New Thai AF guideline 2025

New Thai Atrial Fibrillation (AF) Guideline 2025 – Key Updates and Recommendations

1. Classification of Atrial Fibrillation (AF):

• The 2025 Thai AF guideline now recognizes AF as a disease continuum with four stages (adapted from the 2024 ESC Guidelines and recent updates):
  1. At risk of AF (e.g., hypertension, diabetes, obesity)
  2. Pre-AF (e.g., frequent atrial premature beats, short runs of AF)
  3. AF (paroxysmal, persistent, long-standing persistent)
  4. Permanent AF (irregular rhythm that cannot be restored to sinus rhythm)
• This shift emphasizes early prevention and risk factor modification at earlier stages.

2. Stroke Risk Assessment (CHA₂DS₂-VASc Score):

• CHA₂DS₂-VASc score 0: No antithrombotic therapy required.
• CHA₂DS₂-VASc score 1: Prefer oral anticoagulation (e.g., DOACs) over antiplatelet therapy.
• CHA₂DS₂-VASc score ≥2: Strong recommendation for oral anticoagulation (DOACs preferred over warfarin).
• Note: Direct Oral Anticoagulants (DOACs) like apixaban, rivaroxaban, and edoxaban are preferred due to lower bleeding risk and convenience.

3. Rhythm vs. Rate Control:

• For recent-onset AF (<1 year), the EAST-AFNET 4 trial (2020) supports rhythm control (antiarrhythmic drugs or catheter ablation) over rate control for lower cardiovascular death, stroke, or heart failure hospitalization risk.
• First-line antiarrhythmic drugs: Flecainide, propafenone, sotalol (if no structural heart disease). Digoxin as monotherapy for rhythm control is useful in some case.
• Catheter ablation is now a Class 1 recommendation for symptomatic AF, especially in younger patients with no structural heart disease.

4. Lifestyle and Risk Factor Modification:

• Weight loss, exercise, alcohol reduction, and smoking cessation are now mandatory for all stages of AF due to strong evidence linking obesity and alcohol to AF recurrence.

5. Novel Therapies:

• Apixaban and edoxaban and any DOAC are preferred for anticoagulation due to lower bleeding risk.
• Anticoagulation for low-risk patients: If CHA₂DS₂-VASc score = 1, consider aspirin alternatives (e.g., clopidogrel) only if anticoagulation is refused.
• Ablation for asymptomatic AF: Consider in patients with left atrial remodeling to prevent progression.

6. Special Populations:

• Patients with valvular AF: Warfarin is preferred over DOACs for mechanical heart valves.
• Elderly (≥75 years): DOACs at lower doses if kidney function is normal.

Sources:

• 2025 Thai AF guideline (adapted from 2024 ESC Guidelines and EAST-AFNET 4 trial)

• Kirchhof P et al; N Engl J Med. 2020;32865375

Next Steps for Patients:

• If you have AF, ask your doctor about your CHA₂DS₂-VASc score and whether DOACs are right for you.

• Discuss lifestyle changes (diet, exercise, alcohol) as they can reduce AF burden.

• For recurrent AF, inquire about catheter ablation if medications fail.