Management of Atrial Fibrillation in 2021: An Updated Comparison of the Current CCS/CHRS, ESC, and AHA/ACC/HRS Guidelines

Given its complexity, the management of atrial fibrillation (AF) has relied increasingly on expert guideline recommendations; however, discrepancies between these professional societies can lead to confusion among practicing clinicians. This article compares the recommendations in the 2019 American Heart Association (AHA)/American College of Cardiology (ACC)/Heart Rhythm Society (HRS), the 2020 European Society of Cardiology (ESC), and the 2020 Canadian Cardiovascular Society/Canadian Heart Rhythm Society (CCS/CHRS) AF guidelines. Although many of the recommendations are fundamentally similar, there are important differences among guidelines; specifically, key differences are present in (1) definitions and classification of AF; (2) the role of opportunistic AF detection; (3) symptom and quality-of-life evaluation; (4) stroke-risk stratification and the indication for oral anticoagulation (OAC) therapy; (5) the role of aspirin in prevention of stroke for patients with AF; (6) the antithrombotic regimens employed in the context of coronary artery disease; (7) the role of OAC, and specifically non-vitamin K direct-acting oral anticoagulants (DOACs), in patients with chronic and end-stage renal disease; (8) the target heart rate for patients treated with a rate-control strategy, along with the medications recommended to achieve the heart-rate target; and (9) the role of catheter ablation as first-line therapy or in patients with heart failure. These differences highlight areas of continuing clinical uncertainty in which there are important needs and opportunities for future investigative work.