The Three Pillars of Atrial Fibrillation Management

Atrial fibrillation (AF) is the most prevalent sustained arrhythmia, and given its associations with stroke, heart failure and dementia, AF confers a major impact on public health. Optimal AF management should be based on three pillars: assessment and treatment of stroke risk factors, treatment of comorbidities, and symptom management through rhythm/rate control. In untreated AF, depending on other risk factors, the risk of stroke increases almost fivefold, and one in five strokes is related to AF. Therefore, effective assessment and prevention of stroke are the first pillar of AF management. The basis of stroke prevention is oral anticoagulation, which includes vitamin K antagonists and direct oral anticoagulants. Comorbidities and lifestyle factors exert a substantial influence on the progression risk, course, symptom severity, and prognosis in patients with AF. Hence, the appropriate management of these factors represents a crucial aspect, being the second pillar of AF treatment. The last pillar of AF management is symptom management through rhythm or rate control. Rhythm control in AF encompasses sinus rhythm restoration (antiarrhythmic drugs, cardioversion, and ablation techniques). Conversely, rate control aims to maintain AF while ensuring a well-regulated ventricular rate. Each of these pillars needs regular reassessment and dynamic shared decision-making with patients. The aim of AF treatment is to reduce mortality and improve prognosis and quality of life, which is influenced by each of the three pillars. In addition, it is important to emphasise that each pillar is linked to the others. For example, comorbidities increase the risk of stroke, and inadequate rhythm/rate control can accelerate the development of heart failure. Therefore, treatment of AF must not be punctual, but holistic and personalised, as outlined in this review.