Advertisement

Beyond the 2020 guidelines on atrial fibrillation of the European society of cardiology

  • Giuseppe Boriani
    Correspondence
    Corresponding Author: Professor Giuseppe Boriani, MD, FEHRA, FESC.
    Affiliations
    Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
    Search for articles by this author
  • Marco Vitolo
    Affiliations
    Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy

    Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy

    Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
    Search for articles by this author
  • Deirdre A Lane
    Affiliations
    Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom

    Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
    Search for articles by this author
  • Author Footnotes
    1 Joint senior authorship
    Tatjana S Potpara
    Footnotes
    1 Joint senior authorship
    Affiliations
    School of Medicine, University of Belgrade, Belgrade, Serbia

    Cardiology Clinic, Clinical Centre of Serbia, Belgrade, Serbia
    Search for articles by this author
  • Author Footnotes
    1 Joint senior authorship
    Gregory YH Lip
    Footnotes
    1 Joint senior authorship
    Affiliations
    Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom

    Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark

    School of Medicine, University of Belgrade, Belgrade, Serbia
    Search for articles by this author
  • Author Footnotes
    1 Joint senior authorship
Published:January 28, 2021DOI:https://doi.org/10.1016/j.ejim.2021.01.006

      Highlights

      • The guidelines propose to move from a single-domain AF classification to comprehensive characterization of AF patients
      • Atrial fibrillation patients require an integrated holistic management (ABC pathway)
      • It is mandatory to guarantee stroke prevention to all AF patients, unless they are at low risk for stroke
      • Appropriate management of bleeding risk is needed through a structured clinical assessment

      Abstract

      The most recent atrial fibrillation (AF) guidelines delivered by European Society of Cardiology (ESC) offer an updated approach to AF management, with the perspective of improved characterization of the arrhythmia, the cardiac substrate and the patients profile in terms of associated risk factors and comorbidities. Recommendations were based on careful scrutiny and assessment of all available evidence with the final aim to offer to practitioners a lower level of uncertainty in the complex process of decision making for patients with AF.
      The 2020 ESC guidelines on AF propose a paradigm shift in the clinical approach to AF patients, moving from a single-domain AF classification to comprehensive characterization of AF patients. Given the complex nature of AF, an integrated holistic management of AF patients is suggested by the guidelines for improving patients outcomes through the formal introduction of the CC (Confirm AF and Characterize AF) to ABC (Atrial fibrillation Better Care) pathway. In line with this concept, these new guidelines underline the importance of a more comprehensive management of AF patients which should not be limited to simply prescribe oral anticoagulation or decide between a rhythm or rate control strategy. Indeed, each step of the ABC pathway represents one of the pivotal pillars in the management of AF and only a holistic approach has the potential to improve patients’ outcomes.
      In this review we will discuss the background that supports some of the new recommendations of 2020 ESC guidelines, with important implications for daily management of AF patients.

      Keywords

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to European Journal of Internal Medicine
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Field M.J.
        • Lohr K.N.
        Clinical practice guidelines. Directions for a new program Washington.
        National Academy Pr, 1990
      1. Institute of Medicine Committee on Standards for Developing Trustworthy Clinical Practice G. In: Graham R, Mancher M, Miller Wolman D et al., Hrsg. Clinical Practice Guidelines We Can Trust. Washington (DC): National Academies Press (US) Copyright 2011 by the National Academy of Sciences. All rights reserved.; 2011: 10.17226/13058.

        • Hindricks G.
        • Potpara T.
        • Dagres N.
        • et al.
        2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association of Cardio-Thoracic Surgery (EACTS).
        Eur Heart J. 2020; https://doi.org/10.1093/eurheartj/ehaa612
        • Guyatt G.H.
        • Oxman A.D.
        • Vist G.E.
        • et al.
        GRADE: an emerging consensus on rating quality of evidence and strength of recommendations.
        Bmj. 2008; 336: 924-926https://doi.org/10.1136/bmj.39489.470347.AD
        • Halperin J.L.
        • Levine G.N.
        • SM A.l.-K.h.a.t.i.b.
        • et al.
        Further Evolution of the ACC/AHA Clinical Practice Guideline Recommendation Classification System: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines.
        J Am Coll Cardiol. 2016; 67: 1572-1574https://doi.org/10.1016/j.jacc.2015.09.001
        • [Anonym]
        Secondary prevention of vascular disease by prolonged antiplatelet treatment. Antiplatelet Trialists' Collaboration.
        Br Med J (Clin Res Ed). 1988; 296: 320-331
        • Hart R.G.
        • Benavente O.
        • McBride R.
        • et al.
        Antithrombotic therapy to prevent stroke in patients with atrial fibrillation: a meta-analysis.
        Ann Intern Med. 1999; 131: 492-501https://doi.org/10.7326/0003-4819-131-7-199910050-00003
        • Califf R.M.
        The Future of Cardiovascular Medicine From the Regulatory Perspective.
        J Am Coll Cardiol. 2016; 68: 766-769https://doi.org/10.1016/j.jacc.2016.07.001
        • Tricoci P.
        • Allen J.M.
        • Kramer J.M.
        • et al.
        Scientific evidence underlying the ACC/AHA clinical practice guidelines.
        JAMA. 2009; 301: 831-841https://doi.org/10.1001/jama.2009.205
        • Han H.
        • Chao H.
        • Guerra A.
        • et al.
        Evolution of the American College of Cardiology/American Heart Association Clinical Guidelines.
        J Am Coll Cardiol. 2015; 65: 2726-2734https://doi.org/10.1016/j.jacc.2015.04.050
        • Fanaroff A.C.
        • Califf R.M.
        • Windecker S.
        • et al.
        Levels of Evidence Supporting American College of Cardiology/American Heart Association and European Society of Cardiology Guidelines, 2008-2018.
        JAMA. 2019; 321: 1069-1080https://doi.org/10.1001/jama.2019.1122
        • Camm A.J.
        • Kirchhof P.
        • Lip G.Y.
        • et al.
        Guidelines for the management of atrial fibrillation: the Task Force for the Management of Atrial Fibrillation of the European Society of Cardiology (ESC).
        Eur Heart J. 2010; 31: 2369-2429https://doi.org/10.1093/eurheartj/ehq278
        • Kirchhof P.
        • Benussi S.
        • Kotecha D.
        • et al.
        2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS.
        Eur Heart J. 2016; 37: 2893-2962https://doi.org/10.1093/eurheartj/ehw210
        • Levy S.
        Classification system of atrial fibrillation.
        Current opinion in cardiology. 2000; 15: 54-57
        • Hammond-Haley M.
        • Providencia R.
        • Lambiase P.D.
        Temporal pattern/episode duration-based classification of atrial fibrillation as paroxysmal vs. persistent: is it time to develop a more integrated prognostic score to optimize management?.
        Europace. 2018; 20: f288-f298https://doi.org/10.1093/europace/eux178
        • Malavasi V.L.
        • Fantecchi E.
        • Tordoni V.
        • et al.
        Atrial fibrillation pattern and factors affecting the progression to permanent atrial fibrillation.
        Internal and Emergency Medicine. 2020; https://doi.org/10.1007/s11739-020-02551-5
        • Lubitz S.A.
        • Benjamin E.J.
        • Ruskin J.N.
        • et al.
        Challenges in the classification of atrial fibrillation.
        Nature reviews Cardiology. 2010; 7: 451-460https://doi.org/10.1038/nrcardio.2010.86
        • Potpara T.S.
        • Lip G.Y.
        Lone atrial fibrillation - an overview.
        Int J Clin Pract. 2014; 68: 418-433https://doi.org/10.1111/ijcp.12281
        • Potpara T.S.
        • Stankovic G.R.
        • Beleslin B.D.
        • et al.
        A 12-year follow-up study of patients with newly diagnosed lone atrial fibrillation: implications of arrhythmia progression on prognosis: the Belgrade Atrial Fibrillation study.
        Chest. 2012; 141: 339-347https://doi.org/10.1378/chest.11-0340
        • Chao T.F.
        • Liao J.N.
        • Tuan T.C.
        • et al.
        Incident Co-Morbidities in Patients with Atrial Fibrillation Initially with a CHA2DS2-VASc Score of 0 (Males) or 1 (Females): Implications for Reassessment of Stroke Risk in Initially 'Low-Risk' Patients.
        Thrombosis and haemostasis. 2019; 119: 1162-1170https://doi.org/10.1055/s-0039-1683933
        • Boriani G.
        • Proietti M.
        Screening for atrial fibrillation: Need for an integrated, structured approach.
        Eur J Intern Med. 2019; 67: 33-35https://doi.org/10.1016/j.ejim.2019.07.017
        • Malavasi V.L.
        • Zoccali C.
        • Brandi M.C.
        • et al.
        Cognitive impairment in patients with atrial fibrillation: Implications for outcome in a cohort study.
        Int J Cardiol. 2020; https://doi.org/10.1016/j.ijcard.2020.08.028
        • Boriani G.
        • Imberti J.F.
        • Valenti A.C.
        • et al.
        Managing atrial fibrillation: the need for an individualized approach even in the emergency department.
        Intern Emerg Med. 2020; 15: 9-12https://doi.org/10.1007/s11739-019-02260-8
        • Vitolo M.
        • Lane D.A.
        • Boriani G.
        • et al.
        The importance of adherence and persistence with oral anticoagulation treatment in patients with atrial fibrillation.
        Eur Heart J Cardiovasc Pharmacother. 2020; https://doi.org/10.1093/ehjcvp/pvaa020
        • Chao T.F.
        • Lip G.Y.H.
        • Lin Y.J.
        • et al.
        Incident Risk Factors and Major Bleeding in Patients with Atrial Fibrillation Treated with Oral Anticoagulants: A Comparison of Baseline, Follow-up and Delta HAS-BLED Scores with an Approach Focused on Modifiable Bleeding Risk Factors.
        Thromb Haemost. 2018; 118: 768-777https://doi.org/10.1055/s-0038-1636534
        • Chao T.F.
        • Lip G.Y.H.
        • Liu C.J.
        • et al.
        Relationship of Aging and Incident Comorbidities to Stroke Risk in Patients With Atrial Fibrillation.
        J Am Coll Cardiol. 2018; 71: 122-132https://doi.org/10.1016/j.jacc.2017.10.085
        • Heidbuchel H.
        • Dagres N.
        • Antz M.
        • et al.
        Major knowledge gaps and system barriers to guideline implementation among European physicians treating patients with atrial fibrillation: a European Society of Cardiology international educational needs assessment.
        Europace. 2018; 20: 1919-1928https://doi.org/10.1093/europace/euy039
        • Guo Y.
        • Chen Y.
        • Lane D.A.
        • et al.
        Mobile Health Technology for Atrial Fibrillation Management Integrating Decision Support, Education, and Patient Involvement: mAF App Trial.
        Am J Med. 2017; 130 (e1386): 1388-1396https://doi.org/10.1016/j.amjmed.2017.07.003
        • Guo Y.
        • Lane D.A.
        • Wang L.
        • et al.
        Mobile Health Technology to Improve Care for Patients With Atrial Fibrillation.
        J Am Coll Cardiol. 2020; 75: 1523-1534https://doi.org/10.1016/j.jacc.2020.01.052
        • Kotecha D.
        • Chua W.W.L.
        • Fabritz L.
        • et al.
        European Society of Cardiology smartphone and tablet applications for patients with atrial fibrillation and their health care providers.
        Europace: European pacing, arrhythmias, and cardiac electrophysiology: journal of the working groups on cardiac pacing, arrhythmias, and cardiac cellular electrophysiology of the European Society of Cardiology. 2018; 20: 225-233https://doi.org/10.1093/europace/eux299
        • Lane D.A.
        • McMahon N.
        • Gibson J.
        • et al.
        Mobile health applications for managing atrial fibrillation for healthcare professionals and patients: a systematic review.
        Europace. 2020; https://doi.org/10.1093/europace/euaa269
        • Boriani G.
        • Schnabel R.B.
        • Healey J.S.
        • et al.
        Consumer-led screening for atrial fibrillation using consumer-facing wearables, devices and apps: A survey of health care professionals by AF-SCREEN international collaboration.
        Eur J Intern Med. 2020; https://doi.org/10.1016/j.ejim.2020.09.005
        • Potpara T.S.
        • Lip G.Y.H.
        • Blomstrom-Lundqvist C.
        • et al.
        The 4S-AF Scheme (Stroke Risk; Symptoms; Severity of Burden; Substrate): A Novel Approach to In-Depth Characterization (Rather than Classification) of Atrial Fibrillation.
        Thrombosis and haemostasis. 2020; https://doi.org/10.1055/s-0040-1716408
        • Lip G.
        • Freedman B.
        • De Caterina R.
        • et al.
        Stroke prevention in atrial fibrillation: Past, present and future. Comparing the guidelines and practical decision-making.
        Thrombosis and haemostasis. 2017; 117: 1230-1239https://doi.org/10.1160/TH16-11-0876
        • Nieuwlaat R.
        • Capucci A.
        • Lip G.Y.
        • et al.
        Antithrombotic treatment in real-life atrial fibrillation patients: a report from the Euro Heart Survey on Atrial Fibrillation.
        European heart journal. 2006; 27: 3018-3026https://doi.org/10.1093/eurheartj/ehl015
        • Cemin R.
        • Colivicchi F.
        • Maggioni A.P.
        • et al.
        One-year clinical events and management of patients with atrial fibrillation hospitalized in cardiology centers: Data from the BLITZ-AF study.
        Eur J Intern Med. 2020; 74: 55-60https://doi.org/10.1016/j.ejim.2019.12.006
        • Marietta M.
        • Banchelli F.
        • Pavesi P.
        • et al.
        Direct oral anticoagulants vs non-vitamin K antagonist in atrial fibrillation: A prospective, propensity score adjusted cohort study.
        Eur J Intern Med. 2019; 62: 9-16https://doi.org/10.1016/j.ejim.2018.12.010
        • Hohmann C.
        • Hohnloser S.H.
        • Jacob J.
        • et al.
        Non-Vitamin K Oral Anticoagulants in Comparison to Phenprocoumon in Geriatric and Non-Geriatric Patients with Non-Valvular Atrial Fibrillation.
        Thrombosis and haemostasis. 2019; 119: 971-980https://doi.org/10.1055/s-0039-1683422
        • Hohnloser S.H.
        • Basic E.
        • Nabauer M.
        Changes in Oral Anticoagulation Therapy over One Year in 51,000 Atrial Fibrillation Patients at Risk for Stroke: A Practice-Derived Study.
        Thrombosis and haemostasis. 2019; 119: 882-893https://doi.org/10.1055/s-0039-1683428
        • Hohnloser S.H.
        • Basic E.
        • Hohmann C.
        • et al.
        Effectiveness and Safety of Non-Vitamin K Oral Anticoagulants in Comparison to Phenprocoumon: Data from 61,000 Patients with Atrial Fibrillation.
        Thrombosis and haemostasis. 2018; 118: 526-538https://doi.org/10.1160/TH17-10-0733
        • Hsu C.C.
        • Hsu P.F.
        • Sung S.H.
        • et al.
        Is There a Preferred Stroke Prevention Strategy for Diabetic Patients with Non-Valvular Atrial Fibrillation? Comparing Warfarin, Dabigatran and Rivaroxaban.
        Thrombosis and haemostasis. 2018; 118: 72-81https://doi.org/10.1160/TH17-02-0095
        • Boriani G.
        • Imberti J.F.
        • Vitolo M.
        From meta-analysis to the individual patient with atrial fibrillation and coronary artery disease: the complexity of antithrombotic treatment in real-world clinical practice and the need for a tailored approach.
        Eur J Intern Med. 2020; 77: 27-29https://doi.org/10.1016/j.ejim.2020.04.040
        • Ricottini E.
        • Nenna A.
        • Melfi R.
        • et al.
        Antithrombotic treatment in patients with atrial fibrillation undergoing coronary angioplasty: rational convincement and supporting evidence.
        Eur J Intern Med. 2020; 77: 44-51https://doi.org/10.1016/j.ejim.2020.02.004
        • Hirsh J.
        • Eikelboom J.W.
        • Chan N.C.
        Fifty years of research on antithrombotic therapy: Achievements and disappointments.
        Eur J Intern Med. 2019; 70: 1-7https://doi.org/10.1016/j.ejim.2019.10.023
        • Vitolo M.
        • Javed S.
        • Capodanno D.
        • et al.
        Antithrombotic treatment in atrial fibrillation patients undergoing percutaneous coronary interventions: focus on stent thrombosis.
        Expert Rev Cardiovasc Ther. 2020; : 1-14https://doi.org/10.1080/14779072.2020.1808463
        • Ruff C.T.
        • Giugliano R.P.
        • Braunwald E.
        • et al.
        Comparison of the efficacy and safety of new oral anticoagulants with warfarin in patients with atrial fibrillation: a meta-analysis of randomised trials.
        Lancet. 2014; 383: 955-962https://doi.org/10.1016/S0140-6736(13)62343-0
        • Lip G.Y.
        • Nieuwlaat R.
        • Pisters R.
        • et al.
        Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrillation using a novel risk factor-based approach: the euro heart survey on atrial fibrillation.
        Chest. 2010; 137: 263-272https://doi.org/10.1378/chest.09-1584
        • Yoon M.
        • Yang P.S.
        • Jang E.
        • et al.
        Dynamic Changes of CHA2DS2-VASc Score and the Risk of Ischaemic Stroke in Asian Patients with Atrial Fibrillation: A Nationwide Cohort Study.
        Thrombosis and haemostasis. 2018; 118: 1296-1304https://doi.org/10.1055/s-0038-1651482
        • Pandey A.K.
        • Xu K.
        • Zhang L.
        • et al.
        Lower versus Standard INR Targets in Atrial Fibrillation: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.
        Thrombosis and haemostasis. 2020; 120: 484-494https://doi.org/10.1055/s-0039-3401823
        • Borre E.D.
        • Goode A.
        • Raitz G.
        • et al.
        Predicting Thromboembolic and Bleeding Event Risk in Patients with Non-Valvular Atrial Fibrillation: A Systematic Review.
        Thromb Haemost. 2018; 118: 2171-2187https://doi.org/10.1055/s-0038-1675400
        • Esteve-Pastor M.A.
        • Roldan V.
        • Rivera-Caravaca J.M.
        • et al.
        The Use of Biomarkers in Clinical Management Guidelines: A Critical Appraisal.
        Thrombosis and haemostasis. 2019; 119: 1901-1919https://doi.org/10.1055/s-0039-1696955
        • Rivera-Caravaca J.M.
        • Marin F.
        • Vilchez J.A.
        • et al.
        Refining Stroke and Bleeding Prediction in Atrial Fibrillation by Adding Consecutive Biomarkers to Clinical Risk Scores.
        Stroke; a journal of cerebral circulation. 2019; 50: 1372-1379https://doi.org/10.1161/STROKEAHA.118.024305
        • Malavasi V.L.
        • Proietti M.
        • Spagni S.
        • et al.
        Usefulness of Red Cells Distribution Width to Predict Worse Outcomes in Patients With Atrial Fibrillation.
        Am J Cardiol. 2019; https://doi.org/10.1016/j.amjcard.2019.08.008
        • Camelo-Castillo A.
        • Rivera-Caravaca J.M.
        • Marin F.
        • et al.
        Predicting Adverse Events beyond Stroke and Bleeding with the ABC-Stroke and ABC-Bleeding Scores in Patients with Atrial Fibrillation: The Murcia AF Project.
        Thrombosis and haemostasis. 2020; 120: 1200-1207https://doi.org/10.1055/s-0040-1712914
        • Group N.C.A.F.G.W.
        • Brieger D.
        • Amerena J.
        • et al.
        National Heart Foundation of Australia and the Cardiac Society of Australia and New Zealand: Australian Clinical Guidelines for the Diagnosis and Management of Atrial Fibrillation 2018.
        Heart, lung & circulation. 2018; 27: 1209-1266https://doi.org/10.1016/j.hlc.2018.06.1043
        • Nielsen P.B.
        • Overvad T.F.
        Female Sex as a Risk Modifier for Stroke Risk in Atrial Fibrillation: Using CHA2DS2-VASc versus CHA2DS2-VA for Stroke Risk Stratification in Atrial Fibrillation: A Note of Caution.
        Thrombosis and haemostasis. 2020; 120: 894-898https://doi.org/10.1055/s-0040-1710014
        • Boriani G.
        • Colella J.
        • Imberti J.
        • et al.
        Female sex and stroke in atrial fibrillation: an intriguing relationship.
        Intern Emerg Med. 2019; https://doi.org/10.1007/s11739-019-02169-2
        • Nielsen P.B.
        • Skjoth F.
        • Overvad T.F.
        • et al.
        Female Sex Is a Risk Modifier Rather Than a Risk Factor for Stroke in Atrial Fibrillation: Should We Use a CHA2DS2-VA Score Rather Than CHA2DS2-VASc?.
        Circulation. 2018; 137: 832-840https://doi.org/10.1161/CIRCULATIONAHA.117.029081
        • Pilcher S.M.
        • Alamneh E.A.
        • Chalmers L.
        • et al.
        The Tasmanian Atrial Fibrillation Study (TAFS): Differences in Stroke Prevention According to Sex.
        The Annals of pharmacotherapy. 2020; 54: 837-845https://doi.org/10.1177/1060028020904969
        • Thompson L.E.
        • Maddox T.M.
        • Lei L.
        • et al.
        Sex Differences in the Use of Oral Anticoagulants for Atrial Fibrillation: A Report From the National Cardiovascular Data Registry (NCDR((R))) PINNACLE Registry.
        Journal of the American Heart Association. 2017; 6https://doi.org/10.1161/JAHA.117.005801
        • Proietti M.
        • Vitolo M.
        • Boriani G.
        Tailored oral anticoagulant prescription in patients with atrial fibrillation: Use and misuse of clinical risk prediction scores.
        Eur J Prev Cardiol. 2019; 2047487319877469https://doi.org/10.1177/2047487319877469
        • Essien U.R.
        • Magnani J.W.
        • Chen N.
        • et al.
        Race/Ethnicity and Sex-Related Differences in Direct Oral Anticoagulant Initiation in Newly Diagnosed Atrial Fibrillation: A Retrospective Study of Medicare Data.
        Journal of the National Medical Association. 2020; 112: 103-108https://doi.org/10.1016/j.jnma.2019.10.003
        • Guo Y.
        • Zhu H.
        • Chen Y.
        • et al.
        Comparing Bleeding Risk Assessment Focused on Modifiable Risk Factors Only Versus Validated Bleeding Risk Scores in Atrial Fibrillation.
        The American journal of medicine. 2018; 131: 185-192https://doi.org/10.1016/j.amjmed.2017.09.009
        • Chao T.F.
        • Lip G.Y.H.
        • Lin Y.J.
        • et al.
        Major bleeding and intracranial hemorrhage risk prediction in patients with atrial fibrillation: Attention to modifiable bleeding risk factors or use of a bleeding risk stratification score? A nationwide cohort study.
        International journal of cardiology. 2018; 254: 157-161https://doi.org/10.1016/j.ijcard.2017.11.025
        • Esteve-Pastor M.A.
        • Rivera-Caravaca J.M.
        • Shantsila A.
        • et al.
        Assessing Bleeding Risk in Atrial Fibrillation Patients: Comparing a Bleeding Risk Score Based Only on Modifiable Bleeding Risk Factors against the HAS-BLED Score. The AMADEUS Trial.
        Thrombosis and haemostasis. 2017; 117: 2261-2266https://doi.org/10.1160/TH17-10-0710
        • Pisters R.
        • Lane D.A.
        • Nieuwlaat R.
        • et al.
        A novel user-friendly score (HAS-BLED) to assess 1-year risk of major bleeding in patients with atrial fibrillation: the Euro Heart Survey.
        Chest. 2010; 138: 1093-1100https://doi.org/10.1378/chest.10-0134
        • Gage B.F.
        • Yan Y.
        • Milligan P.E.
        • et al.
        Clinical classification schemes for predicting hemorrhage: results from the National Registry of Atrial Fibrillation (NRAF).
        American heart journal. 2006; 151: 713-719https://doi.org/10.1016/j.ahj.2005.04.017
        • Fang M.C.
        • Go A.S.
        • Chang Y.
        • et al.
        A new risk scheme to predict warfarin-associated hemorrhage: The ATRIA (Anticoagulation and Risk Factors in Atrial Fibrillation) Study.
        Journal of the American College of Cardiology. 2011; 58: 395-401https://doi.org/10.1016/j.jacc.2011.03.031
        • O'Brien E.C.
        • Simon D.N.
        • Thomas L.E.
        • et al.
        The ORBIT bleeding score: a simple bedside score to assess bleeding risk in atrial fibrillation.
        European heart journal. 2015; 36: 3258-3264https://doi.org/10.1093/eurheartj/ehv476
        • Lip G.Y.
        • Andreotti F.
        • Fauchier L.
        • et al.
        Bleeding risk assessment and management in atrial fibrillation patients: a position document from the European Heart Rhythm Association, endorsed by the European Society of Cardiology Working Group on Thrombosis.
        Europace: European pacing, arrhythmias, and cardiac electrophysiology: journal of the working groups on cardiac pacing, arrhythmias, and cardiac cellular electrophysiology of the European Society of Cardiology. 2011; 13: 723-746https://doi.org/10.1093/europace/eur126
        • Lane D.A.
        • Lip G.Y.
        Use of the CHA(2)DS(2)-VASc and HAS-BLED scores to aid decision making for thromboprophylaxis in nonvalvular atrial fibrillation.
        Circulation. 2012; 126: 860-865https://doi.org/10.1161/circulationaha.111.060061
        • Lip G.Y.H.
        • Banerjee A.
        • Boriani G.
        • et al.
        Antithrombotic Therapy for Atrial Fibrillation: CHEST Guideline and Expert Panel Report.
        Chest. 2018; 154: 1121-1201https://doi.org/10.1016/j.chest.2018.07.040
        • Hijazi Z.
        • Oldgren J.
        • Lindbäck J.
        • et al.
        The novel biomarker-based ABC (age, biomarkers, clinical history)-bleeding risk score for patients with atrial fibrillation: a derivation and validation study.
        Lancet (London, England). 2016; 387: 2302-2311https://doi.org/10.1016/s0140-6736(16)00741-8
        • Shireman T.I.
        • Mahnken J.D.
        • Howard P.A.
        • et al.
        Development of a contemporary bleeding risk model for elderly warfarin recipients.
        Chest. 2006; 130: 1390-1396https://doi.org/10.1378/chest.130.5.1390
        • Zulkifly H.
        • Lip G.Y.H.
        • Lane D.A.
        Bleeding Risk Scores in Atrial Fibrillation and Venous Thromboembolism.
        Am J Cardiol. 2017; 120: 1139-1145https://doi.org/10.1016/j.amjcard.2017.06.058
        • Caldeira D.
        • Costa J.
        • Fernandes R.M.
        • et al.
        Performance of the HAS-BLED high bleeding-risk category, compared to ATRIA and HEMORR2HAGES in patients with atrial fibrillation: a systematic review and meta-analysis.
        Journal of interventional cardiac electrophysiology: an international journal of arrhythmias and pacing. 2014; 40: 277-284https://doi.org/10.1007/s10840-014-9930-y
        • Lip G.Y.H.
        • Skjoth F.
        • Nielsen P.B.
        • et al.
        The HAS-BLED, ATRIA, and ORBIT Bleeding Scores in Atrial Fibrillation Patients Using Non-Vitamin K Antagonist Oral Anticoagulants.
        The American journal of medicine. 2018; 131: 574.e513-574.e527https://doi.org/10.1016/j.amjmed.2017.11.046
        • Wang T.J.
        • Massaro J.M.
        • Levy D.
        • et al.
        A risk score for predicting stroke or death in individuals with new-onset atrial fibrillation in the community: the Framingham Heart Study.
        JAMA: the journal of the American Medical Association. 2003; 290: 1049-1056https://doi.org/10.1001/jama.290.8.1049
        • Zhu W.
        • He W.
        • Guo L.
        • et al.
        The HAS-BLED Score for Predicting Major Bleeding Risk in Anticoagulated Patients With Atrial Fibrillation: A Systematic Review and Meta-analysis.
        Clinical cardiology. 2015; 38: 555-561https://doi.org/10.1002/clc.22435
        • Au Yeung S.L.
        • Luo S.
        • Schooling C.M.
        The impact of GDF-15, a biomarker for metformin, on the risk of coronary artery disease, breast and colorectal cancer, and type 2 diabetes and metabolic traits: a Mendelian randomisation study.
        Diabetologia. 2019; 62: 1638-1646https://doi.org/10.1007/s00125-019-4913-2
        • Bettencourt P.
        • Ferreira-Coimbra J.
        • Rodrigues P.
        • et al.
        Towards a multi-marker prognostic strategy in acute heart failure: a role for GDF-15.
        ESC heart failure. 2018; 5: 1017-1022https://doi.org/10.1002/ehf2.12301
        • Tanrıkulu O.
        • Sarıyıldız M.A.
        • Batmaz İ.
        • et al.
        Serum GDF-15 level in rheumatoid arthritis: relationship with disease activity and subclinical atherosclerosis.
        Acta reumatologica portuguesa. 2017; 42: 66-72
        • Esteve-Pastor M.A.
        • Roldán V.
        • Rivera-Caravaca J.M.
        • et al.
        The Use of Biomarkers in Clinical Management Guidelines: A Critical Appraisal.
        Thromb Haemost. 2019; 119: 1901-1919https://doi.org/10.1055/s-0039-1696955
        • Wang C.
        • Yu Y.
        • Zhu W.
        • et al.
        Comparing the ORBIT and HAS-BLED bleeding risk scores in anticoagulated atrial fibrillation patients: a systematic review and meta-analysis.
        Oncotarget. 2017; 8: 109703-109711https://doi.org/10.18632/oncotarget.19858
        • Guo Y.
        • Lane D.A.
        • Chen Y.
        • et al.
        Regular Bleeding Risk Assessment Associated with Reduction in Bleeding Outcomes: The mAFA-II Randomized Trial.
        The American journal of medicine. 2020; https://doi.org/10.1016/j.amjmed.2020.03.019
        • Lip G.Y.H.
        The ABC pathway: an integrated approach to improve AF management.
        Nat Rev Cardiol. 2017; 14: 627-628https://doi.org/10.1038/nrcardio.2017.153
        • Proietti M.
        • Romiti G.F.
        • Olshansky B.
        • et al.
        Improved Outcomes by Integrated Care of Anticoagulated Patients with Atrial Fibrillation Using the Simple ABC (Atrial Fibrillation Better Care) Pathway.
        Am J Med. 2018; 131 (e1356): 1359-1366https://doi.org/10.1016/j.amjmed.2018.06.012
        • Pastori D.
        • Pignatelli P.
        • Menichelli D.
        • et al.
        Integrated Care Management of Patients With Atrial Fibrillation and Risk of Cardiovascular Events: The ABC (Atrial fibrillation Better Care) Pathway in the ATHERO-AF Study Cohort.
        Mayo Clin Proc. 2019; 94: 1261-1267https://doi.org/10.1016/j.mayocp.2018.10.022
        • Yoon M.
        • Yang P.S.
        • Jang E.
        • et al.
        Improved Population-Based Clinical Outcomes of Patients with Atrial Fibrillation by Compliance with the Simple ABC (Atrial Fibrillation Better Care) Pathway for Integrated Care Management: A Nationwide Cohort Study.
        Thromb Haemost. 2019; 19: 1695-1703https://doi.org/10.1055/s-0039-1693516
        • Kozieł M.
        • Simovic S.
        • Pavlovic N.
        • et al.
        Adherence to the ABC (Atrial fibrillation Better Care) pathway in the Balkan region: the BALKAN-AF survey.
        Pol Arch Intern Med. 2020; 130: 187-195https://doi.org/10.20452/pamw.15146
        • Gumprecht J.
        • Domek M.
        • Proietti M.
        • et al.
        Compliance of Atrial Fibrillation Treatment with the Atrial Fibrillation Better Care (ABC) Pathway Improves the Clinical Outcomes in the Middle East Population: A Report from the Gulf Survey of Atrial Fibrillation Events (SAFE) Registry.
        J Clin Med. 2020; 9https://doi.org/10.3390/jcm9051286
        • Proietti M.
        • Romiti G.F.
        • Olshansky B.
        • et al.
        Comprehensive Management With the ABC (Atrial Fibrillation Better Care) Pathway in Clinically Complex Patients With Atrial Fibrillation: A Post Hoc Ancillary Analysis From the AFFIRM Trial.
        J Am Heart Assoc. 2020; 9e014932https://doi.org/10.1161/jaha.119.014932
        • Yang P.S.
        • Sung J.H.
        • Jang E.
        • et al.
        Application of the simple atrial fibrillation better care pathway for integrated care management in frail patients with atrial fibrillation: A nationwide cohort study.
        J Arrhythm. 2020; 36: 668-677https://doi.org/10.1002/joa3.12364
        • Proietti M.
        • Lip G.Y.H.
        • Laroche C.
        • et al.
        Relation of outcomes to ABC (Atrial Fibrillation Better Care) pathway adherent care in European patients with atrial fibrillation: an analysis from the ESC-EHRA EORP Atrial Fibrillation General Long-Term (AFGen LT) Registry.
        Europace. 2020; https://doi.org/10.1093/europace/euaa274
        • Boriani G.
        • Maniadakis N.
        • Auricchio A.
        • et al.
        Health technology assessment in interventional electrophysiology and device therapy: a position paper of the European Heart Rhythm Association.
        Eur Heart J. 2013; 34: 1869-1874https://doi.org/10.1093/eurheartj/eht031
        • Vitolo M.
        • Proietti M.
        • Harrison S.
        • et al.
        The Euro Heart Survey and EURObservational Research Programme (EORP) in atrial fibrillation registries: contribution to epidemiology, clinical management and therapy of atrial fibrillation patients over the last 20 years.
        Intern Emerg Med. 2020; https://doi.org/10.1007/s11739-020-02405-0
        • Boriani G.
        • Proietti M.
        • Laroche C.
        • et al.
        Association between antithrombotic treatment and outcomes at 1-year follow-up in patients with atrial fibrillation: the EORP-AF General Long-Term Registry.
        Europace. 2019; 21: 1013-1022https://doi.org/10.1093/europace/euz032
        • Boriani G.
        • Huisman M.V.
        • Teutsch C.
        • et al.
        Influence of BMI and geographical region on prescription of oral anticoagulants in newly diagnosed atrial fibrillation: The GLORIA-AF Registry Program.
        Eur J Intern Med. 2020; 80: 35-44https://doi.org/10.1016/j.ejim.2020.04.032
        • Steinberg B.A.
        • Simon D.N.
        • Thomas L.
        • et al.
        Management of Major Bleeding in Patients With Atrial Fibrillation Treated With Non-Vitamin K Antagonist Oral Anticoagulants Compared With Warfarin in Clinical Practice (from Phase II of the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation [ORBIT-AF II]).
        Am J Cardiol. 2017; 119: 1590-1595https://doi.org/10.1016/j.amjcard.2017.02.015
        • Torp-Pedersen C.
        • Goette A.
        • Nielsen P.B.
        • et al.
        Real-world' observational studies in arrhythmia research: data sources, methodology, and interpretation. A position document from European Heart Rhythm Association (EHRA), endorsed by Heart Rhythm Society (HRS), Asia-Pacific HRS (APHRS), and Latin America HRS (LAHRS).
        Europace. 2019; https://doi.org/10.1093/europace/euz210
        • Potpara T.S.
        • Lip G.Y.H.
        • Dagres N.
        • et al.
        Cohort profile The ESC EURObservational Research Programme Atrial Fibrillation III (AF III) Registry.
        Eur Heart J Qual Care Clin Outcomes. 2020; https://doi.org/10.1093/ehjqcco/qcaa050