European Heart Journal (2020) 00,1À126 ESC GUIDELINES doi:10.1093/eurheartj/ehaa612 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in Downloaded from https://academic.oup.com/eurheartj/advance-article/doi/10.1093/eurheartj/ehaa612/5899003 by guest on 31 August 2020 collaboration with the European Association of Cardio-Thoracic Surgery (EACTS) The Task Force for the diagnosis and management of atrial fibrillation of the European Society of Cardiology (ESC) Developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC Authors/Task Force Members: Gerhard Hindricks* (Chairperson) (Germany), Tatjana Potpara* (Chairperson) (Serbia), Nikolaos Dagres (Germany), Elena Arbelo (Spain), Jeroen J. Bax (Netherlands), Carina Blomstro¨m-Lundqvist (Sweden), Giuseppe Boriani (Italy), Manuel Castella1 (Spain), Gheorghe-Andrei Dan (Romania), Polychronis E. Dilaveris (Greece), Laurent Fauchier (France), Gerasimos Filippatos (Greece), Jonathan M. Kalman (Australia), Mark La Meir1 * Corresponding authors: The two chairpersons contributed equally to the document. Gerhard Hindricks, University Clinic of Cardiology, Heart Center Leipzig, Department of Cardiology and Electrophysiology, Leipzig Heart Institute, Stru¨mpellstr. 39, 04289 Leipzig, Germany. Tel: þ49 34 1865 1410, Fax: þ49 34 1865 1460, Email: [email protected] Tatjana Potpara, School of Medicine, Belgrade University, dr Subotica 8, 11000 Belgrade, Serbia, and Cardiology Clinic, Clinical Centre of Serbia, Visegradska 26, 11000 Belgrade, Serbia. Tel: þ38 11 1361 6319, Email: [email protected] ESC Committee for Practice Guidelines (CPG) and National Cardiac Societies document reviewers, and Author/Task Force Member affiliations: listed in the Appendix. 1Representing the European Association of Cardio-Thoracic Surgery (EACTS) ESC entities having participated in the development of this document: Associations: Association for Acute CardioVascular Care (ACVC), Association of Cardiovascular Nursing & Allied Professions (ACNAP), European Association of Cardiovascular Imaging (EACVI), European Association of Preventive Cardiology (EAPC), European Association of Percutaneous Cardiovascular Interventions (EAPCI), European Heart Rhythm Association (EHRA), Heart Failure Association (HFA). Councils: Council on Stroke, Council on Valvular Heart Disease. Working Groups: Cardiac Cellular Electrophysiology, Cardiovascular Pharmacotherapy, Cardiovascular Surgery, e-Cardiology, Thrombosis. The content of these European Society of Cardiology (ESC) Guidelines has been published for personal and educational use only. No commercial use is authorized. No part of the ESC Guidelines may be translated or reproduced in any form without written permission from the ESC. Permission can be obtained upon submission of a written request to Oxford University Press, the publisher of the European Heart Journal and the party authorized to handle such permissions on behalf of the ESC ([email protected]). Disclaimer The ESC Guidelines represent the views of the ESC and were produced after careful consideration of the scientific and medical knowledge and the evidence avail- able at the time of their publication. The ESC is not responsible in the event of any contradiction, discrepancy and/or ambiguity between the ESC Guidelines and any other offi- cial recommendations or guidelines issued by the relevant public health authorities, in particular in relation to good use of healthcare or therapeutic strategies. Health professionals are encouraged to take the ESC Guidelines fully into account when exercising their clinical judgment, as well as in the determination and the implementation of pre- ventive, diagnostic or therapeutic medical strategies; however, the ESC Guidelines do not override, in any way whatsoever, the individual responsibility of health professionals to make appropriate and accurate decisions in consideration of each patient’s health condition and in consultation with that patient and, where appropriate and/or necessary, the patient’s caregiver. Nor do the ESC Guidelines exempt health professionals from taking into full and careful consideration the relevant official updated recommendations or guidelines issued by the competent public health authorities, in order to manage each patient’s case in light of the scientifically accepted data pursuant to their respective ethical and professional obligations. It is also the health professional’s responsibility to verify the applicable rules and regulations relating to drugs and medical devices at the time of prescription. VC The European Society of Cardiology 2020. All rights reserved. For permissions please email: [email protected]. 2 ESC Guidelines (Belgium), Deirdre A. Lane (United Kingdom), Jean-Pierre Lebeau (France), Maddalena Lettino (Italy), Gregory Y. H. Lip (United Kingdom), Fausto J. Pinto (Portugal), G. Neil Thomas (United Kingdom), Marco Valgimigli (Switzerland), Isabelle C. Van Gelder (Netherlands), Bart P.Van Putte1 (Netherlands), Caroline L. Watkins (United Kingdom) Downloaded from https://academic.oup.com/eurheartj/advance-article/doi/10.1093/eurheartj/ehaa612/5899003 by guest on 31 August 2020 Document Reviewers: Paulus Kirchhof (CPG Review Coordinator) (United Kingdom/Germany), Michael Ku¨ hne (CPG Review Coordinator) (Switzerland), Victor Aboyans (France), Anders Ahlsson1 (Sweden), Pawel Balsam (Poland), Johann Bauersachs (Germany), Stefano Benussi1 (Italy), Axel Brandes (Denmark), Frieder Braunschweig (Sweden), A. John Camm (United Kingdom), Davide Capodanno (Italy), Barbara Casadei (United Kingdom), David Conen (Canada), Harry J. G. M. Crijns (Netherlands), Victoria Delgado (Netherlands), Dobromir Dobrev (Germany), Heinz Drexel (Austria), Lars Eckardt (Germany), Donna Fitzsimons (United Kingdom), Thierry Folliguet (France), Chris P. Gale (United Kingdom), Bulent Gorenek (Turkey), Karl Georg Haeusler (Germany), Hein Heidbuchel (Belgium), Bernard Iung (France), Hugo A. Katus (Germany), Dipak Kotecha (United Kingdom), Ulf Landmesser (Germany), Christophe Leclercq (France), Basil S. Lewis (Israel), Julia Mascherbauer (Austria), Jose Luis Merino (Spain), Be´ la Merkely (Hungary), Lluıs Mont (Spain), Christian Mueller (Switzerland), Klaudia V. Nagy (Hungary), Jonas Oldgren (Sweden), Nikola Pavlovic (Croatia), Roberto F. E. Pedretti (Italy), Steffen E. Petersen (United Kingdom), Jonathan P. Piccini (United States of America), Bogdan A. Popescu (Romania), Helmut Pu¨ rerfellner (Austria), Dimitrios J. Richter (Greece), Marco Roffi (Switzerland), Andrea Rubboli (Italy), Daniel Scherr (Austria), Renate B. Schnabel (Germany), Iain A. Simpson (United Kingdom), Evgeny Shlyakhto (Russia), Moritz F. Sinner (Germany), Jan Steffel (Switzerland), Miguel Sousa-Uva (Portugal), Piotr Suwalski1 (Poland), Martin Svetlosak (Slovakia), Rhian M. Touyz (United Kingdom) The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website www.escardio.org/guidelines For the Supplementary Data which include background information and detailed discussion of the data that have provided the basis for the Guidelines see European Heart Journal online. ................................................................................................................................................................................................... Keywords Guidelines • atrial fibrillation • anticoagulation • vitamin K antagonists • non-vitamin K antagonist oral antico- agulants • left atrial appendage occlusion • rate control • rhythm control • cardioversion • antiarrhythmic drugs • catheter ablation • pulmonary vein isolation • left atrial ablation • AF surgery • upstream therapy • ABC pathway • screening • stroke • recommendations . Table of contents . 6.2 Definition and assessment of atrial fibrillation burden . 19 . 6.3Atrialfibrillationprogression................................. 20 1Preamble..........................................................6 . 6.4 Atrial cardiomyopathy: definition, classification, clinical 2Introduction.......................................................8 . implications,anddiagnosticassessment........................... 20 2.1Whatisnewinthe2020Guidelines?............................9 . 7Screeningforatrialfibrillation..................................... 20 3Definitionanddiagnosisofatrialfibrillation........................ 13 . 7.1Screeningtools.............................................. 20 3.1Definition ................................................... 13 . 7.2Screeningtypesandstrategies................................ 22 3.2Diagnosticcriteriaforatrialfibrillation ........................ 14 . 7.3 Benefits from and risks of screening for atrial fibrillation . 22 . 3.3 Diagnosis of atrial high-rate episodes/subclinical atrial . 7.4 Cost-effectiveness of screening for atrial fibrillation . 22 fibrillation....................................................... 14 . 7.5Screeninginhigh-riskpopulations ............................ 23 . 4Epidemiology.................................................... 14 . 7.5.1Elderly.................................................. 23 4.1 Prediction of incident atrial fibrillation . 16 . 8 Diagnostic assessment in atrial fibrillation . 23 . 4.2Pathophysiologyofatrialfibrillation........................... 16 . 8.1Symptomsandqualityoflife.................................. 23 5Clinicalfeaturesofatrialfibrillation................................ 16 .