Atrial Fibrillation Update
HeartRhythmBox.com
Early Rhythm Control REDUCES CV Outcomes: EAST-AFNET 4 Trial
EHJ 2014.
EAST-AFNET 4 Trial
EAST-AFNET 4 Trial
EAST-AFNET 4 Trial
EAST-AFNET 4 Trial
EAST-AFNET 4 Trial
 WHY
early rhythm control works?
 Slow the progression of atrial cardiomyopathy.
median time since diagnosis = 36days.
lower stroke rate in rhythm control group but no differences in CV hospitalizations.
 Better & Safer Rhythm Control
no differences in non-CV deaths & Torsades.
very low complication rates from ablation.
 Rhythm control group received more attention.
patients were not blinded to Tx.
rhythm control groups needed to send ECG via Vitaphone 2/wk; would trigger a visit if AF.
 Non-uniform dropout
though some statistical maneuvers were used to fix the dropout, the missing data of nearly 10% can potentially invalidate the analysis.
9% dropout in early rhythm control group and 6.6% in the control.
 Low Event Rates with This Era Regimens
  • Guidelines recommended treatment-- 90% anticoagulated, 40% on Statin, and 70% on MRA.
  • Stroke rate <1%/100 persons-yr in both group.
  • Symptoms improvement approximately from 30% asymptomatic at baseline to 70% asympatomatic after Tx in both groups.
 Early Rhythm Control for WHOM?
  • Age 70, CHA2DS2-VASc 3.4, 88% hypertension.
  • 38% first episode, 27% persistent.
  • 30% asymptomatic.
  • >50% in rhythm control group on IC.
 HOW early?
  • Median 36 days (6-114 days).
  • 38% first episode.
Early rhythm-control therapy was associated with a lower risk of cardiovascular outcomes than usual care among patients with early atrial fibrillation and cardiovascular conditions.
Screening for AF: WHOM? & HOW?
Thromb Haemost. 2013.
Circulation. 2013.
2020 ESC Guidelines for AF.

Suspected AF from non-ECG recording
i.e. pulse palpation or PPG method from wearable.
Confirmatory ECG diagnosis has to be obtained using additional ECG recording (e.g. 12-lead ECG, Holter monitoring, etc.)

Suspected AF from ECG recording
i.e. 12-lead ECG or ≥30s ECG tracing from wearables
Analysed by a physician with expertise in ECG rhythm interpretation
2020 ESC Guidelines for AF.
2020 ESC Guidelines for AF.
The risk of AF and stroke increases with age, thus justifying AF screening in the elderly.
'CC' to 'ABC'
2020 ESC Guidelines for AF.
2020 ESC Guidelines for AF.
2020 ESC Guidelines for AF.
The new approach to AF
1. Confirm AF (12-lead ECG or a rhythm strip of ≥30s of AF) and Characterize by using 4S scheme.
2. 'ABC' for integrated AF management.
Anticoagulation in the Essence
CHA2DS2-VASc
over
CHA2DS2-VA
Circulation 2018.
2020 ESC Guidelines for AF.
 ABSOLUTE
contraindications to anticoagulants.
active serious bleeding
where the source should be identified and treated.
associated comorbidities
e.g. severe thrombocytopenia <50 platelets/mcL, severe anaemia under investigation, etc.
recent high-risk bleeding event
such as intracranial hemorrhage.
2020 ESC Guidelines for AF.
1. For stroke prevention, NOACs are preferred over VKA.
2. For stroke risk assessment, a risk-base approach is recommended.
Catheter Ablation for AF
CASTLE-AF.
CABANA Trial.
Circulation: Arrhythmia and Electrophysiology. 2019.
2020 ESC Guidelines for AF.
NEW in this guidelines. Catheter ablation for AF:
1. is now recommended to improve symptoms after failed AAD in all types of AF including persistent AF.
2. is recommended to reverse LV function in tachycardia induced cardiomyopathy.
3. should be considered to improve SURVIVAL in HFrEF.
Subclinical AF (SCAF) detected by Cardiac Implantable Electronic Devices
Circulation. 2019
Circulation 2019.
2020 ESC Guidelines for AF.
No RCTs on how to manage SCAF available yet. However, OAC may be considered in patients with SCAF of ≥24h and high stroke risks.
PostOperative AF
2020 ESC Guidelines for AF.
JAMA Cardiol. 2018.
JACC. 2018.
1. Periop BB or amiodarone is recommended for prevention of postOp AF.
2. No RCTs on long-term OAC yet. (IIa for non-cardiac Sx and IIb for cardiac Sx)
Lifestyle Intervention
2020 ESC Guidelines for AF.
Am J Med. 2013.
Heart. 2013.
Sci Rep 2019.
Can J Cardiol. 2014.
Weight control, avoid excess alcohol, and exercise but not excessive. Caffeine unlikely contributes to AF.
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