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Atrial fibrillation

Abstract

Atrial fibrillation (AF) is the most common sustained cardiac rhythm disorder, and increases in prevalence with increasing age and the number of cardiovascular comorbidities. AF is characterized by a rapid and irregular heartbeat that can be asymptomatic or lead to symptoms such as palpitations, dyspnoea and dizziness. The condition can also be associated with serious complications, including an increased risk of stroke. Important recent developments in the clinical epidemiology and management of AF have informed our approach to this arrhythmia. This Primer provides a comprehensive overview of AF, including its epidemiology, mechanisms and pathophysiology, diagnosis, screening, prevention and management. Management strategies, including stroke prevention, rate control and rhythm control, are considered. We also address quality of life issues and provide an outlook on future developments and ongoing clinical trials in managing this common arrhythmia.

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Figure 1: Electrical conduction during sinus rhythm and atrial fibrillation.
Figure 2: Mechanisms that can maintain atrial fibrillation.
Figure 3: Afterdepolarization-mediated ectopic activity.
Figure 4: Re-entry and models of arrhythmia development.
Figure 5: Typical electrocardiograms in normal sinus rhythm and in atrial fibrillation and flutter.
Figure 6: Risk stratification and decision making in thromboprophylaxis.
Figure 7: Using the SAMe-TT2R2 score to aid decision making between a non-vitamin K antagonist oral anticoagulant and a vitamin K antagonist.
Figure 8: Selection of oral anticoagulant drugs.
Figure 9: Management of atrial fibrillation.
Figure 10: Atrial fibrillation ablation.

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Affiliations

Authors

Contributions

Introduction (G.Y.H.L.); Epidemiology (T.P.); Mechanisms/pathophysiology (S.N.); Diagnosis, screening and prevention (S.B.F.); Management (A.N., C.G., G.Y.H.L., H.-F.T., I.V.G. and M.R.); Quality of life (D.A.L.); Outlook (L.F.); Overview of Primer (G.Y.H.L.).

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Correspondence to Gregory Y. H. Lip.

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Competing interests

G.Y.H.L. has had guideline membership or has been involved in reviewing the European Society of Cardiology (ESC) Guidelines on Atrial Fibrillation (2010) and Focused Update (2012), the ESC Guidelines on Heart Failure (2012), the American College of Chest Physicians Antithrombotic Therapy Guidelines for Atrial Fibrillation (2012), the National Institute for Health and Care Excellence (NICE) Guidelines on Atrial Fibrillation (2006 and 2014), the NICE Quality Standards on Atrial Fibrillation (2015), the ESC Cardio-oncology Task Force (2015) and the ESC Working Group on Thrombosis position documents (2011–present). He is the chairman of the Scientific Documents Committee for the European Heart Rhythm Association (EHRA) and a reviewer for various guidelines and position statements from the ESC, EHRA, NICE and other organizations. He has been a member of steering committees for various Phase II and III studies, Health Economics and Outcomes Research and other studies, and has been an investigator in various clinical trials in cardiovascular disease, including those on antithrombotic therapies in atrial fibrillation, acute coronary syndrome and lipids. He has been or is currently a consultant for Bayer/Janssen, Astellas, Merck, Sanofi, BMS/Pfizer, Biotronik, Medtronic, Portola, Boehringer Ingelheim, Microlife and Daiichi-Sankyo, and a speaker for Bayer, BMS/Pfizer, Medtronic, Boehringer Ingelheim, Microlife, Roche and Daiichi-Sankyo. L.F. has served as a consultant for Bayer HealthCare, Bristol-Myers Squibb/Pfizer, Boehringer Ingelheim, Medtronic and Novartis and has been on the speakers' bureau for Bayer HealthCare, Bristol-Myers Squibb/Pfizer, Boehringher Ingelheim, Boston Scientific and Medtronic. S.B.F. receives investigator-initiated research grants, personal fees and non-financial support from Bayer Pharma AG, investigator-initiated research grants and non-financial support from Boehringer Ingelheim, investigator-initiated research grants and personal fees from Bristol-Myers Squibb/Pfizer and personal fees from Servier, AstraZeneca and Gilead Sciences. These associations are not related to the submitted work. I.V.G. has had guideline membership of and been involved in reviewing the ESC Guidelines on Atrial Fibrillation (2010). She has received research grants that have been paid to the University Medical Center Groningen from Medtronic, Biotronik and St Jude Medical. A.N. has received consulting fees or honoraria from Janssen Pharmaceuticals, Biosense Webster, St Jude Medical, Medtronic and Boston Scientific. C.G. declares no competing interests. S.N. declares no competing interests. T.P. has received consultant and speaker fees from Bayer HealthCare, Pfizer and Boehringer Ingelheim. M.R. is supported by a grant from the Netherlands Organization for Scientific Research (Veni grant number 016.136.055). He declares no relationship with industry. H.-F.T. is chairman of the Clinical Trial Committee for the Asia Pacific Heart Rhythm Society. He has been or is currently a steering committee member and investigator in various clinical trials in cardiovascular disease, including those on antithrombotic therapies in atrial fibrillation, acute coronary syndrome and lipids. He has been or is currently a consultant for BayerHealthcare/Jensen J&J, MSD, Bristol-Myers Squibb/Pfizer, Boston Scientific, St Jude Medical, Medtronic, Boehringer Ingelheim and Daiichi-Sankyo, and a speaker for Bayer HealthCare/Jensen J&J, MSD, Bristol-Myers Squibb/Pfizer, Boston Scientific, St Jude Medical, Medtronic, Boehringer Ingelheim and Merck. D.A.L. has received investigator-initiated educational grants from Bayer HealthCare, Bristol-Myers Squibb and Boehringer Ingelheim and has been on the speaker bureau for Boehringer Ingelheim, Bayer HealthCare and Bristol-Myers Squibb/Pfizer. She is a steering committee member of a Bristol-Myers Squibb Phase IV trial.

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Lip, G., Fauchier, L., Freedman, S. et al. Atrial fibrillation. Nat Rev Dis Primers 2, 16016 (2016). https://doi.org/10.1038/nrdp.2016.16

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