Optimizing anticoagulation management in atrial fibrillation: beyond the guidelines. How and for whom?

Anticoagulation therapy (AT) is the cornerstone of atrial fibrillation (AF) treatment for thromboembolic event prevention. The AF burden, however, is of predictive relevance and may be utilized as a foundation for therapeutic decisions in individuals with paroxysmal or persistent AF. Remote rhythm monitoring devices can provide early detection of the arrhythmia, long-term rhythm monitoring, and the development of anticoagulation strategies based on AF recurrence profile and the total burden of the arrhythmia. Although the exact thromboembolic cutoff value for the AF burden has not yet been established, targeted anticoagulation treatments in the NOAC era have shown encouraging outcomes. The combined evaluation of AF burden and patient thromboembolic risk reported in some studies supports the concept of tailored anticoagulation management, at least in a subset of patients with low AF burden and intermediate thromboembolic risk, for whom the guidelines recommend that AT should be individualized based on net clinical benefit and patient values and preferences. Although it is still premature to derive firm conclusions or algorithms diverging from the current guidelines, the combination of a patient's AF burden, thromboembolic, and bleeding risk can lead in the future to an individualized management of patients with a CHA2DS2-VASc score of 1 (2 for females), in whom the guidelines do not strictly recommend long-term AT. Herein, we provide an algorithm regarding the individualized implementation of anticoagulation strategies in AF in different patients' thromboembolic risk profiles, based on the available data on the so far tailored anticoagulation strategies in AF.