Recently, the Guidelines for the diagnosis and treatment of atrial fibrillation (AF)  were published, written by the following societies: American College of Cardiology (ACC)/American Heart Association (AHA)/American College of Clinical Pharmacy/Heart Rhythm Society (HRS) (1,2). These current guidelines present modifications and updates compared to those of 2014 and 2019 (3-5), which are in some cases conceptual to paradigm changes in how the appearance and evolution of AF in the patient's life are interpreted, as well as its relationship with other health factors.

Therefore, I would like to emphasize these modifications in the following 4 points:

1. Consider AF as a progressive pathological process, classified into stages, where the modification of risk factors aimed at prevention, progression and optimization of therapeutic measures to prevent adverse events and achieve the best results is of capital importance. Among the most remarkable to take into account are management of obesity, weight loss, physical activity, smoking cessation, alcohol moderation, hypertension, and other comorbidities.

2. A new approach of evaluating thromboembolic risk, with the use of different scores and the relationship with clinical factors more flexible, individualizing patients who can benefit from anticoagulation therapy. Also including the usefulness of devices for AF detection, and the value of the arrhythmic burden.

3. Early rhythm control, focusing on maintaining sinus rhythm and decreasing arrhythmic burden. From the classic indication of rhythm control for symptomatic patients (IIa), recommendations are incorporated regardless of the presence of symptoms. Ablation therapy is given a class I recommendation in patients with AF and reduced EF and shares the same level of recommendation for young patients with paroxysmal AF, and also includes those with few comorbidities and those diagnosed with AF within 1 year of presentation (Class IIa). Recommendations are also incorporated to prevent the progression of the disease and reduce the probability of the onset of dementia (IIb).

4.Since 2015, when the percutaneous left atrial appendage closure device (LAAO) Watchman  (Boston Scientific) had received FDA authorization, the recommendation level was IIb. In this guideline, IIa is awarded for patients with AF, a moderate to high risk of stroke (CHA2DS₂- VASc score ≥ 2 points), and a contraindication to long-term oral anticoagulation. This risk consists of severe bleeding due to a non-reversible cause, spontaneous intracranial/intraspinal bleeding due to a non-reversible cause, and serious bleeding related to recurrent falls when the cause of falls was not felt to be treatable.

In summary, the latest guidelines provide a conceptual change considering AF as a progressive pathology with an indivisible relationship with other risk factors, recognizing the need for a new approach for the evaluation of embolic risk, and prioritizing two procedures of interventionism in electrophysiology (AF ablation and left atrial appendage occlusion) in the therapy of patients with AF, based on their safety and effectiveness, revealed in numerous studies.

Luis Antonio Arabia

Arrhythmia Unit

Instituto Oulton

Córdoba, Argentina

Peer-review: Internal

Conflict of interest: None to declare

   Authorship: L.A.A.

            Acknowledgement and funding: None to declare