The 10th AFNET/European Heart Rhythm Association (EHRA) Consensus Conference, held in May 2025, brought together more than 80 international experts to reassess how atrial fibrillation (AF) should be treated in light of major advances in rhythm control, ablation, monitoring, and understanding of AF biology. The conference concludes that AF management must move beyond a narrow focus on stroke prevention to an integrated strategy centred on reducing AF burden and managing comorbidities.
AF has traditionally been treated as a binary condition: once AF is detected, patients are classified as having lifelong disease and managed primarily to prevent stroke. However, increasing evidence shows that AF burden, rather than the mere presence of AF, is strongly linked to clinical outcomes, including heart failure, stroke, cognitive decline, quality of life, and mortality.
Patients with very low AF burden appear to have a much lower risk of complications, challenging the current one-size-fits-all diagnostic and therapeutic approach. This supports a transition towards continuous rhythm monitoring, quantification of AF burden, and personalised rhythm-based treatment decisions rather than treating AF as a simple on/off diagnosis.
The conference emphasised that AF is not an isolated electrical disorder but reflects an underlying atrial cardiomyopathy driven by ageing, hypertension, diabetes, obesity, sleep apnoea, inflammation, fibrosis, and metabolic dysfunction. These comorbidities not only promote AF but also mediate many of its adverse outcomes, including stroke, heart failure, and cognitive decline.
Cognitive impairment is highlighted as a major but under-recognised complication of AF. Brain infarcts, cerebral hypoperfusion, inflammation, and microvascular injury may all link AF burden to dementia risk. Effective AF management, therefore, requires anticoagulation, rhythm control, and aggressive management of comorbidities such as smoking, alcohol use, obesity, sleep apnoea, and physical inactivity.
Data from implantable devices and trials such as CASTLE-AF and EAST-AFNET 4 show that lower AF burden is associated with fewer cardiovascular events, particularly when it is reduced to approximately 15–20%. Although causality has not been fully established, these findings suggest that AF burden should become a primary therapeutic target, potentially replacing “time to first recurrence” as the dominant outcome in trials and clinical practice.
Continuous rhythm monitoring with wearable and implantable devices enables accurate quantification of AF burden and provides a framework for adaptive, data-driven therapy, including titration of anti-arrhythmic drugs, optimisation of ablation strategies, and, potentially, tailoring of anticoagulation in the future.
Despite safety concerns dating back to the CAST trials, anti-arrhythmic drugs (AADs) remain central to rhythm control. Newer evidence suggests that long-term low-dose amiodarone has a lower pulmonary risk than previously feared and does not increase mortality, supporting broader use in selected patients. AADs also remain effective after ablation to suppress recurrences.
Early rhythm control produces clinical benefit within weeks, shifting the balance between safety and efficacy and justifying limited risk in exchange for meaningful outcome improvement.
A new generation of mechanism-based AADs is emerging, including SK-channel blockers, TASK-1 inhibitors, multi-channel blockers, TRP-channel blockers, connexin modulators, and epigenetic agents. Advances in genomics, AI-assisted structural biology, and stem-cell models are accelerating drug discovery and enabling targeting of both cardiomyocytes and non-myocyte contributors such as fibroblasts, adipocytes, and macrophages.
AF ablation is increasingly delivered through lean, standardised, patient-centred pathways, with the growing use of same-day procedures and same-day discharge. When carefully implemented, these approaches reduce costs, improve patient satisfaction, and preserve safety.
Technologies such as pulsed-field ablation and cryoballoon ablation enable rapid, reproducible pulmonary vein isolation with low complication rates, supporting scalable same-day discharge models across centres.
The consensus conference concludes that modern AF care must be personalised, data-driven, and multi-modal, integrating rhythm control, AF burden monitoring, stroke prevention, ablation, and aggressive management of comorbidities. This approach bridges current clinical needs with emerging innovations in digital health, pharmacology, and interventional therapy, offering the potential for safer, more effective, and more accessible AF management.
Source: EP Europace
Image Credit: iStock
