Atrial Fibrillation Management (ESC 2024 AF-CARE)

Algorithm Steps

1. ▶

   Start

   New-Onset AFib Detected

   Patient presents with atrial fibrillation

   1. ●

      Action

      [C] Comorbidities & Risk Factors

      Address modifiable risk factors

      • Hypertension management
      • Obesity/weight loss
      • Diabetes control
      • Sleep apnea treatment (CPAP)
      • Alcohol reduction
      • Exercise program
      1. ◆

         Decision

         [A] Stroke Risk Assessment

         Calculate CHA₂DS₂-VA Score

         • C: Congestive HF (+1)
         • H: Hypertension (+1)
         • A₂: Age ≥75 (+2)
         • D: Diabetes (+1)
         • S₂: Stroke/TIA/TE (+2)
         • V: Vascular disease (+1)
         • A: Age 65-74 (+1)
         • Note: Sex removed in ESC 2024
         1. ●

            Action

            Score ≥2: Anticoagulate

            Oral anticoagulation recommended (Class I)

            • DOAC preferred over warfarin
            • Apixaban, Rivaroxaban, Edoxaban, or Dabigatran
            • Check renal function for dosing
            1. ◆

               Decision

               [R] Symptom Management

               Rate vs Rhythm Control Strategy

               • Assess symptom burden (EHRA score)
               • Consider patient preference
               • Age and activity level
               1. ●

                  Action

                  Rate Control

                  Target HR <110 bpm at rest (lenient)

                  • Beta-blocker (bisoprolol, metoprolol)
                  • Diltiazem/Verapamil (if no HFrEF)
                  • Digoxin (adjunct, not monotherapy)
                  • Stricter control (<80) if persistent symptoms
                  1. ●

                     Action

                     [E] Evaluate & Reassess

                     Ongoing monitoring and adjustment

                     • Regular follow-up (3-6 months)
                     • Symptom assessment (EHRA score)
                     • Check therapy adherence
                     • Renal function monitoring (DOAC dosing)
                     • Adjust strategy as needed
                     1. ✓

                        Outcome

                        AFib Controlled

                        Symptoms managed, stroke risk addressed

                     2. ⚠

                        Warning

                        Consider Specialist Referral

                        Complex cases, refractory symptoms, ablation candidate

               2. ●

                  Action

                  Rhythm Control

                  Preferred for younger, symptomatic patients

                  • Cardioversion (electrical or pharmacological)
                  • Antiarrhythmic drugs (Class I, III)
                  • Catheter ablation (Class I for symptom control)
                  • Consider early rhythm control (EAST-AFNET 4)
         2. ●

            Action

            Score 1: Consider OAC

            Shared decision-making (Class IIa)

            • Discuss bleeding vs stroke risk
            • Use HAS-BLED to identify modifiable risks
            • Do NOT withhold OAC due to bleeding risk
         3. ●

            Action

            Score 0: No OAC

            Anticoagulation not recommended

            • Reassess if risk factors develop
            • Annual stroke risk <1%