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An international panel of experts published recommendations to improve management of atrial fibrillation (AF). The position paper summarizes the results of the 9th AFNET/EHRA consensus conference – a two-day expert meeting which was jointly organized by the German Atrial Fibrillation Network (AFNET) and the European Heart Rhythm Association (EHRA) in Münster, Germany, in September 2023. Today the consensus report was presented at the EHRA congress in Berlin by Prof. Dominik Linz, Maastricht, The Netherlands, and simultaneously published in Europace (1).

Atrial fibrillation (AF) is the most common arrhythmia and a growing health problem in an aging society. It affects several million people in Europe and worldwide.

During the 9th AFNET/EHRA consensus conference 83 international interdisciplinary scientists pooled their knowledge on AF management and research and discussed new insights and treatment options. Prof. Linz, first author of the paper, explained: “After two days of fruitful discussion, we merged our findings. The essence of the meeting was summarized in five recommendations.”

1. Active rhythm management should be part of the default initial treatment for all suitable patients with AF.

2. Patients with device-detected AF have a low burden of AF and a low risk of stroke. Anticoagulation prevents some strokes but also increases major but non-lethal bleeding.

3. More research is needed to improve stroke risk prediction in patients with AF, especially in those with a low AF burden. Biomolecules, genetics and imaging can support this.

4. The presence of AF should trigger systematic work-up and comprehensive treatment of concomitant cardiovascular conditions.

5. Machine learning algorithms have been used to improve detection of AF and can help to prevent development of AF. Cooperation between clinicians and data scientists is needed to leverage the potential of data science applications for patients with AF.

Prof. Paulus Kirchhof, Hamburg, Germany, one of the four chairpersons of the conference and board member of AFNET, concluded: “Combining active rhythm control, anticoagulation, rate control, and therapy of concomitant cardiovascular conditions can improve the lives of patients with AF. A low AF burden is associated with low rates of stroke and heart failure. Reducing AF burden is developing into a therapeutic goal in patients with AF.”

Prof. Andreas Goette, Paderborn, Germany, also chairman of the conference and AFNET board member, stated: “We are curious to see whether our recommendations will be incorporated into the upcoming AF guidelines and change clinical practice.”

Participants of the 9th AFNET/EHRA Consensus Conference came from Europe, USA, Canada, and Australia. The meeting was chaired by four cardiologists: Prof. Andreas Goette, Paderborn, Germany, and Prof. Paulus Kirchhof, Hamburg, Germany, both from AFNET, and Prof. Helmut Pürerfellner, Linz, Austria, and Prof. Isabell van Gelder, Groningen, Netherlands, both from EHRA.

The conference was organized and co-financed by AFNET and EHRA with additional financial support from MAESTRIA which is funded under European Union's (EU) Horizon 2020 research and innovation program (grant number 965286). Industry participants paid an attendance fee.

References

1. Linz D et al. Longer and better lives for patients with atrial fibrillation: The 9th AFNET/EHRA Consensus Conference. Europace 2024 April 9. DOI: 10.1093/europace/euae070

About AFNET

The Atrial Fibrillation NETwork is an interdisciplinary research network comprising scientists and physicians from hospitals and practices dedicated to improving the management of atrial fibrillation through coordinated research in Germany, Europe, and worldwide. Its main objective is to conduct high quality investigator-initiated clinical trials and registries on a national and international level as well as translational research projects. The AFNET continues the long-term activities of the network which has been funded by the German Federal Ministry of Research and Education over a decade. Since January 2015, specific projects and infrastructures of the AFNET are funded by the German Centre for Cardiovascular Research (DZHK), and some projects by EU research grants. AFNET has long expertise in the management of atrial fibrillation, but also provides support for work in other fields informing cardiovascular care. The results of 20 years of clinical and translational research improved the lives of patients with cardiovascular diseases and influenced treatment guidelines.

www.af-net.eu

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Angelika Leute, PhD

Phone: +49 202 2623395

a.leute@t-online.de

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In patients with device-detected atrial fibrillation the risk of stroke appears low (1% per year) compared to patients with ECG-detected atrial fibrillation, even in patients with long episodes. Anticoagulation can slightly reduce stroke risk, but also increase major bleeding. This is the main finding of a sub-analysis of the NOAH – AFNET 6 trial presented by Dr Nina Becher, University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany, in the late-breaking clinical trials session at the annual congress of the American Heart Association (AHA) in Philadelphia, USA, and published on 12th November, 2023, in the European Heart Journal (1).

Device-detected atrial fibrillation, also called sub-clinical atrial fibrillation (SCAF) or atrial high-rate episodes (AHRE), are short and rare atrial arrhythmias detected by implanted pacemakers, defibrillators, and loop recorders that enable long-term monitoring of heart rhythm. The episodes resemble atrial fibrillation. Device-detected atrial fibrillation is found in every fifth patient with a pacemaker or another cardiac implanted electronic device (2). Device-detected atrial fibrillation can lead to stroke, but the stroke risk in patients with device-detected atrial fibrillation appears lower than the stroke risk in patients with ECG-documented atrial fibrillation. Observational data suggested that patients with very long episodes of device-detected atrial fibrillation may have a higher stroke risk.

Recently, the NOAH – AFNET 6 (Non vitamin K antagonist Oral anticoagulants in patients with Atrial High-rate episodes) trial found that anticoagulation increases bleeding events in patients with device-detected atrial fibrillation while the effect on stroke was smaller than expected (3).

Dr Becher and the NOAH – AFNET 6 team evaluated the efficacy and safety of anticoagulation with edoxaban in patients with long episodes of device-detected atrial fibrillation lasting 24 hours or more in the NOAH – AFNET 6 trial (1). The findings are consistent with the main trial: Anticoagulation had only has a minor effect on stroke and systemic embolism. An additional analysis including AHRE duration as a continuous variable confirmed that episode duration did not interact with the effect of anticoagulation. The low stroke rate without anticoagulation came as a surprise compared to older analyses. The results will need confirmation in larger and independent data sets.

Dr Becher states: “The effects of anticoagulation in patients with device-detected atrial fibrillation appear consistent across episode durations, including in patients with very long episodes. This highlights the need to involve all patients with device-detected AF in a balanced decision-making process on anticoagulation that considers the effects on stroke and bleeding.”

NOAH – AFNET 6 compared the anticoagulant edoxaban to placebo. A similar trial called ARTESiA (Apixaban for the Reduction of Thrombo-Embolism in Patients with Device-Detected Sub-Clinical Atrial Fibrillation) trial tested the efficacy and safety of another anticoagulant, apixaban, in patients with device-detected atrial fibrillation. A trial-level meta-analysis of these two first-in-kind randomized trials of anticoagulation in patients with device-detected atrial fibrillation shows consistent results in both trials (4): Anticoagulation prevents on average three strokes and induces seven major bleeding events per 1000 patient-years of treatment.

Professor Andreas Goette, St. Vincenz Hospital, Paderborn, Germany, who was involved in the NOAH – AFNET 6 trial and in the meta-analysis observes: “On average, anticoagulation reduces stroke by a small absolute amount. This desirable effect comes at the price of an increase in major bleeding events. Clinicians need to consider these effects when taking individual decisions on anticoagulation in patients with device-detected atrial fibrillation.”

Professor Paulus Kirchhof, UKE, lead investigator of the NOAH – AFNET 6 trial, states: “We now have much better estimates of the efficacy and safety of oral anticoagulation in patients with device-detected atrial fibrillation. We clearly need additional methods to identify patients with device-detected atrial fibrillation at high risk of stroke.”

References

(1) Becher N, Toennis T, Bertaglia E, et al. Anticoagulation with edoxaban in patients with long Atrial High-Rate Episodes ≥24 hours. Eur H J 2023; in press. DOI: 10.1093/eurheartj/ehad771

(2) Toennis T, Bertaglia E, Brandes A, et al. The influence of Atrial High Rate Episodes on Stroke and Cardiovascular Death - An update. Europace 2023. DOI: 10.1093/europace/euad166.

(3) Kirchhof P, Toennis T, Goette A, et al. Anticoagulation with Edoxaban in Patients with Atrial High-Rate Episodes. N Engl J Med 2023;389(13):1167-1179. DOI: 10.1056/NEJMoa2303062.

(4) McIntyre WF, Benz A, Becher N, et al. Direct oral anticoagulants for stroke prevention in patients with device-detected atrial fibrillation: A study-level meta-analysis of NOAH-AFNET 6 and ARTESiA. Circulation 2023; in press. 

About the Atrial Fibrillation NETwork (AFNET)

The Atrial Fibrillation NETwork is an interdisciplinary research network comprising scientists and physicians from hospitals and practices dedicated to improving the management of atrial fibrillation through coordinated research in Germany, Europe, and worldwide. Its main objective is to conduct high quality investigator-initiated clinical trials and registries on a national and international level as well as translational research projects. The AFNET continues the long-term activities of the network which has been funded by the German Federal Ministry of Research and Education over a decade. Since January 2015, specific projects and infrastructures of the AFNET are funded by the German Centre for Cardiovascular Research (DZHK), and some projects by EU research grants. AFNET has long expertise in the management of atrial fibrillation, but also provides support for work in other fields informing cardiovascular care. The results of 20 years of clinical and translational research improved the lives of patients with cardiovascular diseases and influenced treatment guidelines.

www.af-net.eu

Funding of the NOAH trial: AFNET, DZHK, Daiichi Sankyo

NOAH registration: NCT 02618577, ISRCTN 17309850

Press Contact

Angelika Leute, PhD
Phone: +49 202 2623395
a.leute@t-online.de

Press release

On 12 and 13 September international experts in atrial fibrillation come together in Münster, Germany, to take part in the 9^th AFNET/EHRA consensus conference. “Longer and better lives for patients with atrial fibrillation” is the pronounced intention of the two-day expert meeting which is jointly organized by the German Atrial Fibrillation Network (AFNET) and the European Heart Rhythm Association (EHRA) every two years.

Atrial fibrillation (AF) is the most common heart arrhythmia and a growing health problem in an aging society. It affects several million people in Europe and worldwide.

Prof. Paulus Kirchhof, Hamburg, Germany, one of the four chairpersons of the conference and board member of AFNET, explains the background of the expert meeting: “Despite improved treatment options AF patients still suffer strokes, heart failure, and premature death. There are various approaches to optimize care for AF patients. We set out to bring these approaches together. The AFNET/EHRA consensus conference provides a high-level expert forum to discuss recent advances in AF diagnosis and therapy.”  

The participating scientists will discuss new results in AF screening, the therapeutic impact of rare atrial arrhythmias picked up by implanted devices and consumer electronics, the role of early rhythm control, new data on the interaction of comorbidities with AF and AF management, new technologies for AF detection and management, the role of pacing and devices in the management of AF and heart failure, as well as new trial results from the main 2023 congresses.

Participants of the 9^th AFNET/EHRA Consensus Conference come from Europe, USA, Canada, and Australia. The meeting is chaired by four cardiologists: Prof. Andreas Goette, Paderborn, Germany, and Prof. Paulus Kirchhof, Hamburg, Germany, both from AFNET, and Prof. Helmut Pürerfellner, Linz, Austria, and Prof. Isabell van Gelder, Groningen, Netherlands, both from EHRA.

This is already the 9^th meeting of its kind. Since 2007, AFNET and EHRA organize biennial joint conferences in which international AF experts pool their knowledge. After detailed discussions, the scientists publish their results in a consensus report.

Prof. Goette summarizes the experts` aim: “During the conference, we will jointly develop recommendations for better AF management, and we will summarize them afterwards in a position paper. We hope our results will be integrated into the upcoming treatment guidelines of the European Society of Cardiology (ESC) next year.”

The conference is organized and co-financed by AFNET – celebrating 20 years anniversary in 2023 – and EHRA with additional financial support from MAESTRIA which is funded under European Union's (EU) Horizon 2020 research and innovation program (grant number 965286).

About AFNET

The Atrial Fibrillation NETwork is an interdisciplinary research network comprising scientists and physicians from hospitals and practices dedicated to improving the management of atrial fibrillation through coordinated research in Germany, Europe, and worldwide. Its main objective is to conduct high quality investigator-initiated clinical trials and registries on a national and international level as well as translational research projects. The AFNET continues the long-term activities of the network which has been funded by the German Federal Ministry of Research and Education over a decade. Since January 2015, specific projects and infrastructures of the AFNET are funded by the German Centre for Cardiovascular Research (DZHK), and some projects by EU research grants. AFNET has long expertise in the management of atrial fibrillation, but also provides support for work in other fields informing cardiovascular care. The results of 20 years of clinical and translational research improved the lives of patients with cardiovascular diseases and influenced treatment guidelines.

www.af-net.eu

Press Contact

Angelika Leute, PhD

Phone: +49 202 2623395

a.leute@t-online.de