Comments: focus update of the guidelines of the European Society of Cardiology (ESC) on management of atrial fibrillation

The updated 2012 guidelines of the European Society of Cardiology for the management of atrial fibrillation focus on the novelties and new innovations since the last edition in 2010. The evaluation of patients with atrial fibrillation concerning the thromboembolic stroke risk by using the CHA 2DS2-VASc score instead of the CHADS2 score is discussed extensively. As almost all patients with atrial fibrillation benefit from anticoagulation the guidelines focus on the identification of lowrisk patients who should not receive oral anticoagulants. Stroke prevention with acetylsalicylic acid is not recommended. The results and advantages of the new direct oral antico-agulants are extensively discussed and their use is recommended as a preferred option in contrast to the vitamin K antagonists. The implantation of a left atrial appendage closure device as prophylaxis for cardiac thromboembolism is mentioned for the first time and recommended as an alternative for patients with contraindications for anticoagulants and a high risk for bleeding. In addition to stroke prevention by anticoagulants the results using vernakalant and recommendations for pharmacological cardioversion are discussed as an alternative to electrical cardioversion. In the recommendations for pharmacological long-term antiarrhythmic therapy dronedarone is discussed and positioned as an alternative to class IC antiarrhythmics and amiodarone. Catheter ablation of atrial fibrillation targeting pulmonary vein electrical isolation is recommended for patients with paroxysmal atrial fibrillation and a low risk for procedure- related complications as first line therapy, given that the institutional conditions are met and the procedure is performed by an experienced electrophysiologist.