Screening and diagnosis

Classification and risk stratification

Perioperative care

Quality improvement

Patient education

Nonpharmacologic interventions

Therapeutic procedures

Respiratory support

Follow-up and surveillance

Specific circumstances

Preventative measures

Medical management

Surgical interventions

Inpatient care

Diagnostic procedures

Diagnostic investigations

Insufficient evidence to make a recommendation.

Strongly favor this test or intervention.

This comprehensive tool helps to categorize the impact of atrial fibrillation symptoms on a person's daily life using the mEHRA classification system. By understanding and interpreting this classification, individuals and healthcare providers can have better insights into the condition's severity.

Here's how it works: You provide an input describing your symptoms based on their effect on daily activities. There are five possible descriptions:

- No symptoms
- No impact on daily activity, symptoms not troublesome
- No impact on daily activity, but troublesome symptoms
- Impact on daily activity
- Discontinuation of daily activity

Based on your selection, the calculator assigns an mEHRA classification that reflects the severity of your symptoms:

- If you experience "No symptoms," this represents the mildest situation and is classified as "mEHRA class 1."
- If your symptoms have "No impact on daily activity" and are "not troublesome," you're assigned "mEHRA class 2a."
- Symptoms that have "No impact on daily activity" but are "troublesome" fall into "mEHRA class 2b."
- When symptoms "Impact on daily activity," it is a sign of increasing severity, corresponding to "mEHRA class 3."
- The most severe category is "Discontinuation of daily activity" due to symptoms, leading to "mEHRA class 4."

These classifications provide critical insights. The transition from class 1 to class 4 highlights the increasing impact and distress caused by symptoms, guiding treatment and management priorities. This structured classification aids in better understanding and communication between patients and healthcare professionals, ensuring that attention is focused appropriately based on the symptom impact level.

The mEHRA classification of atrial fibrillation, also known as the modified European Heart Rhythm Association (mEHRA) score, is a clinical calculator used specifically for patients with atrial fibrillation. This scoring system is used to categorize the severity of symptoms in patients with atrial fibrillation, ranging from no symptoms to disabling symptoms. 

The mEHRA score is clinically useful in guiding treatment decisions and assessing the impact of interventions on symptom severity. It can also be used to monitor the progression of the disease over time. 

There are no specific exclusion criteria for the use of the mEHRA score. However, it is important to note that this score is subjective and relies on patient-reported symptoms, so it may not be as accurate in patients who have difficulty communicating their symptoms.

mEHRA classification of atrial fibrillation

The CHA₂DS₂-VASc score is a tool used to estimate the risk of stroke in individuals with atrial fibrillation. It assigns points based on various risk factors, and the total score guides clinical decisions regarding anticoagulation therapy.

Here’s how the scoring works:

- Age:
  - Below 65 years scores 0 points.
  - Between 65 and 74 years scores 1 point.
  - 75 years or older scores 2 points.

- Sex:
  - Female scores 1 point.
  - Male scores 0 points.

- Hypertension:
  - If present, scores 1 point.
  - If absent, scores 0 points.

- Diabetes Mellitus:
  - If present, scores 1 point.
  - If absent, scores 0 points.

- Congestive Heart Failure/Left Ventricular Dysfunction:
  - If present, scores 1 point.
  - If absent, scores 0 points.

- History of Stroke/Thromboembolism/Transient Ischemic Attack:
  - If present, scores 2 points.
  - If absent, scores 0 points.

- History of Vascular Disease (such as prior myocardial infarction or peripheral artery disease):
  - If present, scores 1 point.
  - If absent, scores 0 points.

To calculate the score, assess each of these factors for the individual and sum the respective points.

Once the total score is determined, it is interpreted as follows:
- A score of 0 implies a 0.2% risk of ischemic stroke and a 0.3% risk of stroke/transient ischemic attack/systemic embolism.
- A score of 1 indicates a 0.6% risk of ischemic stroke and a 0.9% risk of stroke/TIA/systemic embolism.
- A score of 2 suggests a 2.2% risk of ischemic stroke and a 2.9% risk of stroke/TIA/systemic embolism.
- A score of 3 means a 3.2% risk of ischemic stroke and a 4.6% risk of stroke/TIA/systemic embolism.
- A score of 4 reveals a 4.8% risk of ischemic stroke and a 6.7% risk of stroke/TIA/systemic embolism.
- A score of 5 corresponds to a 7.2% risk of ischemic stroke and a 10.0% risk of stroke/TIA/systemic embolism.
- A score of 6 represents a 9.7% risk of ischemic stroke and a 13.6% risk of stroke/TIA/systemic embolism.
- A score of 7 reflects an 11.2% risk of ischemic stroke and a 15.7% risk of stroke/TIA/systemic embolism.
- A score of 8 implies a 10.8% risk of ischemic stroke and a 15.2% risk of stroke/TIA/systemic embolism.
- A score of 9 equates to a 12.2% risk of ischemic stroke and a 17.4% risk of stroke/TIA/systemic embolism.

This comprehensive scoring system helps identify the stroke risk and aids healthcare providers in making informed decisions about patient care.

The CHA₂DS₂-VASc score is a clinical prediction rule for estimating the risk of stroke in patients with non-rheumatic atrial fibrillation (AF). The acronym stands for Congestive heart failure, Hypertension, Age ≥75 years (doubled), Diabetes mellitus, Stroke (doubled), Vascular disease, Age 65–74 years, and Sex category (female). Each factor is assigned a certain number of points, and the total score is used to estimate the risk of stroke. 

This calculator is specifically applicable to patients with non-rheumatic atrial fibrillation, including those who are being considered for anticoagulation therapy. The clinical utility of the CHA₂DS₂-VASc score is to guide clinicians in making decisions about anticoagulation therapy, as higher scores indicate a greater risk of stroke and may warrant more aggressive treatment.

The CHA₂DS₂-VASc score should not be used in patients with rheumatic atrial fibrillation, as the risk factors and stroke risk in these patients are different. It is also not applicable to patients with transient causes of atrial fibrillation, such as those due to a reversible cause like surgery or acute illness.

CHA₂DS₂-VASc score for stroke risk in atrial fibrillation

The HAS-BLED score evaluates the likelihood of major bleeding in patients with atrial fibrillation by examining nine different risk factors. Each factor contributes a point to the total score if present, leading to a potential range from 0 to 9. The elements considered in this assessment include:

- Uncontrolled hypertension, defined by systolic blood pressure exceeding 160 mmHg
- Renal dysfunction indicated by dialysis, transplant, or creatinine levels over 2.26 mg/dL (200 mcmol/L)
- Liver dysfunction characterized by cirrhosis or significant liver test abnormalities
- Previous stroke history
- Prior incidents of major bleeding, which necessitated hospitalization, transfusion, or a decrease in hemoglobin by more than 2 g/L
- Labile International Normalized Ratio (INR), where the therapeutic range falls below 60%
- Age over 65
- Use of medications such as antiplatelet agents or NSAIDs
- High alcohol consumption of 8 or more units per week

For each risk factor that applies (input marked 'true'), a score of 1 is added to the overall total. The cumulative score reflects the bleeding risk as follows:

- Scores of 0 or 1 suggest a low annual bleeding risk of about 1%.
- A score of 2 indicates a risk of 1.88% per year.
- A score of 3 raises the estimated risk to 3.74% annually.
- A score of 4 suggests an elevated risk of about 8.70% per year.
- Scores of 5 or above point to a substantial risk, at or surpassing 12.5% annually.

This calculated score provides both the total score and an interpretation, enabling healthcare providers to gauge the bleeding risk for patients with atrial fibrillation comprehensively.

The HAS-BLED score is a clinical calculator used to assess the risk of major bleeding in patients with atrial fibrillation. The acronym stands for Hypertension, Abnormal renal/liver function, Stroke, Bleeding history or predisposition, Labile INR, Elderly (>65), and Drugs/alcohol concomitantly. Each factor is assigned one point, and the total score ranges from 0 to 9. 

This scoring system is specifically applicable to patients with atrial fibrillation, a common heart rhythm disorder. The clinical utility of the HAS-BLED score is to guide clinicians in making decisions about anticoagulant therapy, balancing the risk of stroke against the risk of major bleeding. 

There are no specific exclusion criteria for the use of the HAS-BLED score. However, it should be noted that the score does not consider all possible risk factors for bleeding, and clinical judgment should always be used in conjunction with the score.

HAS-BLED score for major bleeding risk in atrial fibrillation

The ATRIA bleeding risk score calculator is a tool used to assess the risk of bleeding in patients with atrial fibrillation who are on warfarin therapy. It evaluates five specific risk factors, assigning a score to each, and uses the total to estimate the annual risk of hemorrhage.

For each factor, points are assigned as follows:

- Age 75 years or older: 2 points
- Diagnosed hypertension: 1 point
- History of any hemorrhage: 1 point
- Hemoglobin less than 13 g/dL in males or less than 12 g/dL in females: 3 points
- Glomerular filtration rate less than 30 mL/min or dialysis dependence: 3 points

Each risk factor is considered as either present or absent (true or false). If a factor is present, its associated point value is added to a cumulative score. The total possible score ranges from 0 to 10.

The overall score determines the interpretation of the patient's annual risk of hemorrhage while on warfarin:

- A score between 0 and 3 suggests a low annual bleeding risk of approximately 0.76%.
- A score of 4 indicates a moderate risk, with an annual hemorrhage probability of about 2.62%.
- Scores of 5 or higher correspond to a high risk, with the annual probability of bleeding rising to approximately 5.76%.

This score assists healthcare providers in evaluating and managing anticoagulation treatment strategies, balancing the benefits of anticoagulation against its risks.

The ATRIA score, or Anticoagulation and Risk Factors in Atrial Fibrillation Bleeding Risk Score, is a clinical calculator used specifically for patients with atrial fibrillation. This scoring system is designed to assess the risk of major bleeding in patients with atrial fibrillation who are on anticoagulation therapy. The ATRIA score takes into account several factors including age, prior bleeding, anemia, severe renal disease, and hypertension. 

The clinical utility of the ATRIA score is to guide clinicians in making informed decisions about anticoagulation therapy in patients with atrial fibrillation, balancing the risk of stroke against the risk of major bleeding. 

There are no specific exclusion criteria for the use of the ATRIA score, but it is most applicable to patients with atrial fibrillation who are on anticoagulation therapy. It may not be as useful or accurate in patients without atrial fibrillation or those not receiving anticoagulation therapy.

Anticoagulation and risk factors in atrial fibrillation bleeding risk score (ATRIA score)

The CHADS₂ score is widely used to estimate stroke risk in individuals with atrial fibrillation by evaluating five specific risk factors. Each factor contributes a designated number of points, and their combined total offers an assessment of stroke likelihood.

For the CHADS₂ score calculation, consider the following risk factors, each assigned a set point value:

- Age 75 years or older: 1 point
- Hypertension: 1 point
- Diabetes mellitus: 1 point
- Congestive heart failure: 1 point
- History of stroke or transient ischemic attack: 2 points

To compute the score, determine if each condition is present. Assign points based on the presence (true) of these conditions and sum the points for a total score ranging from 0 to 6. This total score then assists health professionals in the decision-making process regarding anticoagulation therapy.

Once you have the total score, assess the risk of stroke by interpreting the score as follows:

- If the score is 0, the annual stroke risk is approximately 1.9%.
- A score of 1 equates to a 2.8% risk.
- A score of 2 suggests a 4.0% risk.
- A score of 3 indicates a 5.9% risk.
- A score of 4 corresponds to an 8.5% risk.
- A score of 5 translates to a 12.5% risk.
- A score of 6 represents an 18.2% risk.

This scoring system not only provides a numeric assessment but also aids in evaluating the necessity of preventive treatment to reduce stroke risk in patients with atrial fibrillation.

The CHADS₂ score is a clinical prediction rule for estimating the risk of stroke in patients with non-rheumatic atrial fibrillation (AF), a common and serious heart rhythm disturbance. This score is simple and has been validated by many studies in different groups of AF patients. 

The CHADS₂ acronym stands for Congestive heart failure, Hypertension, Age ≥75 years, Diabetes mellitus, and prior Stroke or transient ischemic attack (TIA). Each factor scores one point, except for prior stroke or TIA, which scores two points. The total score ranges from 0 to 6, with higher scores indicating a greater risk of stroke.

The clinical utility of the CHADS₂ score is to help clinicians decide whether or not to anticoagulate a patient with AF. Patients with a score of 0 are at low risk and do not require anticoagulation. Patients with a score of 1 can be considered for anticoagulation, and those with a score of 2 or more should definitely be anticoagulated, unless contraindicated.

The CHADS₂ score should not be used in patients with rheumatic AF, valvular heart disease, or those who have a contraindication to antico

CHADS₂ score for stroke risk in atrial fibrillation

The ORBIT bleeding risk score evaluates the likelihood of bleeding in individuals with atrial fibrillation through a straightforward assessment of five patient factors. Each factor's presence contributes to the overall score, helping clinicians estimate the potential bleeding risk.

Here's how the score is computed:

1. Age greater than 74 years: 
   - Assign 1 point for "Yes", 0 points for "No".

2. Presence of reduced hemoglobin/hematocrit or anemia:
   - Assign 2 points for "Yes", 0 points for "No".

3. History of bleeding:
   - Assign 2 points for "Yes", 0 points for "No".

4. Glomerular filtration rate (GFR) less than 60 mL/min/1.73 m²:
   - Assign 1 point for "Yes", 0 points for "No".

5. Treatment with antiplatelet agents:
   - Assign 1 point for "Yes", 0 points for "No".

Total the points from all of these inputs to get a score ranging from 0 to 7. This overall score provides an interpretation of the patient's bleeding risk:

- Scores from 0 to 2 suggest a bleeding risk of approximately 2.4%.
- A score precisely at 3 indicates a bleeding risk of roughly 4.7%.
- Scores ranging from 4 to 7 reflect an elevated bleeding risk of about 8.1%.

This systematic approach allows healthcare providers to assess and communicate bleeding risks effectively, enabling informed decision-making for managing atrial fibrillation.

The ORBIT (Outcomes Registry for Better Informed Treatment) bleeding risk score is a clinical calculator specifically designed for patients with atrial fibrillation. This scoring system is used to predict the risk of major bleeding in patients with atrial fibrillation who are receiving anticoagulant therapy. The ORBIT score includes five variables: age, anemia, severe renal disease, prior bleeding, and treatment with antiplatelet agents. The score ranges from 0 to 7, with higher scores indicating a higher risk of bleeding. This tool is particularly useful in guiding clinicians in their decision-making process regarding the initiation or continuation of anticoagulant therapy in patients with atrial fibrillation. It should not be used in patients without atrial fibrillation or those not receiving anticoagulant therapy, as it has not been validated in these populations.

ORBIT bleeding risk score in atrial fibrillation

The calculator categorizes the severity of heart failure using the New York Heart Association (NYHA) functional classification system. It does this by analyzing a patient's reported physical abilities related to cardiac disease and matches them to one of the four NYHA classes.

Here's the breakdown of each class:

- Class I involves patients who have cardiac disease but do not experience any limitations in physical activity. Regular activities do not cause undue fatigue, palpitation, or shortness of breath.
  
- Class II fits patients who have a slight limitation in physical activity due to cardiac disease. They feel comfortable when at rest, but ordinary physical activities might lead to fatigue, palpitation, or breathlessness.
  
- Class III describes patients with a marked limitation in physical activity. These individuals are comfortable when resting, but even less than ordinary activities cause fatigue, palpitations, breathlessness, or chest pain.
  
- Class IV covers patients who cannot engage in any physical activity without experiencing discomfort. They exhibit symptoms of heart failure even when at rest, and any physical activity worsens these symptoms.

To determine the appropriate class for a patient, the calculator compares the user’s description of their physical ability with these four established patterns. Each condition is linked specifically to one of the NYHA classes, providing a clear pathway from symptom description to classification. For example, if a patient’s physical condition matches the criteria for Class I, then the result is "Class I." This comparison method efficiently identifies the level of heart failure severity based on self-reported abilities and symptoms.

The NYHA functional classification for heart failure, or New York Heart Association Functional Classification, is a scoring system used to quantify the severity of symptoms in patients with heart failure. This classification system is applicable to patients diagnosed with heart failure and is used to assess their functional capacity and limitations during physical activity. 

The NYHA classification is divided into four classes: Class I (no symptoms and no limitation in ordinary physical activity), Class II (mild symptoms and slight limitation during ordinary activity), Class III (marked limitation in activity due to symptoms, even during less-than-ordinary activity), and Class IV (severe limitations, experiences symptoms even while at rest).

The clinical utility of this calculator is to guide treatment decisions, assess prognosis, and evaluate the effectiveness of therapeutic interventions in patients with heart failure. It is also commonly used in clinical trials to stratify patients and measure outcomes. 

There are no specific exclusion criteria for its use, but it is subjective and relies on patient self-report, so it may not be as accurate in patients with cognitive impairment or communication difficulties.

NYHA functional classification for heart failure

Atrial fibrillation

Management of bleeding

Management of bleeding, direct thrombin inhibitors

Quality of care

Pre-procedural anticoagulation bridging

Patients with peripheral artery disease

Patients with PAD

Young patients

Young patients, evaluation

As per ACC/ACCP/AHA/HRS 2024 guidelines, 

Rate control

Rate control, acute control, choice of agents

Patients with congenital heart disease

Patients with CHD, anticoagulation

Rate control (long-term control, targets)

Rhythm control

Rhythm control, pharmacological cardioversion, pill-in-the-pocket

Critically ill patients

Elderly patients

Anticoagulant therapy

Anticoagulant therapy, general indications

Initial evaluation

Management of hypertension

Management of hypertension (rate control)

Rhythm control, pharmacological cardioversion, choice of agent

Rate control, acute control, targets

Atrioventricular nodal ablation

Atrioventricular nodal ablation, indications

Surgical ablation

Patients with acute coronary syndrome

Patients with ACS

Patients with atrial flutter

Patients with atrial flutter, anticoagulation

Patients with chronic kidney disease

Patients with CKD

Weight loss

Rate control, long-term control, amiodarone and dronedarone

Patients with postoperative atrial fibrillation

Patients with postoperative AF, anticoagulation

Smoking cessation

Evaluation for hypertension

Rate control, long-term control, digoxin

Athletes

Athletes (physical activity)

Stroke risk assessment

Anticoagulant therapy, VKAs

Physical activity

Patients with subclinical atrial fibrillation

Patients with subclinical AF (evaluation)

Anticoagulant therapy, peri-cardioversion

Patients with atrial flutter, catheter ablation

Catheter ablation

Catheter ablation, indications

Pre-procedural anticoagulation interruption

Patients with chronic liver disease

General principles

Indications for screening

Indications for screening, cardiac implantable electronic devices

Patients with obesity

Catheter ablation (post-ablation antiarrhythmics)

Anticoagulant therapy, peri-catheter ablation

Management of bleeding, general principles

Patients with postoperative AF, monitoring

As per ACC/ACS/AHA/…/SVM 2024 guidelines, 

Patients with Wolff-Parkinson-White and pre-excitation syndromes

Patients with WPW and pre-excitation syndromes, rate control

Patients with valvular heart disease

Anticoagulant therapy, DOACs

Confirmatory testing

Evaluation for sleep apnea

Athletes, catheter ablation

Patients with subclinical AF, anticoagulation

Atrioventricular nodal ablation, pacemaker placement

Pregnant patients

Pregnant patients, rate control

Left atrial appendage closure

LAA closure, indications

Management of hypertension, antihypertensive therapy

Rhythm control, electrical cardioversion

Rhythm control, pharmacological cardioversion, indications

Patients with pulmonary disease

Young patients, catheter ablation

Alcohol restriction

Management of bleeding, direct factor Xa inhibitors

Indications for screening, stroke

Rate control, long-term control, beta-blockers and CCBs

Patients with coronary artery disease

Patients with CAD

Catheter ablation, technical considerations

Rhythm control, maintenance therapy

General counseling

Evaluation for ischemia

Rhythm control, general indications

Patients with heart failure

Patients with HF (rate control)

Updated 2024 STS guidelines for surgical management of atrial fibrillation


Updated 2024 ESC guidelines for the diagnosis and management of atrial fibrillation


Atrial fibrillation

Background

Overview

Guidelines

Key sources