy for patients with AF (except with moderate-to-severe mitral stenosis or a mechanical heart valve) and a CHA2DS2-VASc score of 0 in males or 1 in females. C As per CCS 2018 guidelines, initiate oral anticoagulation therapy in most patients with AF aged 65 years or with a CHADS2 score 1. B Landmark trials: AVERROES In patients with AF who were at increased risk for stroke and for whom vitamin K antagonist therapy was unsuitable, apixaban was superior to aspirin with respect to the incidence of stroke or systemic embolism. Connolly SJ et al. N Engl J Med. 2011 Mar 3. As per NHFA 2018 guidelines, initiate OACs for the prevention of stroke and systemic embolism in patients with nonvalvular AF and a CHA2DS2-VA score of 2, unless there are contraindications to anticoagulation. A Show 3 more Anticoagulation, direct oral anticoagulants: https://web.pathway.md/diseases/recZrV7qZIxyavdK7 6/20 6/23/23, 3:15 AM Atrial fibrillation Pathway As per EACTS/EHRA/ESC 2021 guidelines: Prefer direct OACs over vitamin K antagonists (excluding patients with mechanical heart valves or moderate-to-severe mitral stenosis) for stroke prevention in patients with AF eligible for oral anticoagulation. A Consider (re)initiating OACs in patients with AF at high risk of ischemic stroke, with preference for direct OACs over vitamin K antagonists in direct OAC-eligible patients, in consultation with a neurologist/stroke specialist after: a trauma-related ICH acute spontaneous ICH (including subdural, subarachnoid, or intracerebral hemorrhage), after careful consideration of risks and benefits. C As per HRS/ACC/AHA 2019 guidelines: Administer novel OACs (such as dabigatran, rivaroxaban, apixaban, and edoxaban) rather than warfarin in novel OAC-eligible patients with AF (except with moderate-to-severe mitral stenosis or a mechanical heart valve). A Administer a novel OAC for patients with AF (except with moderate-to-severe mitral stenosis or a mechanical heart valve) who are unable to maintain a therapeutic INR level with warfarin. B Updated evidence: INVICTUS In patients with AF and echocardiographically documented rheumatic heart disease, rivaroxaban was not noninferior to vitamin K antagonist with respect to the incidence of composite outcome of stroke, systemic embolism, myocardial infarction, or death from vascular or unknown causes. Stuart J Connolly et al. N Engl J Med. 2022 Sep 15. As per CCS 2018 guidelines, use dabigatran, rivaroxaban, apixaban, or edoxaban in most patients with nonvalvular AF in whom oral anticoagulation is indicated. A Landmark trials: ENGAGE AF-TIMI 48 In patients with moderate-to-high-risk AF, high-dose and low-dose once-daily regimens of edoxaban, as compared with warfarin, were noninferior to warfarin with respect to the prevention of stroke or systemic embolism. The annualized rate of primary end point in high- dose edoxaban vs. warfarin was 1.18% vs. 1.50% (HR 0.79, 97.5% CI 0.63-0.99, p < 0.001 for noninferiority) and in low-dose edoxaban vs. warfarin was 1.61% vs. 1.50% (HR 1.07, 97.5% CI 0.87-1.31, p = 0.005 for noninferiority). There was a favorable trend for high-dose edoxaban vs. warfarin (HR 0.87, 97.5% CI 0.73-1.04, p = 0.08) and an unfavorable trend for low-dose edoxaban vs. warfarin (HR 1.13, 97.5% CI 0.96-1.34, p = 0.10). The annualized rate of major bleeding with high-dose edoxaban vs. warfarin was 2.75% vs. 3.43% (HR 0.80, 95% CI 0.71-0.91, p < 0.001) and with low-dose edoxaban vs. warfarin was 1.61% vs. 3.43% https://web.pathway.md/diseases/recZrV7qZIxyavdK7 7/20 6/23/23, 3:15 AM Atrial fibrillation Pathway (HR 0.47, 95% CI 0.41-0.55, p < 0.001). The corresponding annualized rates of death from cardiovascular causes were 2.74% vs. 3.17% (HR 0.86, 95% CI 0.77-0.97, p = 0.01) and 2.71% vs. 3.17% (HR 0.85, 95% CI 0.76-0.96, p = 0.008). The corresponding rates of the key secondary end point were 3.85% vs. 4.43% (HR 0.87, 95% CI 0.78-0.96, p = 0.005) and 4.23% vs. 4.43% (HR 0.95, 95% CI 0.86-1.05, p = 0.32). Giugliano RP et al. N Engl J Med. 2013 Nov 28. As per NHFA 2018 guidelines, prefer a direct OAC (apixaban, dabigatran, or rivaroxaban) over warfarin in patients with nonvalvular AF requiring oral anticoagulation. B Anticoagulation, vitamin K antagonists: As per EACTS/EHRA/ESC 2021 guidelines: Target an INR of 2-3 if a vitamin K antagonist is used, with individual time in therapeutic range 70%. B Undertake one of the following options in patients taking vitamin K antagonists with low time in INR therapeutic range, such as < 70%: switch to a direct OAC but ensure good adherence and persistence with therapy B attempt to improve time in therapeutic range, such as education/counseling and more frequent INR checks. B As per CCS 2018 guidelines, prefer warfarin over direct OACs, if oral anticoagulation is required, in patients with a mechanical prosthetic valve, rheumatic mitral stenosis, or estimated GFR of 15-30 mL/min/1.73 m . B As per NHFA 2018 guidelines, administer warfarin in patients with valvular AF (mechanical heart valves or moderate-to-severe mitral stenosis). B Show 2 more Anticoagulation, peri-cardioversion: As per EACTS/EHRA/ESC 2021 guidelines, administer effective anticoagulation for a minimum of 3 weeks before cardioversion of AF. B Show 7 more As per HRS/ACC/AHA 2019 guidelines, consider administering heparin, a factor Xa inhibitor, or a direct thrombin inhibitor in patients with AF of < 48 hours duration with a CHA2DS2-VASc score of 0 in males and 1 in females before cardioversion, without the need for post- cardioversion oral anticoagulation. C Show 3 more As per CCS 2018 guidelines, administer therapeutic anticoagulation for 3 weeks before cardioversion in most hemodynamically stable patients with AF or atrial flutter for whom elective electrical or pharmacological cardioversion is planned. B Show 4 more As per NHFA 2018 guidelines, administer anticoagulation at the time of electrical or pharmacological cardioversion, and for at least 4 weeks post-procedurally. B https://web.pathway.md/diseases/recZrV7qZIxyavdK7 8/20 6/23/23, 3:15 AM Atrial fibrillation Pathway Anticoagulation (peri-catheter ablation): initiate pre-procedural anticoagulation in patients with AF and risk factors of stroke not taking OACs for at least 3 weeks before ablation B , or alternatively obtain TEE to exclude LA thrombus before ablation. B Show 2 more Antiplatelet therapy: As per ESC 2021 guidelines, do not administer antiplatelet therapy alone (monotherapy or aspirin in combination with clopidogrel) for stroke prevention in patients with AF. D Show 6 more As per AHA 2019 guidelines, consider initiating double therapy with a P2Y12 inhibitor (such as clopidogrel or ticagrelor) and dose-adjusted vitamin K antagonist, in patients with AF at increased risk of stroke (based on CHA2DS2-VASc risk score of 2) who have undergone PCI with stenting for acute coronary syndrome, to reduce the risk of bleeding as compared with triple therapy. C Show 4 more As per CCS 2018 guidelines, consider using triple therapy (aspirin 81 mg PO once daily, clopidogrel 75 mg PO once daily, and a reduced dose OAC) for patients with AF 65 years of age or with a CHADS2 score 1 undergoing high-risk elective PCI or PCI for acute coronary syndrome. OAC options for triple pathway therapy include: rivaroxaban 2.5 mg PO BID (preferred) warfarin with a target INR 2-2.5. B Show 5 more As per NHFA 2018 guidelines: Administer low-dose aspirin (100 mg) and clopidogrel (75 mg) in patients with AF if dual antiplatelet therapy is required in combination with OACs. Do not use ticagrelor or prasugrel in this situation. B Administer triple therapy (aspirin, P2Y12 inhibitor and OAC) with a duration as short as possible to minimize bleeding, while ensuring coverage of the initial period of high risk of stent thrombosis and/or recurrent coronary ischemia. B 5. Nonpharmacologic interventions Lifestyle modifications: As per ESC 2021 guidelines, advise strict control of risk factors and avoiding triggers as part of a rhythm control strategy. B Show 6 more As per AHA 2019 guidelines, advise weight loss, combined with risk factor modification for overweight and obese patients with AF. B As per NHFA 2018 guidelines: Advise intensive management of weight to a target of 10% body weight loss, aiming for a BMI of < 27 in overweight and obese patients with AF. B https://web.pathway.md/diseases/recZrV7qZIxyavdK7 9/20 6/23/23, 3:15 AM Atrial fibrillation Pathway Offer concomitant management of associated cardiovascular risk factors to target levels in overweight and obese patients with AF. B 6. Therapeutic procedures Electrical cardioversion: Perform emergency electrical cardioversion in patients with AF and acute or worsening hemodynamic instability. B Show 3 more Initiate anticoagulation as soon as possible in patients with AF of > 48 hours duration or unknown duration requiring immediate cardioversion for hemodynamic instability, and continue for at least 4 weeks after cardioversion unless contraindicated. B Decide on long-term anticoagulation therapy based on the thromboembolic and bleeding risk profiles after cardioversion for AF of any duration. B Consider performing immediate electrical cardioversion in patients whose recent-onset AF or atrial flutter is the direct cause of instability with hypotension, acute coronary syndrome, or pulmonary edema. B Perform urgent electrical cardioversion in hemodynamically unstable patients with AF. B Consider performing electrical cardioversion (either as first-line option or when pharmacological rhythm control fails) in hemodynamically stable patients with AF, after consideration of thromboembolic risk. B Catheter ablation: As per ESC 2021 guidelines, take into consideration the procedural risks and the major risk factors for recurrence following the procedure for the decision on catheter ablation of AF, and discuss the risks with the patient. B Show 10 more As per AHA 2019 guidelines, consider performing catheter ablation in selected patients with symptomatic AF and HFrEF to potentially lower mortality rate and reduce hospitalization for HF. C As per NHFA 2018 guidelines, perform catheter ablation of the atrioventricular node after a permanent pacing device has been implanted, if pharmacological rate control fails. B Show 3 more As per CCS 2014 guidelines, perform catheter ablation of AF in patients remaining symptomatic after an adequate trial of antiarrhythmic drug therapy and if a rhythm control strategy remains desired. B Atrioventricular node ablation: consider performing atrioventricular node ablation to control HR in patients with AF unresponsive or intolerant to intensive rate and rhythm control therapy, and not eligible for rhythm control by LA ablation, recognizing that these patients will become pacemaker dependent. C https://web.pathway.md/diseases/recZrV7qZIxyavdK7 10/20 6/23/23, 3:15 AM Atrial fibrillation Pathway 7. Perioperative care Pre-procedural anticoagulation interruption: balance the risks of a thromboembolic event (as indicated by a higher CHADS2 score, mechanical heart valve, or rheumatic heart disease) against a bleeding event (as indicated by a higher HASBLED score and procedures with higher bleeding risks) in patients with atrial flutter/AF to decide on interrupting antithrombotic therapy for an invasive procedure. B Show 6 more Pre-procedural anticoagulation bridging: As per AHA 2019 guidelines: Bridge with UFH or LMWH in patients with AF and a mechanical heart valve undergoing procedures requiring interruption of warfarin. Recognize that decisions on bridging therapy should balance the risks of stroke and bleeding. B Recognize that decisions about bridging therapy (UFH or LMWH) in patients with AF without mechanical heart valves requiring interruption of warfarin for procedures should balance the risks of stroke and bleeding and the duration of time the patient will not be anticoagulated. B As per NHFA 2018 guidelines, avoid bridging with LMWH or UFH in patients treated with warfarin, at low-to-moderate risk of stroke undergoing planned surgical intervention. D Show 2 more As per CCS 2014 guidelines, consider bridging with LMWH or UFH when the INR is below the therapeutic INR target when a decision to interrupt warfarin therapy for an invasive procedure has been made in patients with atrial flutter/AF at high risk of thromboembolic events (CHADS2 score 3, mechanical heart valve, stroke or TIA within 3 months, rheumatic heart disease). C Show 2 more Post-procedural resumption of anticoagulation: Consider restarting therapy once hemostasis is established when warfarin, acetylsalicylic acid, or clopidogrel have been withdrawn for an invasive procedure (usually 24-48 hours for procedures at low risk of bleeding). C Consider restarting therapy after the procedure 1 day after hemostasis is established when apixaban, dabigatran, or rivaroxaban have been withdrawn for an invasive procedure. C 8. Surgical interventions Left atrial appendage closure, indications: As per SCAI/HRS 2023 guidelines, consider performing transcatheter LA appendage closure in patients with nonvalvular AF with high thromboembolic risk unsuitable for long-term oral anticoagulation and having adequate life expectancy (minimum > 1 year) and quality of life to benefit from LA appendage closure. Ensure a patient-provider discussion for shared decision- making. E As per EACTS/EHRA/ESC 2021 guidelines: https://web.pathway.md/diseases/recZrV7qZIxyavdK7 11/20 6/23/23, 3:15 AM Atrial fibrillation Pathway Consider performing LA appendage occlusion for stroke prevention in patients with AF and contraindications for long-term anticoagulant treatment (such as intracranial bleeding without a reversible cause). C Consider performing surgical occlusion or exclusion of the LA appendage for stroke prevention in patients with AF undergoing cardiac surgery. C As per HRS/ACC/AHA 2019 guidelines: Consider performing surgical occlusion of the LA appendage in patients with AF undergoing cardiac surgery S4.4.2-1, as a component of an overall heart team approach to the management of AF. C Consider performing percutaneous LA appendage occlusion in patients with AF at increased risk of stroke who have contraindications to long-term anticoagulation. C As per NHFA 2018 guidelines, consider performing LA appendage occlusion for stroke prevention in patients with nonvalvular AF at moderate to high risk of stroke and with contraindications to OACs. B As per STS 2017 guidelines, consider performing LA appendage excision or exclusion in conjunction with surgical ablation for AF for long-term prevention of morbidity from thromboembolic events. C Left atrial appendage closure (perioperative imaging): obtain baseline TEE or cardiac CT before LA appendage closure. E Show 2 more Left atrial appendage closure, technical considerations: As per SCAI/HRS 2023 guidelines, comply with the testing and labeling of each specific LA appendage closure device for procedural venous access, anticoagulation, transseptal puncture, delivery sheath selection and placement, left atria pressure measurement, and device deployment. E Show 4 more As per CCS 2014 guidelines, avoid using non-approved LA appendage closure devices, except in the context of research, or in systematically documented use protocols in patients at high risk of stroke (CHADS2 score 2) if antithrombotic therapy is contraindicated. D Left atrial appendage closure (management of complications): ensure that operators are familiar with avoidance, recognition, and management of complications associated with LA appendage closure. E Show 4 more Left atrial appendage closure, postoperative anticoagulation: As per SCAI/HRS 2023 guidelines, initiate antithrombotic therapy with warfarin, direct OACs, or dual antiplatelet therapy after LA appendage closure according to the studied regimen and instructions for use for each specific device and tailored to the bleeding risks of each patient. E As per EACTS/EHRA/ESC 2021 guidelines, initiate long-term oral anticoagulation in patients after surgery for AF and appendage closure, based on the patient's thromboembolic risk assessed with the CHA2DS2-VASc score. B https://web.pathway.md/diseases/recZrV7qZIxyavdK7 12/20 6/23/23, 3:15 AM Atrial fibrillation Pathway Surgical ablation: As per ESC 2021 guidelines, consider performing concomitant ablation of AF in patients undergoing cardiac surgery, balancing the benefits of freedom from atrial arrhythmias and the risk factors for recurrence (LA dilatation, years in AF, age, renal dysfunction, and other cardiovascular risk factors). B Show 2 more As per NHFA 2018 guidelines: Consider performing surgical ablation of AF to restore sinus rhythm in the context of concomitant cardiac surgery in patients with symptomatic paroxysmal, persistent, or long- standing persistent AF. B Consider performing stand-alone surgical or hybrid ablation of AF in patients with symptomatic paroxysmal, persistent or long-standing persistent AF if: it is refractory or intolerant to at least one Class I or III antiarrhythmic drug percutaneous ablation failed the likelihood of successful percutaneous ablation is low. C As per STS 2017 guidelines, perform surgical ablation of AF in patients undergoing concomitant operations on the mitral valve. A Show 4 more 9. Specific circumstances Subclinical atrial fibrillation: As per ESC 2021 guidelines, obtain the following in patients with atrial high rate episodes/subclinical AF detected by cardiac implantable electronic devices or insertable cardiac monitor: complete cardiovascular evaluation with ECG recording, clinical risk factors/comorbidity evaluation, and thromboembolic risk assessment using the CHA2DS2-VASc score continued patient follow-up and monitoring (preferably with the support of remote monitoring) to detect progression to clinical AF, monitor the atrial high rate episodes/subclinical AF burden (especially transition to 24 hours), and detect changes in underlying clinical conditions. B As per AHA 2019 guidelines, perform further evaluation to document clinically relevant AF to guide treatment decisions in patients with cardiac implantable electronic devices (such as pacemakers or implanted cardioverter-defibrillators), in case of recorded atrial high-rate episodes. B As per CCS 2018 guidelines, consider initiating oral anticoagulation in patients who are aged 65 years or older or with a CHADS2 score of 1 who have episodes of subclinical AF lasting > 24 continuous hours in duration. High-risk patients (such as those with a recent embolic stroke of unknown source) with shorter-lasting episodes might also be considered for oral anticoagulation. C Postoperative atrial fibrillation (prevention): https://web.pathway.md/diseases/recZrV7qZIxyavdK7 13/20 6/23/23, 3:15 AM Atrial fibrillation Pathway Administer perioperative amiodarone or -blockers for the prevention of postoperative AF after cardiac surgery. A Do not administer -blockers routinely for the prevention of postoperative AF in patients undergoing non-cardiac surgery. D Postoperative atrial fibrillation (anticoagulation): consider initiating long-term OACs for the prevention of thromboembolic events, considering the anticipated net clinical benefit of OACs and informed patient preferences, in patients at risk for stroke with postoperative AF after either non- cardiac C or cardiac surgery. C Patients with active bleeding: As per ESC 2021 guidelines, interrupt OACs in patients with AF and severe active bleeding until the cause of bleeding is identified and active bleeding is resolved. B Show 2 more As per AHA 2019 guidelines: Administer idarucizumab for the reversal of dabigatran in the event of life-threatening bleeding or an urgent procedure. B Consider administering andexanet alfa for the reversal of rivaroxaban and apixaban in the event of life-threatening or uncontrolled bleeding. C As per NHFA 2018 guidelines, administer idarucizumab in patients taking dabigatran experiencing life-threatening bleeding or requiring emergency surgery. B 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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