Black Holes in Atrial Fibrillation Therapy

Dear Colleagues,

Atrial fibrillation (AF) is the most common rhythm problem that we face in daily clinical activity. Advances in oral anticoagulation, ablation therapy, and antiarrhythmic drugs have been extremely useful in helping us to treat most cases, but despite international guidelines being released regularly, there are still some black holes to be covered. Risk factors such as overweight or obesity are well-known but rarely considered to be modifiable and almost never treated as the main point in AF. Kidney failure is also often associated with AF, influencing outcomes and sometimes representing a barrier to treatment opportunities. Even age, which is increasing all around the world and associated with higher incidence of this rhythm problem, should be considered when deciding on the best treatment for our patients. Ideal therapies for young patients should often not be suggested or even discouraged in elderly patients. Oral anticoagulation is another main point: it is recommended based on clinical risk features usually summarized in the CHA₂DS₂-Va Score, but there is no clear data about patients with a score of 0 or 1, who could be completely different from each other. This score has probably been applied in a too-simplistic way and needs to be integrated case-by-case, as using a too-simplistic score could mean that the decision to start lifelong anticoagulation therapy is made based on a single episode of AF with a 30-second duration. The definite allocation of alternative therapies, such as left atrial appendage closure and consumer devices, still needs to be found, as they are facing widespread diffusion and cannot be ignored. With this Special Issue, we aim to help set the record straight.

This Special Issue aims to bring these “black holes” into sharp focus, moving beyond oversimplified guidelines to champion a more nuanced, patient-tailored approach to AF management. By synthesizing evidence and expert opinion, we seek to illuminate pathways for integrating novel therapies, refining risk stratification, and ultimately improving outcomes across the diverse spectrum of AF patients.

Dr. Roberto Cemin
Guest Editor

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