ESC Congress FA eBook 2016 - 3

ESC CONGRESS 2016

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IN REVIEW

FOCUS ON ARRHYTHMIAS

regularly for atrial high-rate episodes (AHRE; > 5 to 6 minutes and > 180 bpm). AHRE are associated with a 2.5-fold
increase in the risk of thromboembolic event [Healey JS et
al. N Engl J Med. 2012] but lower risk of stroke than overt
AF. Patients with AHRE should therefore undergo further
electrocardiogram monitoring to document AF before initiating anticoagulant therapy.
There is evidence of inconsistent approaches to cardiovascular risk reduction in patients with AF, underuse of anticoagulation, and inappropriate use of rhythm
control therapy [Pilote L et al. Can J Cardiol. 2013].
According to the guidelines, almost all patients with AF
will likely benefit from anticoagulation unless they are at
truly low risk for stroke (CHA2DS2VASc score 0 for men or
1 for women) or have absolute contraindications.
The ESC recommends an integrated approach to
management of AF with structured organization of care
and follow-up to improve guideline adherence and
reduce hospitalizations and mortality. Encouraging
patients to take a central role in their care process by
providing information and education on lifestyle and
risk factor management empowers them to support their
AF management.
All patients diagnosed with AF should be evaluated
for underlying conditions independently associated with
AF, including HF, hypertension, chronic kidney disease,
airways disease, sleep apnea and diabetes, with careful
attention to lifestyle factors such as obesity.
The guidelines recommend using the modified
European Heart Rhythm Association (EHRA) symptom
scale to score AF-related symptoms to facilitate monitoring over time (Table 1).

STROKE RISK STRATIFICATION AND PREVENTION

Jonas Oldgren, MD, Uppsala University, Uppsala,
Sweden, presented the guideline recommendations for
stroke prevention therapy in AF. Oral anticoagulants
(OACs) can prevent the majority of ischemic strokes
and prolong survival. Although OAC therapy is recommended for most patients, underuse or premature termination of therapy is common because of the perceived
risk of bleeding and the effort required to monitor vitamin K antagonists (VKAs). However, the benefit in stroke
reduction with OACs outweighs the risk of bleeding in
most patients, and therefore bleeding risk should not
prevent the use of OACs in patients at risk of stroke.
The CHA2DS2-VASc clinical risk score is recommended for estimating stroke risk in patients with AF
(Table 2) [Lip GY et al. Chest 2010]. Men and women
without risk factors do not usually require OAC or antiplatelets. Women with a CHA2DS2-VASc of 2 and men
with a CHA2DS2-VASc score of 1 should consider OAC,
based on individual characteristics and patient preferences due to the low and variable risk of stroke. Women
with a CHA2DS2-VASc of 3 and above, and men with a
CHA2DS2-VASc score of 2 and above are recommended
to receive OAC. The new guidelines give a preference to
non-vitamin K OAC, except in patients with prosthetic
heart valves, moderate-severe mitral stenosis or severe
chronic kidney disease, where VKAs such as warfarin are
recommended.
Table 2. Clinical Risk Factors for Stroke, Transient Ischemic
Attack, and Systemic Embolism
CHA2DS2-VASc Risk Factor

Points

Congestive HF Signs or symptoms of HF or objective
evidence of reduced LVEF

Hypertension
Resting blood pressure > 140/90 mm Hg on at least 2
occasions or current antihypertensive treatment

Age 75 years or older

Diabetes mellitus
Fasting glucose > 125 mg/dL (7 mmol/L) or treatment with
oral hypoglycemic agent or insulin

Previous stroke, transient ischemic attach, or
thromboembolism

Vascular disease
Previous MI, peripheral artery disease, or aortic plaque

AF, atrial fibrillation; EHRA, European Heart Rhythm Association.

Age 65-74 years

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.

Sex category (female)

Table 1. Modified EHRA Symptom Scale
Modified EHRA Score

Symptoms

Description

None

AF does not cause any symptoms

Mild

Normal daily activity not affected
by symptoms related to AF

Moderate

Normal daily activity not affected
by symptoms related to AF but
patient troubled by symptoms

Severe

Normal daily activity affected by
symptoms related to AF

Disabling

Normal daily activity discontinued

HF, heart failure; MI, myocardial infarction.

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