Patients with arrhythmia should choose the treatment plan with their health professionals, according to European Society of Cardiology (ESC) guidelines published online today in European Heart Journal, and on the ESC website—coinciding with the ESC Congress 2020 (Virtual, 29 August–1 September).
The document was developed in collaboration with the European Association of Cardio-Thoracic Surgery (EACTS). “Patients want to be involved in decisions about their care and their preferences should be respected,” said Gerhard Hindricks, chairperson of the guidelines Task Force and medical director of the Rhythmology Department, Heart Centre Leipzig, Leipzig, Germany.
It is estimated that one in three Europeans will develop atrial fibrillation. It is associated with a twofold increased risk of death in women and a 1.5-fold increase in men. People with atrial fibrillation are twice as likely to be admitted to hospital as their peers without the condition. Symptoms include palpitations, shortness of breath, fatigue, and difficulty sleeping. Up to one in five patients are depressed. More than 60% of patients report significantly impaired quality of life, while cognitive decline and dementia are around 50% more likely than in the general population.
The guidelines advocate the Atrial fibrillation Better Care (ABC) pathway. ‘A’ (Anticoagulation/Avoid stroke) involves anticoagulation medication to prevent stroke except in patients at low risk. ‘B’ (Better symptom management) refers to controlling heart rate and heart rhythm with medications and procedures. ‘C’ (Cardiovascular and Comorbidity optimisation) is management of other conditions such as high blood pressure and lifestyle – for example smoking cessation, improved nutrition to lose weight, avoiding excess alcohol, and moderate intensity exercise.
An individualised care plan should be agreed after patients and their family discuss the advantages and limitations of each treatment option with an interdisciplinary team including cardiologists, nurses, and psychologists. Success of treatment from the patient’s perspective should be assessed by routinely collecting information on quality of life, symptoms, cognitive function, and ability to work and be physically active. Prevention of stroke is a vital part of treatment.
Atrial fibrillation is one of the most frequent heart rhythm disorders during pregnancy—especially in older women and those born with heart defects – and is associated with an increased risk of death. Vaginal delivery is contraindicated in women taking warfarin because of bleeding risks for the baby. Use of non-vitamin K antagonist oral anticoagulants (NOACs) is prohibited during pregnancy.
Athletes are around five times more likely to develop atrial fibrillation during their lifetime compared to sedentary individuals. Endurance sports such as running, cycling, and cross-country skiing carry the highest risk. Professional athletes should be advised that long-lasting intense sports participation may promote atrial fibrillation. Contact sports should be avoided in patients on oral anticoagulants due to the risks of bleeding.
Screening could identify people with previously undiagnosed atrial fibrillation who could then receivetreatment to prevent stroke. More than 100,000 apps for smartphones, wrist bands, and watches and at least 400 wearable activity monitors are available—but the guidelines state that caution is needed as many are not clinically validated to detect atrial fibrillation.
Opportunistic screening is advised for people aged 65 and over and for people with high blood pressure, who should have their pulse taken or undergo an electrocardiogram (ECG). Individuals should be informed about the treatment implications of detecting atrial fibrillation. Those who test positive should be referred to a physician to confirm the diagnosis.
“People with unhealthy lifestyles are more likely to develop atrial fibrillation,” said Tatjana Potpara, Chairperson of the guidelines Task Force and head of the Department for Intensive Arrhythmia Care, Clinical Centre of Serbia, Belgrade, Serbia. “Risk can be reduced by lifestyle modification – for example, weight control, and moderate physical activity.”