ESC Congress 2016 - 3

Your FREE access to ESC Congress content all year long www.escardio.org/365 ESC CONGRESS 2016 IN REVIEW Most patients with AF benefit from oral anticoagulation. The ESC algorithm on the initiation of anticoagulation for stroke prevention is based on the presence or absence of diseased mechanical heart valves or mitral stenosis, risk assessment, clinical stroke risk assessment using the CHA2DS2-VASc score, and assessment for true, contraindications to anticoagulation (Figure 2). NOACs are recommended as first-line therapy in suitable patients based on their safety. The guidelines recommend reduction of modifiable bleeding risk factors in anticoagulated patients. Active bleeding should be managed according to severity, with delay of anticoagulation, symptomatic treatment, and reversal of anticoagulation in severe or life-threatening cases. These recommendations, supported by an integrated approach to care, should help to reduce the number of AF patients in whom oral anticoagulation is stopped despite high stroke risk. Long-term heart rate control preserves left ventricular (LV) function and ameliorates AF symptoms. Figure 3 shows rate control recommendations. The ESC guidelines recommend rhythm control therapy for symptom improvement in patients with AF (Tables 1 and 2). Figure 2. Algorithm for Initiation of Stroke Prevention Therapy Figure 3. Algorithm for Long-Term Rate Control Mechanical heart valves or moderate or severe mitral stenosis Yes Long-term heart rate control of AF No Estimate stroke risk based on number of CHA 2DS 2-VASc risk factors 0a 1 Perform echocardiogram (IC) Choose initial rate control therapy (IB) and combination therapy if required (IIaC) Target initial resting heart rate <110 bpm (IIaB), avoiding bradycardia ≥ 2b LVEF <40% No antiplatelet or anticoagulant treatment (IIIB) OAC should be considered (IIaB) Oral anticoagulation indicated Assess for contra-indications Correct reversible bleeding risk factors LAA occluding devices may be considered in patients with clear contraindications for OAC (IIbC) ß-blocker LVEF ≥40% Digoxin Consider early low-dose combination therapy NOAC (IA) VKA (IA) c Add digoxin Includes women without other stroke risk factors b IIaB for women with only one additional stroke risk factor c IB for patients with mechanical heart valves or mitral stenosis a LAA, left atrial appendage; NOAC, non-vitamin K antagonist oral anticoagulant; OAC, oral anticoagulant; VKA, vitamin K antagonist. Reprinted from Kirchhof P et al. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J. 2016. doi:10.1093/eurheartj/ehw210. By permission of Oxford University Press on behalf of the European Society of Cardiology. Add ß-blocker Diltiazem/ verapamil ß-blocker Digoxin Add therapy to achieve target heart rate or if ongoing symptoms Add digoxin Add digoxin Add diltiazem, verapamil or ß-blocker AF, atrial fibrillation; LVEF, left ventricular ejection fraction. Reprinted from Kirchhof P et al. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J. 2016. doi:10.1093/eurheartj/ehw210. By permission of Oxford University Press on behalf of the European Society of Cardiology. Table 1. Major Recommendations for Antiarrhythmic Therapy Recommendations Class Level I B Electrical conversion of AF is recommended in patients with acute hemodynamic instability to restore cardiac output. I B Cardioversion of AF (either electrical or pharmacological) is recommended in symptomatic patients with persistent or long-standing persistent AF as part of rhythm control therapy. I B I A IIa B III (harm) C General recommendations Rhythm control therapy is indicated for symptom improvement in patients with AF. Cardioversion of AF AAD for long-term maintenance of sinus rhythm/prevention of recurrent AF The choice of AAD needs to be carefully evaluated, taking into account the presence of comorbidities, CV risk and potential for serious proarrhythmia, extracardiac toxic effects, patient preferences, and symptom burden. ECG recording during the initiation of AAD therapy should be considered to monitor heart rate, detect QRS and QT interval prolongation, and the occurrence of AV block. AAD therapy is not recommended in patients with prolonged QT interval (> 0.5 s) or those with significant sinoatrial node disease or AV node dysfunction who do not have a functioning permanent pacemaker. AF, atrial fibrillation; AAD, antiarrhythmic drug; AV, atrioventricular; CV, cardiovascular; ECG, electrocardiogram. Adapted from Kirchhof P et al. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J. 2016. doi:10.1093/eurheartj/ehw210. By permission of Oxford University Press on behalf of the European Society of Cardiology. Official Peer-Reviewed Highlights From ESC Congress 2016 3 http://www.escardio.org/365

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