Atrial fibrillation (AF) is one of the most common heart diseases worldwide(1). In addition to the elevated rates of morbidity and mortality, this condition also entails a substantial economic burden on health care systems. Moreover, according to the latest epidemiological data, the prevalence of atrial fibrillation will double in the next decades(2,3). This phenomenon is a result of the advancements in the diagnostic management of this arrhythmia and the aging of the population(2,3).
The early management of the risk factors for AF and comorbidities of these patients has been demonstrated to be the most effective method of enhancing their prognosis(4). Consequently, the 2024 European Society of Cardiology (ESC) guidelines for the management of AF established the AF-CARE framework (C = comorbidities and risk factor management; A = avoidance of stroke and thromboembolism; R = reduction of symptoms by rate and rhythm control; E = evaluation and dynamic reassessment)(4). This new guideline recommends:
• lowering blood pressure values in patients with AF and hypertension to avoid the recurrence and advancement of AF, but also the incidence of other adverse cardiovascular events;
• the use of diuretics in patients with AF and congestive heart failure (HF) to reduce symptoms;
• the use of sodium-glucose cotransporter 2 inhibitors in patients with AF and HF, regardless of the ejection fraction of the left ventricle, to reduce the risk of hospitalization and cardiovascular death;
• control of glycemic levels in patients with AF and diabetes;
• weight loss of at least 10% in overweight or obese patients;
• regular physical exercises in patients with paroxysmal or persistent AF to reduce recurrent AF;
• bariatric surgery can be considered (along with lifestyle modifications) in patients with AF and a body mass index ≥40 kg/m2.
• reduce alcohol consumption to less than 30 grams per week.
• management of obstructive sleep apnea4.
Another key aspect of this guideline is represented by the active involvement of the patient in therapeutic decisions, the final goal being to increase his compliance to treatment and, secondly, to improve his prognosis(4).
AF is an important risk factor for thromboembolic events(4). Thus, the assessment of the necessity for anticoagulant therapy is one of the foundations of the management of these patients. The current ESC 2024 guideline comes with a change regarding the score used to estimate the thromboembolic risk in patients with AF, namely, the replacement of the CHA2DS2-VASc (congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, prior stroke/transient ischemic attack/arterial thromboembolism, vascular disease, age 65-74 years, sex category) score with the CHA2DS2-VA (congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, prior stroke/transient ischemic attack/arterial thromboembolism, vascular disease, age 65-74 years) score, which removes the patient’s gender from the criteria(4). According to this score, it is recommended to initiate anticoagulant treatment in patients with a CHA2DS2-VA score ≥2, as well as to consider anticoagulant treatment in those with a CHA2DS2-VA score ≥1(4). Among anticoagulant medications, the direct oral anticoagulants (DOAC) apixaban, rivaroxaban, edoxaban, and dabigatran are favored, excepting patients with mechanical heart valves or moderate to severe mitral stenosis, for whom vitamin K antagonists (VKAs) are advised(4). When using VKAs, the recommended dosage adjustment is to maintain a target INR of 2-3(4). It is also recommended to switch from DOAC to VKA in patients with an increased risk of intracranial hemorrhage or a poor control of INR values. Adding an antiplatelet agent to anticoagulant therapy to mitigate the risk of thromboembolic events is not advisable(4).
Concerning the risk of hemorrhage, there are infrequent circumstances that necessitate the cessation of anticoagulant therapy(4). It is advisable to address the hemorrhagic risk factors prior to initiating anticoagulant treatment. This includes reducing excessive alcohol consumption, maintaining strict control of arterial hypertension, refraining from the use of antiplatelet and anti-inflammatory medications, and evaluating the risk of polypharmacy(4). The same guideline recommends using a specific antidote for DOAC only for hemorrhage that is life-threatening(4).
In summary, the delicate equilibrium between thromboembolic and hemorrhagic risk requires vigilant surveillance and multidisciplinary management of patients with AF.
Full text sources https://doi.org/10.31688/ABMU.2024.59.4.327
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Address for correspondence:
Camelia C. DIACONU
E-mail: drcameliadiaconu@gmail.com
