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Recently, the European Society of Cardiology (ESC) has updated its guidelines for the diagnosis and treatment of atrial fibrillation (AF). A lot of emphasis was placed on the “CC-ABC” strategy. Here are the most important changes for electrophysiology experts.

The European Society of Cardiology’s 2020 atrial fibrillation (AF) guidelines promote the “CC” approach for diagnosis: Conformation via ECG and Characterization of AF according to four domains. The guidelines also propose the “ABC” treatment strategy with three components: 1) Assessing the need for Anticoagulation via bleeding risk scores and managing those risks. 2) Better symptom management, which includes catheter ablation as a new class I recommendation for AF treatment in specific patients and the collection of patient reported outcomes. 3) Cardiovascular and Comorbidity risk optimization, which encompasses the management of comorbidities such as hypertension or diabetes mellitus.

CC: Confirmation and Characterization

The first new recommendation emphasizes the importance of documenting the diagnosis. Definite diagnosis of clinical AF is established only after confirmation by a conventional 12-lead electrocardiogram (ECG) or a single-lead ECG tracing of ≥30 seconds. After diagnosis, structured characterization of AF should be considered in all patients. The newly recommended 4S-AF scheme for a structured characterization of AF takes into account a patient’s stroke risk, the severity of symptoms, the severity of AF burden and the substrate severity. The idea behind this is to streamline assessment, inform treatment decision-making and facilitate communication among physicians of various specialties.

A: Avoid Stroke/Anticoagulation

To help address modifiable bleeding risk factors and to identify patients at high bleeding risk, a risk score-based assessment, including use of the HAS-BLED score should be performed for all patients. Depending on the individual stroke risk (CHA2DS2VASc score), stroke prevention in the form of an oral anticoagulant should be offered.

B: Better Symptom Management

Catheter ablation is the new class I recommendation for rhythm control to improve symptoms of AF recurrences after one failed or intolerant class I or III antiarrhythmic drug. This relates to patients with paroxysmal AF and patients with persistent AF with or without major risk factors for AF recurrence. AF catheter ablation is also recommended as a first-line therapy to reverse left ventricular dysfunction in AF patients when tachycardia-induced cardiomyopathy is highly probable, independent of their symptom status (class I recommendation). In selected AF patients with heart failure with reduced ejection fraction (HFrEF), AF catheter ablation should be considered to improve survival and reduce hospitalizations due to heart failure (class IIa recommendation). For all AF catheter-ablation procedures complete electrical isolation of the pulmonary veins is recommended (class I). Another new class I recommendation in the current guideline is to routinely collect patient-reported outcomes to assess treatment success and improve patient care.

C: Cardiovascular and Comorbidity Risk Optimization

Since cardiovascular risk-factor burden and comorbidities such as hypertension or diabetes mellitus significantly affect the lifetime risk for AF development, screening for and reduction of such risk factors, e.g. via lifestyle changes, has gained importance. Weight loss for example is now a class I recommendation for obese patients with AF, particularly for patients who are being evaluated to undergo AF ablation. The importance of good blood pressure control in patients with hypertension is also emphasized.


Hindricks G et al. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J. 2021;42(5):373-498.