Incorrect. To establish diagnosis, confirmation by an electrocardiogram is recommended.

Incorrect. The diagnosis of clinical AF is based on the ECG (12-lead, multiple or single leads). However, if an asymptomatic episode of AF is detected on continuous monitoring devices, then it will be labelled as a Device-detected subclinical AF, which warrants further confirmation, as device-detected subclinical AF is a predictor of future clinical AF.

Incorrect. Previous guidelines published in 2020 recommended using minimum of 30s to establish diagnosis, but in current 2024 guidelines no specific time duration is recommended. The minimum duration to establish the diagnosis of clinical AF for ambulatory ECG is not clear and depends on the clinical context. Periods of 30 s or more may indicate clinical concern, and trigger further monitoring or risk stratification for thromboembolism.

Correct! AF is reflected on the surface electrocardiogram (ECG) by the absence of discernible and regular P waves, and irregular activation of the ventricles. This results in no specific pattern to RR intervals, in the absence of an atrioventricular block.

Incorrect. 2 points would be awarded for age ≥75 years, and 1 point for the presence of type 2 diabetes mellitus, making it 3 in total.

Incorrect. 2 points would be awarded for age ≥75 years, and 1 point for the presence of type 2 diabetes mellitus, making it 3 in total.

Correct! Age is an independent determinant of ischaemic stroke risk. Age-related risk is a continuum, but for reasons of practicality, two points are given for age ≥75 years. Diabetes mellitus (type 1 or type 2), as defined by currently accepted criteria, or treatment with glucose lowering therapy - awarded by 1 point.

Incorrect. 2 points would be awarded for age ≥75 years, and 1 point for the presence of type 2 diabetes mellitus, making it 3 in total.

Correct! This is class I, level C recommendation.

Incorrect. A CHA2DS2-VA score of 1 should be considered an indicator of elevated thromboembolic risk for decisions on initiating oral anticoagulation. Class IIa, level C recommendation.

Correct! This is a class IIa, level C recommendation.

Incorrect. There is not a particular recommendation for the use of one specific risk score. However, the task force for the 2024 guidelines proposes, in the absence of other locally validated alternatives, that clinicians and patients should use the CHA2DS2-VA score to assist in decisions on OAC therapy.

Correct! The DOACs have all demonstrated at least non-inferior efficacy compared with warfarin for the prevention of thromboembolism, but with the added benefit of a 50% reduction in intracranial haemorrhage (ICH).

Incorrect. Direct oral anticoagulants as a class should be avoided in this specific patient group. In patients with mechanical heart valves, an excess of thromboembolic and major bleeding events among patients on dabigatran therapy vs. VKA was observed, with a trial terminated prematurely. A trial of apixaban vs. VKA after implantation of a mechanical aortic valve was also stopped due to excess thromboembolic events in the apixaban group.

Incorrect. Direct oral anticoagulants are recommended in preference to VKAs to prevent ischaemic stroke and thromboembolism, except in patients with mechanical heart valves or moderate-to severe mitral stenosis. Class I, level A recommendation.

Correct! VKA are preferred in this patient group. In patients with mechanical heart valves, an excess of thromboembolic and major bleeding events among patients on dabigatran therapy vs. VKA was observed, with an randomised controlled trial terminated prematurely.

Incorrect. DOACs are the prefered OAC (except in patients with mechanical heart valves or moderate-to-severe mitral stenosis). In a phase 3, international, double-blind trial comparing asundexian with apixaban, the treatment with asundexian was associated with higher incidence of stroke or systemic embolism than treatment with apixaban, which led to the trial being stopped prematurely.

Correct! Direct oral anticoagulants as a class should be avoided in specific patient groups, such as those with mechanical heart valves or moderate-to-severe mitral stenosis. VKA should be used in preference.

Incorrect. Antiplatelet drugs, such as aspirin and clopidogrel, are not an alternative to OAC. They should not be used for stroke prevention, and can lead to potential harm (especially among elderly patients with AF).

Correct! Direct oral anticoagulants are recommended in preference to VKAs to prevent ischaemic stroke and thromboembolism, except in patients with mechanical heart valves or moderate-to severe mitral stenosis. Class I, level A recommendation.

Incorrect. In this situation, direct oral anticoagulants (DOACs) are preferred. The restriction on DOAC use does not apply to bioprosthetic heart valves (including mitral) or after transcatheter aortic valve implantation, where DOACs can be used and trial data show non-inferiority for clinical events compared with VKAs.

Correct! DOACs as a class should be avoided in this specific patient group. In patients with mechanical heart valves, an excess of thromboembolic and major bleeding events among patients on dabigatran therapy vs. VKA was observed, with a trial terminated prematurely. A trial of apixaban vs. VKA after implantation of a mechanical aortic valve was also stopped due to excess thromboembolic events in the apixaban group.

Correct! In 4531 randomized patients with rheumatic heart disease (82% of the patients had a mitral valve area ≤2 cm) and AF, VKAs led to a lower rate of composite cardiovascular events and death than rivaroxaban, without a higher rate of bleeding, supporting the restriction of DOAC use in patients with moderate-to-severe mitral stenosis.

Incorrect. The restriction to VKA applies to moderate-to-severe mitral stenosis. Patients with other types of valve disease (mitral regurgitation and others) should preferentially be prescribed a DOAC, and the term ‘valvular’ AF is obsolete and should be avoided.

Correct! Two out of three criteria are needed for dose reduction of apixaban: (i) age ≥80 years (ii) body weight ≤60 kg (iii) serum creatinine ≥133 mmol/L.

Incorrect. The criterion for dose reduction of rivaroxaban is creatinine clearance 15–49 mL/min.

Correct! Dose reduction of edoxaban from 60 mg to 30 mg once daily is recommended if any apply: (i) moderate or severe renal impairment (creatinine clearance 15–50 mL/min) (ii) body weight ≤60 kg (iii concomitant use of cyclosporin, dronedarone, erythromycin, or ketoconazole.

Correct! Dose reduction of dabigatran from 150 mg to 110 mg twice daily is recommended if any apply: (i) age ≥80 years (ii) receiving concomitant verapamil.

Incorrect. A target INR of 2.0–3.0 is recommended for patients with AF prescribed a VKA for stroke prevention to ensure safety and effectiveness.

Correct! A target INR of 2.0–3.0 is recommended for patients with AF prescribed a VKA for stroke prevention to ensure safety and effectiveness. Class I, level B recommendation.

Correct! Keeping the time in therapeutic range above 70% should be considered in patients taking a VKA to ensure safety and effectiveness, with INR checks at appropriate frequency and patient directed education and counselling.

Incorrect. There is not a specific recommendation on routine switching from VKA to DOAC therapy. In view of the potential safety benefits, switching from VKAs to a DOAC is justified where there are concerns about intracranial bleeding or for patient-choice reasons, and is recommended for eligible patients that have failed to maintain an adequate time in therapeutic range on a VKA (TTR <70%). In case of older patients with polypharmacy, a recent trial showed that switching from VKAs to DOACs led to a higher primary outcome rate of major or clinically relevant non-major bleeding events compared with continuing with INR-guided VKA. Hence, in such patients who are clinically stable with good TTR, VKAs may be continued rather than switching to a DOAC after an open discussion with the patient and shared decision-making.

Correct! Antiplatelet drugs, such as aspirin and clopidogrel, are not an alternative to OAC (oral anticoagulation). They should not be used for stroke prevention, and can lead to potential harm (especially among elderly patients with AF). Class III, level B recommendation.

Incorrect. In ACTIVE W trial, dual antiplatelet therapy (DAPT) with aspirin and clopidogrel was less effective than warfarin for the prevention of stroke, systemic embolism, MI, or vascular death (annual risk of events 5.6% vs. 3.9%, respectively; P = .0003), with similar rates of major bleeding.

Incorrect. Bleeding events are more common when antithrombotic agents are combined, and no clear benefit has been observed in terms of prevention of stroke or death. In general, combining antiplatelet drugs with anticoagulants (DOACs or VKAs) should only occur in selected patients with acute vascular disease (e.g. acute coronary syndromes).

Incorrect.

Correct! This is class I, level B recommendation.

Correct! There is a potential advantage for stand-alone epicardial over percutaneous LAA closure in patients with a contraindication for OAC, as there is no need for post-procedure anticoagulation after epicardial closure. Observational data show that stand-alone LAA closure using an epicardial clip is feasible and safe.

Incorrect. Percutaneous LAA occlusion may be considered in patients with AF and contraindications for long-term anticoagulant treatment to prevent ischaemic stroke and thromboembolism.

Correct! Class IIb, level C recommendation. LAA occlusion (Watchman device) was associated with significantly lower rates of haemorrhagic stroke in comparison to warfarin (but also a 71% non-significant increase in ischaemic stroke and systemic embolism). In the PRAGUE-17 trial, 402 AF patients were randomized to DOAC or LAAO (Watchman or Amulet), with non-inferiority reported for a broad composite primary endpoint of stroke, TIA, systemic embolism, cardiovascular death, major or non-major clinically relevant bleeding, and procedure/device-related complications.

Correct! Absolute contraindications for OAC therapy are rare, and include primary intracranial tumours and intracerebral bleeds related to amyloid angiopathy. Authors of a recent 2022 meta-analysis on the risk of ICH (intracranial haemorrhage) in patients with primary or metastatic brain cancer conclude the not-negligible risk of ICH in patients with primary brain cancer or brain metastases. Anticoagulation is associated with an increase in the risk of ICH and major ICH in patients with primary brain cancer.

Incorrect. The presence of previous major bleeding is considered a non-modifiable risk factor for bleeding. This is not a reason not to start OAC therapy, per se. Instead, patients with non-modifiable risk factors should be reviewed more often, and where appropriate, a multidisciplinary team approach should be instituted to guide management.

Incorrect. Bleeding risk factors are rarely a reason to withdraw or withhold OAC in eligible patients, as the risk of stroke without anticoagulation often outweighs the risk of major bleeding. Instead, all potentially modifiable bleeding risk factors (e.g. reduced platelet count, anaemia, diabetes mellitus, etc.) should be addressed with shared decision-making.

Incorrect.

Correct!

Incorrect. Atrial high-rate episodes need to be visually inspected because some may be electrical artefacts or false positives.

Incorrect. Atrial high-rate episodes are detected by implanted cardiac devices that allow for automated continuous monitoring and storage of atrial rhythm.

Incorrect.

Incorrect. Interrupting anticoagulation and performing diagnostic or treatment interventions is recommended in AF patients with active bleeding until the cause of bleeding is identified and resolved. Class I, level C recommendation.

Correct! If the patient is taking dabigatran, idarucizumab can fully reverse its anticoagulant effect and help to achieve haemostasis within 2–4 h in uncontrolled bleeding. Specific antidotes should be considered in AF patients on a DOAC (direct OAC) who develop a life threatening bleed, or bleed into a critical site, to reverse the antithrombotic effect. Class IIa, level B recommendation.

Incorrect. Idarucizumab is an antidote for dabigatran.

Correct! For major bleeding events in patients taking VKAs, administration of fresh frozen plasma restores coagulation more rapidly than vitamin K, but prothrombin complex concentrates achieve even faster blood coagulation with fewer complications, and so are preferable to achieve haemostasis. PCC should be considered in AF patients on VKAs who develop a life-threatening bleed, or bleed into a critical site, to reverse the antithrombotic effect. Class IIa, level C recommendation.

Correct! An open-label RCT (randomized controlled trial) comparing andexanet alfa to usual care in patients presenting with acute ICH within 6 h of symptom onset was stopped early due to improved control of bleeding after 450 patients had been randomized.

Incorrect. Andexanet alfa rapidly reverses the activity of factor Xa inhibitors - apixaban, edoxaban, rivaroxaban.

Correct! In DOAC-treated patients where the last DOAC dose was taken within 2–4h, charcoal administration and/or gastric lavage may reduce further exposure.

Incorrect. In DOAC-treated patients where the last DOAC dose was taken within 2–4h, charcoal administration and/or gastric lavage may reduce further exposure.

Incorrect. Rate control therapy is recommended in patients with AF, as initial therapy in the acute setting, an adjunct to rhythm control therapies, or as a sole treatment strategy to control heart rate and reduce symptoms. Class I, level B recommendation.

Incorrect. In general for acute rate control, beta-blockers (for all LVEF) are preferred over digoxin because of their more rapid onset of action and dose-dependent effects. More selective beta-1 receptor blockers have a better efficacy and safety profile than non selective beta-blockers.

Correct! Beta-blockers, diltiazem, verapamil, or digoxin are recommended as first-choice drugs in patients with AF and LVEF >40% to control heart rate and reduce symptoms. Class I, level B recommendation.

Correct! Beta-blockers and/or digoxin are recommended in patients with AF and LVEF ≤40% to control heart rate and reduce symptoms. Class I, level B recommendation.

Correct! High plasma levels are associated with adverse events. Serum digoxin concentrations can be monitored to avoid toxicity, especially in patients at higher risk due to older age, renal dysfunction, or use of interacting medications. Check renal function before starting digoxin and adapt dose in CKD (chronic kidney disease) patients.

Incorrect. In RCTs (randomized controlled trials), there is no association between the use of digoxin and any increase in all-cause mortality. Lower doses of digoxin may be associated with better prognosis.

Incorrect. Intravenous digoxin, (or amiodarone, esmolol, and landiolol) may be considered in patients with AF who have haemodynamic instability or severely depressed LVEF (left ventricular ejection fraction) to achieve acute control of heart rate. Class IIb, level B recommendation.

Incorrect. In RATE-AF (RAte control Therapy Evaluation in permanent Atrial Fibrillation), a trial in patients with symptomatic permanent AF, there was no difference between low-dose digoxin and bisoprolol for patient-reported quality of life outcomes at 6 months. However, those randomized to digoxin demonstrated fewer adverse effects, a greater improvement in mEHRA and NYHA scores, and a reduction in BNP.

Correct! Atrioventricular node ablation in combination with pacemaker implantation should be considered in patients unresponsive to, or ineligible for, intensive rate and rhythm control therapy to control heart rate and reduce symptoms. Class IIa, level B recommendation.

Correct! Atrioventricular node ablation combined with cardiac resynchronization therapy should be considered in severely symptomatic patients with permanent AF and at least one hospitalization for HF to reduce symptoms, physical limitations, recurrent HF hospitalization, and mortality. In the APAF-CRT trial in a population with narrow QRS complexes, atrioventricular node ablation combined with CRT was superior to rate control drugs for the primary outcomes (all-cause mortality, and death or hospitalization for heart failure), and secondary outcomes (symptom burden and physical limitation). Class IIa, level B recommendation.

Incorrect. Currently, there is not a specific recommendation for atrioventricular node ablation with CSP in the guidelines. Conduction system pacing may become a potentially useful alternate pacing mode when implementing a pace and ablate strategy, once safety and efficacy have been confirmed in larger randomized controlled trials.

Incorrect. This strategy does not worsen LV function, and may even improve LVEF in selected patients.

Incorrect. A minimum of 3 weeks is recommended by the current guidelines.

Correct! Therapeutic oral anticoagulation for at least 3 weeks is recommended before scheduled cardioversion of AF and atrial flutter to prevent procedure related thromboembolism. Class I, level B recommendation.

Incorrect. Any rhythm control procedure has an inherent risk of thromboembolism. Patients undergoing cardioversion require at least 3 weeks of therapeutic anticoagulation prior to the electrical or pharmacological procedure.

Incorrect. A minimum of 3 weeks is recommended by the current guidelines. However, a minimum of 4 weeks of oral anticoagulation is recommended in all patients after cardioversion and long-term in patients with thromboembolic risk factor(s) irrespective of whether sinus rhythm is achieved, to prevent thromboembolism.

Correct! Rates of major adverse clinical events after cardioversion are significantly lower with DOACs compared with warfarin. Direct oral anticoagulants are recommended in preference to VKAs in eligible patients with AF undergoing cardioversion for thromboembolic risk reduction. Class I, level A recommendation.

Incorrect. DOACs are preferred, as the rates of of major adverse clinical events after cardioversion are significantly lower with DOACs compared with warfarin.

Incorrect. When the definite duration of AF is less than 48 hours, cardioversion has typically been considered without the need for pre-procedure OAC or TOE for thrombus exclusion. However, the ‘definite’ onset of AF is often not known, and observational data suggest that stroke/thromboembolism risk is lowest within a much shorter time period. This task force reached consensus that safety should come first. Cardioversion is not recommended if AF duration is longer than 24 hours, unless the patient has already received at least 3 weeks of therapeutic anticoagulation or a TOE is performed to exclude intracardiac thrombus. Early cardioversion is therefore not recommended without appropriate anticoagulation or transoesophageal echocardiography if AF duration is longer than 24 h, or there is scope to wait for spontaneous cardioversion. Class III, level C recommendation.

Correct!

Incorrect. Intravenous amiodarone is recommended when cardioversion of AF in patients with severe left ventricular hypertrophy, HFrEF, or coronary artery disease is desired, accepting there may be a delay in cardioversion.

Correct! Flecainide should not be used in patients with severe structural or coronary artery disease, Brugada syndrome, or severe renal failure (CrCl <35 mL/min/1.73 m2).

Correct! Class IC AADs include flecainide and propafenone which should not be used in patients with severe structural or coronary artery disease, Brugada syndrome, or severe renal failure (CrCl <35 mL/min/1.73 m2).

Incorrect. Class III AADs include amiodarone which can be used in in patients with severe left ventricular hypertrophy, HFrEF, or coronary artery disease.

Incorrect. There is a class III recommendation (meaning not recommended) for the use of pharmacological cardioversion in this situation.

Incorrect. There is a class III recommendation (meaning not recommended) for the use of pharmacological cardioversion in this situation.

Incorrect. There is a class III recommendation (meaning not recommended) for the use of pharmacological cardioversion in this situation.

Correct! Pharmacological cardioversion is not recommended for patients with sinus node dysfunction, atrioventricular conduction disturbances, or prolonged QTc (>500 ms), unless risks for proarrhythmia and bradycardia have been considered. Class III, level C recommendation.

Incorrect. Even though intravenous and oral formulations of Class IC antiarrhythmics (flecainide more so than propafenone) are superior regarding conversion rates within 12 h, a meta-analysis demonstrated that intravenous vernakalant was found to be the most effective agent for pharmacologic cardioversion within 4 h.

Incorrect. Digoxin is used for the rate control of AF, not for the rhythm control. Intravenous digoxin offers no substantial advantages over placebo in recent onset atrial fibrillation with respect to conversion.

Correct! Vernakalant exhibits the shortest time to sinus rhythm, therefore the fastest rate of conversion (approximately 10 minutes).

Incorrect. Amiodarone efficacy is exhibited in a delayed fashion (within 24 h).

Incorrect. This is the definition of "First-diagnosed AF", by temporal pattern of AF.

Incorrect. Paroxysmal AF terminates spontaneously within 7 days.

Correct! Evidence suggests that most self-terminating paroxysms last <48 h.

Incorrect. Even though evidence suggests that most self-terminating paroxysms last less than 48 h, paroxysmal AF terminates spontaneously within 7 days or with the assistance of an intervention.

Incorrect. Sotalol may be considered (class IIb recommendation) in patients with AF requiring long-term rhythm control with normal LVEF (left ventricular ejection fraction) or coronary artery disease to prevent recurrence and progression of AF, but requires close monitoring of QT interval, serum potassium levels, renal function, and other proarrhythmia risk factors.

Incorrect. Propafenone (or flecainide) is recommended in patients with AF requiring long-term rhythm control to prevent recurrence and progression of AF, excluding those with impaired left ventricular systolic function, severe left ventricular hypertrophy, or coronary artery disease.

Incorrect. Amiodarone is recommended in patients with AF and HFrEF (heart failure with reduced ejection fraction) requiring long-term antiarrhythmic drug therapy to prevent recurrence and progression of AF.

Correct! Dronedarone is recommended in patients with AF requiring long-term rhythm control, including those with HFmrEF, HFpEF, ischaemic heart disease, or valvular disease to prevent recurrence and progression of AF. In the ATHENA trial dronedarone significantly reduced the risk of hospitalization due to cardiovascular events or death as compared with placebo in patients with paroxysmal or persistent AF.

Incorrect. Catheter ablation can be a first-line option of rhythm control strategy, with class I recommendation for patients with paroxysmal AF, and class IIb recommendation for patients with persistent AF. Also in patients with paroxysmal or persistent AF resistant or intolerant to antiarrhythmic drug therapy, catheter ablation is recommended to reduce symptoms, recurrence, and progression of AF. Class I, level A recommendation.

Incorrect. It may be considered. It is not clear whether first-line ablation is superior to drug therapy in persistent AF. As the 2024 EHRA consensus statement concludes: Although the relative efficacy of catheter ablation in reducing AF burden and first AF recurrence is similar in paroxysmal and persistent AF types, extrapolation of the beneficial impact of first-line catheter ablation from the paroxysmal to the persistent patient group needs further verification.

Correct! Multiple randomized controlled trials have provided evidence in favour of catheter ablation as a first-line approach for rhythm control in patients with paroxysmal AF, with a similar risk of adverse events as compared with initial AAD (antiarrhythmic drug) treatment. Catheter ablation is recommended as a first-line option within a shared decision-making rhythm control strategy in patients with paroxysmal AF, to reduce symptoms, recurrence, and progression of AF. Class I, level A recommendation.

Correct! In contrast with paroxysmal AF, it is not clear whether first-line ablation is superior to drug therapy in persistent AF. Therefore, catheter ablation may be considered as a first-line option within a shared decision-making rhythm control strategy in selected patients with persistent AF to reduce symptoms, recurrence, and progression of AF. Class IIb, level C recommendation.

Incorrect. Ablation is recommended in patients with AF and heart failure with reduced ejection fraction (HFrEF) with high probability of tachycardia-induced cardiomyopathy to reverse left ventricular dysfunction

Correct! Randomized trials have shown that AF catheter ablation in patients with HFrEF significantly reduces arrhythmia recurrence and increases ejection fraction, with improvement in clinical outcomes and mortality also observed in selected patients.

Correct! This is a class IIa, level B recommendation. Catheter ablation in HFrEF patients may also have a beneficial impact on patient prognosis. A pooled analysis of randomized data concluded that rhythm control strategy reduces hospitalizations and confers a survival benefit in HFrEF patients when implemented with catheter ablation but not with antiarrhythmic medications.

Incorrect.

Correct! The presence of left atrial thrombus is a contraindication to catheter-based AF ablation due to the risk of thrombus dislodgement leading to ischaemic stroke. Patients planned for catheter ablation of AF with an increased risk of thromboembolism should be on OAC for at least 3 full weeks prior to the procedure.

Incorrect. Patients planned for catheter ablation of AF with an increased risk of thromboembolism should be on OAC for at least 3 full weeks prior to the procedure.

Incorrect. All patients should be kept on an OAC for at least 2 months after an AF ablation procedure irrespective of estimated thromboembolic risk.

Correct! All patients should be kept on an OAC for at least 2 months after an AF ablation procedure irrespective of estimated thromboembolic risk. Meta-analyses of observational studies have tried to assess the safety of stopping OAC treatment after catheter ablation for AF, but the results have been heterogenous. Until the completion of relevant randomized controlled trials, it is recommended to continue OAC therapy post-AF ablation according to the patient’s CHA2DS2-VA score and not the perceived success of the ablation procedure.

Incorrect. Endoscopic and hybrid ablation procedures should be considered - class IIa

Correct! Endoscopic and hybrid ablation procedures should be considered in patients with symptomatic persistent AF refractory to AAD therapy to prevent symptoms, recurrence, and progression of AF, within a shared decision-making rhythm control team of electrophysiologists and surgeons. For persistent AF, endoscopic or hybrid ablation approaches are suitable as a first procedure to maintain long-term sinus rhythm in selected patients. A meta-analysis of three RCTs (randomized controlled trials) confirmed a lower rate of atrial arrhythmia recurrence after thoracoscopic vs. catheter ablation. An RCT with 12 month follow-up published after the meta-analysis in patients with long-standing persistent AF found no difference in arrhythmia freedom comparing thoracoscopic with catheter ablation.

Incorrect. Endoscopic and hybrid ablation procedures should be considered - class IIa.

Incorrect. Endoscopic and hybrid ablation procedures should be considered - class IIa.

Incorrect. Endoscopic and hybrid ablation procedures may be considered - class IIb.

Incorrect. Endoscopic and hybrid ablation procedures may be considered - class IIb.

Correct! Endoscopic and hybrid ablation procedures may be considered in patients with symptomatic paroxysmal AF refractory to AAD therapy and failed percutaneous catheter ablation strategy to prevent symptoms, recurrence, and progression of AF, within a shared decision-making rhythm control team of electrophysiologists and surgeons. Long-term follow-up of the FAST trial (mean of 7.0 years), which included patients with paroxysmal and persistent AF, found arrhythmia recurrence was common but substantially lower with thoracoscopic ablation than catheter ablation.

Incorrect. Endoscopic and hybrid ablation procedures may be considered - class IIb.

Correct! Concomitant surgical ablation is recommended in patients undergoing mitral valve surgery and AF suitable for a rhythm control strategy to prevent symptoms and recurrence of AF, with shared decision-making supported by an experienced team of electrophysiologists and arrhythmia surgeons. A number of randomized controlled trials have shown that surgical AF ablation during cardiac surgery increases freedom from arrhythmia recurrence.

Incorrect. It is recommended - class I recommendation.

Incorrect. There is a class IIa, level B recommendation for concomitant surgical ablation in patients undergoing non-mitral valve cardiac surgery and AF.

Correct! Concomitant surgical ablation should be considered in patients undergoing non-mitral valve cardiac surgery and AF suitable for a rhythm control strategy to prevent symptoms and recurrence of AF, with shared decision-making supported by an experienced team of electrophysiologists and arrhythmia surgeons.

Incorrect. Clopidogrel is the preferred P2Y12 inhibitor.

Incorrect. Clopidogrel is the preferred P2Y12 inhibitor.

Correct! Clopidogrel is the preferred P2Y12 inhibitor, as the evidence for ticagrelor and prasugrel is less clear with higher bleeding risk.

Incorrect.

Correct! In a meta-analyses, amiodarone (oral or intravenous [i.v.]) and beta-blockers were equally effective in reducing post-operative AF, but their combination was better than beta-blockers alone. Peri-operative amiodarone therapy is recommended where drug therapy is desired to prevent post-operative AF after cardiac surgery. Class I, level A recommendation.

Incorrect. In 3209 patients undergoing non-cardiac thoracic surgery, administration of colchicine did not significantly reduce the incidence of clinically important atrial fibrillation but increased the risk of mostly benign non-infectious diarrhoea.

Correct! Peri-operative posterior pericardiotomy, due to the reduction of post-operative pericardial effusion, showed a significant decrease in POAF in patients undergoing cardiac surgery.

Correct! Routine use of beta-blockers is not recommended in patients undergoing non cardiac surgery for the prevention of post-operative AF. An umbrella review of 89 randomized controlled trials from 23 meta-analyses showed no benefit from beta-blockers in cardiac surgery for mortality, myocardial infarction, or stroke. In non-cardiac surgery, beta-blockers were associated with reduced rates of MI after surgery, but higher mortality, and increased risk of stroke.

Incorrect. Initiation of oral anticoagulation in ESUS patients without documented AF is not recommended.

Incorrect. Initiation of oral anticoagulation in ESUS patients without documented AF is not recommended.

Incorrect. Initiation of oral anticoagulation in ESUS patients without documented AF is not recommended.

Correct! Currently available evidence, including two completed randomized controlled trials and one stopped for futility, do not support the use of DOACs compared with aspirin in patients with acute ESUS without documented AF. Initiation of oral anticoagulation in ESUS patients without documented AF is not recommended due to lack of efficacy in preventing ischaemic stroke and thromboembolism. Class III, level A recommendation.

Incorrect. This is the definition of paroxysmal AF.

Correct! Many intervention trials have used 7 days as a cut-off for defining persistent AF.

Incorrect. This is the definition of a long-standing persistent AF, which is arbitrarily defined as continuous AF of at least 12 months’ duration but where rhythm control is still a treatment option in selected patients, distinguishing it from permanent AF.

Incorrect. This is the definition of permanent AF.

Correct! The preferred agents for anticoagulation of AF during pregnancy are unfractionated or low molecular weight heparins (LMWHs), which do not cross the placenta. Class I, level C recommendation.

Incorrect. Vitamin K antagonists should be avoided in the first trimester (risk of miscarriage, teratogenicity) and from week 36 onwards (risk of foetal intracranial bleeding if early unexpected delivery).

Incorrect. Vitamin K antagonists should be avoided in the first trimester (risk of miscarriage, teratogenicity) and from week 36 onwards (risk of foetal intracranial bleeding if early unexpected delivery).

Incorrect. Direct oral anticoagulants are not recommended during pregnancy due to concerns about safety (a meta-analysis displayed a higher rate of fetal loss and fetal abnormalities with DOACs use compared to LMWH, notwithstanding similar bleeding complications). However, an accidental exposure during pregnancy should not lead to a recommendation for termination of the pregnancy.

Incorrect. Cardiac-specific AF symptoms such as palpitations are less common than non-specific symptoms such as fatigue, but they significantly impair quality of life.

Incorrect. AF-related symptoms are classified by mEHRA (modified European Heart Rhythm Association score) classification system.

Incorrect. Depressed mood can be a symptom of AF. Patients with AF report a higher burden of anxiety and severity of depression as compared with the general population, with higher prevalence of these symptoms in women with AF.

Correct! Depressed mood as well as anxiety or disordered sleep can be symptoms of AF.

Incorrect. Heart failure is the most common non-fatal outcome.

Correct! The most common non-fatal outcome in those with AF is heart failure, occurring in around half of patients over time. Patients with AF have a four- to five-fold increase in the relative risk (RR) of heart failure compared with those without AF, as demonstrated in two meta-analyses.

Incorrect. Ischaemic stroke is the next most common adverse impact from AF (relative risk=2,3), after heart failure.

Incorrect. Even though patients with AF also have an increased risk of cognitive impairment and dementia, when carefully controlling for the confounding effects of stroke, comorbidities, and oral anticoagulation, AF exposure was still significantly associated with vascular dementia, but not Alzheimer’s disease.

Incorrect. mEHRA score of 1 would be AF that does not cause any symptoms.

Incorrect. A Patient with score 2a would only have mild symptoms - their normal daily activity is not affected by symptoms related to AF.

Incorrect. A Patient with score 2b would only have moderate symptoms - their normal daily activity is not affected by symptoms related to AF, but the patient is troubled by symptoms.

Correct!

Incorrect. Atrial fibrillation is a major risk factor for thromboembolism, irrespective of whether it is paroxysmal, persistent, or permanent. Using the temporal pattern of clinical AF (paroxysmal, persistent, or permanent) is not recommended to determine the need for oral anticoagulation. Class of recommendation: III, level of evidence: B

Correct! Oral anticoagulation is recommended in patients with clinical AF at elevated thromboembolic risk to prevent ischaemic stroke and thromboembolism. Class I, level A recommendation.

Incorrect. HAS-BLED score is used to determine bleeding risk in AF patients.

Incorrect. mEHRA score is not used to determine the need for oral anticoagulation, but to assess symptoms related to AF. mEHRA score correlates with quality of life scores in clinical trials, and is associated with clinical progress and events, and may be a valuable starting point in routine practice to assess the burden and impact of symptoms.

Correct! The development of heart failure in patients with AF is associated with a two-fold increase in stroke and thromboembolism, even after anticoagulation, and 25% higher all-cause mortality. However, rates of stroke and incident heart failure hospitalization are similar regardless of LVEF.

Correct! The development of heart failure in patients with AF is associated with a two-fold increase in stroke and thromboembolism, even after anticoagulation, and 25% higher all-cause mortality. However, rates of stroke and incident heart failure hospitalization are similar regardless of LVEF.

Correct! Even though CKD is not included in the most popular risk score - the CHA2DS2–VASc score - data suggest a correlation between decreasing glomerular filtration rate and proteinuria with stroke risk, and cohort data suggest a two-fold increased risk of ischaemic stroke and mortality in AF patients with CKD vs. without.

Correct! Cardiac amyloidosis, as well as hypertrophic cardiomyopathy (HCM) are associated with increased risk of stroke - the EORP registry indicated 3x higher annual incidence of stroke/transient ischaemic attack in the cardiomyopathy group with AF. Therefore, oral anticoagulation is recommended in all patients with AF and hypertrophic cardiomyopathy or cardiac amyloidosis, regardless of CHA2DS2-VA score, to prevent ischaemic stroke and thromboembolism. Class I, level B recommendation.