POLSKI
Introduction
Atrial fibrillation (AF) is the most common supraventricular arrhythmia, affecting over 50 million people worldwide in 2021 [1]. In Europe and the United States, the prevalence of AF is approximately 1–4%, while in Asia, it is significantly lower, ranging between 0.49% and 1.9% [2]. With the aging population, an increasing number of risk factors, advancements in diagnostic technologies, and growing patient awareness, both the incidence and prevalence of atrial fibrillation continue to rise. Projections indicate that by 2060, the number of individuals affected by AF will double [1].
Risk factors for atrial fibrillation can be divided into non-modifiable and modifiable categories. The first group includes: age (the risk increases with age, especially after 65 years), male gender, a family history of the arrhythmia, and Caucasian race [7]. The second group encompasses cardiac conditions such as coronary artery disease, valvular defects (particularly mitral regurgitation), heart failure, and hypertension. Non-cardiac conditions predisposing to atrial fibrillation include obesity, diabetes, hyperlipidemia, thyroid disorders (even subclinical), obstructive sleep apnea, chronic obstructive pulmonary disease, and chronic kidney disease. Additionally, lifestyle-related factors such as excessive alcohol consumption, smoking, physical inactivity, stress, and the use of psychoactive substances should also be considered [3-13].
The consequences of atrial fibrillation pose a serious threat to patients’ health and significantly affect their quality of life. The most severe complications are thromboembolic events, primarily stroke, which can result in increased mortality or permanent disability [14]. AF increases the risk of stroke fivefold in patients without valvular defects and tenfold in those with coexisting mitral stenosis [15]. Current data estimate that AF accounts for approximately 25% of ischemic strokes [15]. Subclinical brain damage is another concern, as even asymptomatic AF episodes can lead to small, multiple ischemic lesions in the brain, potentially contributing over time to cognitive impairment and vascular dementia [16]. AF with rapid, uncontrolled ventricular response can result in tachyarrhythmic cardiomyopathy or exacerbate pre-existing heart failure [17,18]. Furthermore, AF may lead to anxiety, depression, and a sense of uncertainty, driven by fear of sudden health deterioration [19, 20].
Diagnosis of AF
The diagnosis of atrial fibrillation requires documentation of the arrhythmia on an electrocardiogram (ECG). Diagnostic criteria include the absence of repetitive P waves, the presence of irregular, varying f-waves with a frequency of 350–600/min, and irregular RR intervals (in the absence of atrioventricular block) [21]. Recording the arrhythmia on a standard 12-lead ECG or during prolonged monitoring (single- or multi-lead) lasting at least 30 seconds is recommended to confirm the diagnosis of AF and initiate risk assessment and treatment [22]. Recently, many commercially available heart monitoring devices, such as smartwatches or fitness bands, have become widespread. While detecting arrhythmias with such devices is useful, it cannot confirm an AF diagnosis and requires verification with an ECG. For earlier detection of AF, routine heart rhythm assessment during a medical visit is recommended for all individuals over 65 years of age (class I recommendation). Population-based screening using non-invasive ECG monitoring should be considered for individuals aged ≥75 years or ≥65 years with additional CHA2DS2-VA risk factors (class IIa recommendation) [22].
Atrial fibrillation can be classified according to its duration as follows:
First-diagnosed AF – When the arrhythmia has not been previously diagnosed, regardless of symptoms or duration.
Paroxysmal AF – Self-terminates or resolves with intervention within 7 days. Spontaneous resolution typically occurs within <48 hours from the onset of the arrhythmia.
Persistent AF – Lasts for more than 7 days or is terminated by cardioversion (electrical or pharmacological) after more than 7 days. Long-standing persistent AF refers to arrhythmia lasting >12 months, where a rhythm control strategy is still being considered.
Permanent AF – When both the patient and the physician accept the arrhythmia, and no attempts are made to restore sinus rhythm [23].
The symptoms of atrial fibrillation are varied and extend beyond the typical heart palpitations. Less specific symptoms include shortness of breath, fatigue, reduced exercise tolerance, chest pain, dizziness, fainting, anxiety, depression, and sleep disturbances. Asymptomatic episodes can also occur, although 90% of patients with AF report symptoms of varying intensity, which undoubtedly affect their quality of life. Among symptomatic patients, some episodes of atrial fibrillation may still remain unnoticed [22]. The severity of symptoms can be assessed using the modified EHRA scale (Table 1).
Table 1
Modified classification of AF symptoms according to the European Heart Rhythm Association (mEHRA) based on [22].
The treatment of atrial fibrillation requires a comprehensive approach due to the diverse symptoms, risk of complications, and often coexisting diseases. The latest 2024 ESC guidelines on AF emphasize the active role of the patient and the multidisciplinary team in the therapeutic process. A new strategy, AF-CARE, has been proposed, focusing on four key areas: treatment of comorbidities and elimination of risk factors (C), prevention of stroke and thromboembolic complications (A), symptom reduction through rate and rhythm control (R), and ongoing dynamic assessment of patient status (E). The guidelines also highlight the importance of education and shared decision-making in the therapeutic process. Educating patients, their families, and healthcare providers, as well as shared decision-making between the patient and the multidisciplinary medical team, will improve adherence to recommendations and treatment outcomes. Ensuring equal access to specialized care for all patients with AF, regardless of gender, ethnicity, and socio-economic status, is also crucial [22].
(C) Comorbidity and risk factor management
As mentioned earlier, atrial fibrillation is associated with many comorbidities, and many of these conditions can contribute to the development of this arrhythmia. Identifying and treating risk factors and comorbid diseases is crucial in the comprehensive care of the patient, as it reduces the risk of AF occurrence and recurrence, prevents adverse cardiovascular events, decreases the frequency of rehospitalizations, and improves quality of life by reducing the frequency and severity of symptoms [24, 25].
Hypertension in patients with atrial fibrillation increases the risk of stroke, heart failure, bleeding, and contributes to higher cardiovascular mortality [26-28]. The target values for systolic blood pressure should be 120–129 mmHg, and in cases of poor tolerance to such treatment, for individuals over 85 years old and those with frailty syndrome, it should be <140 mmHg. The optimal target values for diastolic blood pressure are 70–79 mmHg [22]. Available data suggest that the use of angiotensin-converting enzyme inhibitors (ACEI) and angiotensin II receptor blockers (ARB) may be more beneficial in preventing AF recurrence [29].
Heart failure is a key factor determining prognosis in patients with AF, and it is also a significant factor influencing the recurrence and progression of this arrhythmia [30,31]. The development of heart failure in patients with AF is associated with an increased risk of overall mortality and hospitalization [32,33]. Prognosis depends on the left ventricular ejection fraction (LVEF), with the highest mortality occurring when LVEF < 40% [34]. Optimization of heart failure treatment should align with the current ESC guidelines from 2023 [35]. The use of diuretics can be helpful in maintaining euvolemia, which in turn may lead to better heart rhythm control in patients with AF [22]. Furthermore, the use of beta-blockers or digoxin improves heart rhythm control, which in turn reduces symptoms of heart failure and the number of hospitalizations [36]. Regardless of LVEF, the use of sodium-glucose cotransporter 2 (SGLT2) inhibitors is recommended in heart failure patients to reduce the risk of hospitalization due to heart failure and improve prognosis [37,38].
Diabetes occurs in approximately 25% of patients with atrial fibrillation. Effective glycemic control is associated with improved treatment outcomes, including reduced AF burden, symptom reduction, and even reversal of the type of atrial fibrillation (from persistent to paroxysmal or no arrhythmia) [22]. Furthermore, better diabetes control promotes the stabilization of sinus rhythm [39,40].
Obesity (body mass index [BMI] ≥30 kg/m2) negatively impacts the hemodynamics of the cardiovascular system as well as the structure and function of the heart, contributing to an increased incidence of atrial fibrillation [41,42]. Overweight and obese patients with AF are recommended to lose ≥10% of their body weight to reduce symptoms and AF burden, as well as to improve sinus rhythm maintenance and potentially reverse the type of AF [22,42,43]. Bariatric surgery can be considered as an adjunct to pharmacological treatment and lifestyle changes in patients with AF and a BMI ≥40 kg/m2 when a rhythm control strategy is planned [22].
Reduced physical activity is often associated with other modifiable cardiovascular risk factors and is linked to the risk of AF recurrence [44]. Regular moderate-intensity aerobic exercise improves exercise tolerance, which is associated with reduced AF burden and more sustained maintenance of sinus rhythm [45]. Therefore, patients with AF should be encouraged to engage in physical activity to reduce symptoms and improve quality of life [46].
Patients with atrial fibrillation who consume alcohol are at risk for a range of adverse effects, such as thromboembolic complications, including stroke, death, or readmissions due to AF [47,48]. Attention should be given to the danger of combining excessive alcohol consumption with anticoagulant therapy, as this can increase the risk of bleeding. Furthermore, reducing alcohol intake improves the maintenance of sinus rhythm and reduces the burden of atrial fibrillation [49]. The latest ESC guidelines on AF from 2024 recommend limiting alcohol consumption to a maximum of 30 grams per week [22].
Obstructive sleep apnea (OSA) is a significant, independent risk factor for atrial fibrillation, contributing to the initiation of arrhythmia, its persistence, worsening of symptoms, and reduced therapy effectiveness [50]. The use of continuous positive airway pressure (CPAP) in individuals with OSA and AF may positively impact the maintenance of sinus rhythm and reduce the propensity for arrhythmia development [51,52]. Therefore, OSA treatment can be considered as part of comprehensive risk factor management in individuals with atrial fibrillation to reduce recurrences and disease progression [22].
(A) Avoid stroke and thromboembolism
The presence of atrial fibrillation is associated with a significant risk of thromboembolic complications, especially stroke, and this is independent of whether the arrhythmia is paroxysmal, persistent, or permanent [14]. Therefore, to reduce this risk, the use of oral anticoagulation (OAC) is essential for all eligible patients, except for those in whom the risk is assessed as low. To assess thromboembolic complications, the latest ESC guidelines for atrial fibrillation from 2024 recommend the CHA2DS2-VA score, which, unlike the previously used CHA2DS2-VASc score, does not include criteria for biological sex or gender identity (Table 2) [22].
Table 2
CHA2DS2-VA Score for Assessing the Risk of Ischemic Stroke in Patients with Atrial Fibrillation based on [22].
The basic ESC recommendations regarding the use of anticoagulant therapy are as follows:
Oral anticoagulation is recommended for patients with atrial fibrillation who have scored at least 2 points on the CHA2DS2-VA scale (class I recommendation).
For patients with a CHA2DS2-VA score of 1, the use of OAC should be considered (class IIa recommendation).
OAC is recommended for patients with AF and hypertrophic cardiomyopathy or cardiac amyloidosis, regardless of their CHA2DS2-VA score (class I recommendation).
For patients with AF who score 0 on the CHA2DS2-VA scale, regular reassessment of thromboembolic risk should be performed to initiate OAC when necessary (class I recommendation).
Direct oral anticoagulants may be considered for patients with subclinical AF detected by a device and an elevated thromboembolic risk, excluding those with a high risk of bleeding (class IIb recommendation).
Antiplatelet therapy is not recommended as an alternative to anticoagulant therapy for patients with AF (class III recommendation).
The type of AF (paroxysmal, persistent, or permanent) should not be used as a criterion for anticoagulant therapy (class III recommendation) [22].
When choosing an anticoagulant, direct oral anticoagulants (DOACs) such as apixaban, rivaroxaban, dabigatran, and edoxaban should be preferred, except in patients with mechanical heart valves or moderate to severe mitral stenosis – for this group of patients, vitamin K antagonists (VKAs) such as warfarin or acenocoumarol remain the treatment of choice [55]. To prevent ischemic stroke and thromboembolism in patients with AF who have contraindications to long-term use of OACs, left atrial appendage closure may be considered [22]. In clinical practice, both cardiac surgical methods, which are most often performed as part of other cardiac surgical procedures, and percutaneous procedures involving implantation of an atrial appendage occluder, are available [53,54].
When starting anticoagulant therapy, in addition to the patient’s preferences, all bleeding risk factors should be considered. Identifying modifiable factors allows them to be effectively treated. This approach helps increase the safety of the therapy. Blood pressure should be closely monitored, alcohol consumption should be limited, unnecessary use of anti-inflammatory and antiplatelet drugs should be avoided, interactions with other medications (e.g., antibiotics) should be considered, proton pump inhibitors should be used in patients with a high risk of gastrointestinal bleeding, DOACs should be used instead of VKAs when antiplatelet therapy is necessary, and in patients treated with VKAs, the INR (International Normalized Ratio) should be maintained in the range of 2.0–3.0 for > 70% of the TTR (time in therapeutic range), while limiting the duration of heparin bridge therapy. Potentially modifiable bleeding risk factors, such as anemia, thrombocytopenia or platelet dysfunction, kidney damage, diabetes, heart failure, and fall risk, require a multidisciplinary approach to patient care. In the case of risk factors that cannot be corrected (e.g., dialysis therapy, liver cirrhosis, cancer, previous major bleeding, intracranial pathology, or advanced age), more frequent monitoring should be conducted [22].
In clinical practice, the HAS-BLED scale (Table 3) is most commonly used to assess the risk of bleeding complications [23]. A score of at least 3 points on this scale is considered high risk; however, this should not be the sole basis for making decisions about starting or stopping anticoagulant therapy [22]. The focus should rather be on identifying bleeding risk factors and optimally correcting those that are treatable.
Table 3
HAS-BLED Scale for assessing the risk of major bleeding in patients with atrial fibrillation based on [23].
(R) Reduce symptoms by rate and rhythm control
The decision regarding the strategy (rhythm control vs. rate control) should be made individually, depending on the symptoms, age, and preferences of the patient.
Rate control of the ventricular rhythm is recommended at every stage of treatment, regardless of the type of AF (paroxysmal, persistent, or permanent). It can be used as an initial therapy in acute conditions, as an adjunct to rhythm control therapy, or as the sole therapeutic strategy. The choice of medication depends on symptoms, comorbidities, and potential side effects and interactions. In acute conditions, beta-blockers (for all LVEF) or diltiazem/verapamil (for patients with LVEF > 40%) are preferred over digoxin due to a faster onset of action and dose-dependent effects. If a single drug does not provide satisfactory results, combination therapy can be considered, avoiding the combination of beta-blockers with diltiazem/verapamil, except in closely monitored situations. These drugs can also be used in long-term rate control, with careful monitoring to avoid bradycardia. In selected patients with hemodynamic instability or significantly reduced LVEF, intravenous administration of digoxin, amiodarone, esmolol, or landiolol can be considered. Due to numerous extracardiac side effects, long-term use of amiodarone should be limited to patients with AF who continue to experience arrhythmia symptoms despite combination therapy at the maximum tolerated doses or are not candidates for atrioventricular node ablation with pacemaker implantation. The initial goal of therapy should be a resting ventricular rate below
110 beats per minute, and in patients with persistent symptoms, a more stringent control should be pursued. If optimal rate control therapy fails or if there are contraindications to such treatment, consideration should be given to atrioventricular node ablation combined with pacemaker implantation or a resynchronization system in patients with severe symptoms, persistent AF, and at least one previous hospitalization due to heart failure [22,56-61].
Rhythm control should not be used as a standalone strategy but always as part of a comprehensive AF-CARE approach. In addition to reducing symptoms associated with atrial fibrillation, long-term maintenance of sinus rhythm is associated with a reduction in morbidity and mortality in selected patient groups [62,63]. Methods aimed at restoring and maintaining sinus rhythm include electrical or pharmacological cardioversion, as well as catheter-based, endoscopic, hybrid ablation, and surgical „open” methods.
Immediate electrical cardioversion is recommended for patients with symptoms of hemodynamic instability caused by AF (class I recommendation). In stable AF patients, the timing of cardioversion depends on the duration of the arrhythmia and the effectiveness of anticoagulation therapy. In general, restoration of sinus rhythm is recommended within 12 months of diagnosis (class IIa recommendation), and due to the lower incidence of undesirable clinical events after cardioversion, DOACs should be preferred over warfarin (class I recommendation). Patients with AF who have been effectively anticoagulated for a minimum of 3 weeks can undergo cardioversion (either electrical or pharmacological) immediately (class IIa recommendation). Alternatively, a wait-and-see strategy can be applied, with spontaneous return to sinus rhythm if the arrhythmia lasts less than 48 hours (class IIa recommendation). For patients with ineffective anticoagulation, if possible, anticoagulation should be effectively managed for at least 3 weeks before attempting cardioversion (class IIa recommendation). If the patient cannot wait and AF has lasted more than 24 hours, the presence of a clot should first be excluded by TEE before attempting to restore sinus rhythm (class I recommendation). The duration of anticoagulation therapy after cardio-version depends on the estimated thromboembolic risk. It may be limited to 4 weeks for patients with a CHA2DS2-VA score of 0, while for other patients, with at least 1 point, long-term OAC should be used. For patients without thromboembolic risk factors who have restored sinus rhythm within 24 hours of the onset of AF, continuing OAC after cardioversion is optional [22].
The choice of a specific antiarrhythmic drug for pharmacological cardioversion depends on the type and severity of coexisting heart diseases. According to the 2024 ESC guidelines on atrial fibrillation, five antiarrhythmic drugs are available: amiodarone, propafenone, flecainide, ibutilide, and vernakalant. Currently, in Poland, only the first three are available for daily practice. These drugs are available in both intravenous and oral forms, so in addition to emergency restoration of sinus rhythm, they can also be used in long-term rhythm control strategies. Propafenone and flecainide are reserved for patients without left ventricular systolic dysfunction, hypertrophic cardiomyopathy, or coronary artery disease (class I recommendation). For patients with reduced left ventricular ejection fraction (HFrEF), amiodarone remains the treatment of choice (class I recommendation) [22]. In selected patients, the „pill-in-the-pocket” method with a single dose of flecainide or propafenone may be an effective solution (class IIa recommendation) [22,64]. Safe use of this strategy requires exclusion of sinoatrial node dysfunction, atrioventricular conduction disorders, and Brugada syndrome in the patient, and its initial use should be under medical supervision in a hospital setting. To prevent 1:1 conduction in the event of conversion of atrial fibrillation to atrial flutter, an anti-arrhythmic drug from class IC according to the Vaughan Williams classification should be combined with a drug blocking atrioventricular conduction (class IIa recommendation) [22].
Long-term rhythm control aims to maintain sinus rhythm, improve quality of life, slow the progression of atrial fibrillation and reduce the risk of complications associated with AF episodes [65]. When choosing an antiarrhythmic drug, coexisting diseases and the safety profile should be taken into account. The decision should be made in collaboration with the patient, after presenting the benefit-to-risk ratio of such treatment compared to other strategies. In addition to propafenone, flecainide, and amiodarone mentioned above, dronedarone and possibly sotalol can be used. The former is intended for patients with mildly reduced (HfmrEF) or preserved (HfpEF) ejection fraction, coronary artery disease, and valvular disease (class I recommendation), while sotalol is recommended for patients with normal ejection fraction and coronary artery disease (class IIb recommendation) [22].
Pharmacological methods for treating atrial fibrillation are relatively limited, and their long-term effectiveness is moderate [66]. Therefore, invasive methods for treating arrhythmias are playing an increasingly important role [67]. Recently, catheter ablation has become very popular, including balloon cryoablation of pulmonary vein ostia or ablation using radiofrequency (RF) current. This treatment method is recommended for patients with paroxysmal or persistent atrial fibrillation who cannot tolerate antiarrhythmic treatment or in whom it is ineffective (class I recommendation). The goal of this treatment is to reduce symptoms, recurrences, and the progression of AF. Catheter ablation as a first-line option is recommended for patients with paroxysmal atrial fibrillation (class I recommendation) and may be considered (class IIb recommendation) for patients with persistent arrhythmia in a shared decision-making process. This method is also recommended for patients with AF and heart failure with reduced ejection fraction (HFrEF) in suspected tachycardiomyopathy (class I recommendation), and should be considered in selected patients with HFrEF to reduce the number of heart failure hospitalizations and extend survival (class IIa recommendation). Another indication for this treatment is AF-related bradycardia or sinus pauses associated with the termination of AF, in order to improve symptoms and avoid pacemaker implantation (class IIa recommendation) (22). Surgical ablation is mainly performed during other cardiac surgical procedures.
(E) Evaluation and dynamic reassessment
Each patient diagnosed with atrial fibrillation requires periodic re-assessment of their health to ensure treatment effectiveness, limit disease progression, prevent complications, and improve quality of life. The first follow-up should take place 6 months after diagnosis, with subsequent checks once a year or more frequently if needed. The process of evaluating and managing AF should involve a team of specialists, including cardiologists, family doctors, nurses, pharmacists, and others, depending on the patient’s needs. For every patient with AF, the following should be done:
Regularly assess new and existing risk factors and comorbidities (class I recommendation) and adjust their treatment as needed.
Reassess stroke and thromboembolic complication risk stratification (class I recommendation).
Evaluate bleeding risk factors and modify modifiable ones, e.g., adjusting OAC dose based on worsening/improvement of kidney function (class I recommendation).
Regularly assess symptoms related to AF both before and after initiating treatment (class I recommendation).
Continue OAC despite restoring sinus rhythm in patients with elevated thromboembolic risk (class I recommendation) (22).
Tools that can assist in patient management include: ECG tests, ambulatory ECG monitoring, imaging tests (e.g., echocardiography, cardiac magnetic resonance), and blood tests. Collaboration with the patient, education, the use of supporting tools (apps, reminders, brochures), and an individualized approach increase engagement and adherence to recommendations. Additionally, using tools to measure quality of life and symptoms reported by patients helps better assess treatment effectiveness and tailor care to individual needs [22,68].
The role of AF-CARE in specific situations such as pregnancy, cancer, or acute coronary syndromes, etc., goes beyond the scope of this work and requires separate discussion. The reader is referred to the latest ESC guidelines on the management of patients with atrial fibrillation from 2024 [22].
Conclusions
Long-term management of patients with atrial fibrillation requires an individualized approach that takes into account the risk of complications, patient preferences, and the availability of therapeutic methods. A combination of pharmacotherapy, invasive procedures, and lifestyle changes enables the optimization of treatment outcomes, improvement in patients’ quality of life, and reduction of the social burden associated with AF.
