For centuries, the pulse of patients was the only access to the heart. Irregular pulse, most probably reflecting atrial fibrillation, was first described by the Andalusian Philosopher Moses Maimonides in the 11th century. After him, William Stokes, Karel Frederik Wenckebach, and J. McKenckie described what we would today consider atrial fibrillation. With the introduction of the ECG by Willem Einthoven in 1901, atrial fibrillation was later clearly defined by him and Sir Thomas Lewis. The relationship between atrial fibrillation and stroke, and, more recently, cognitive decline and dementia and prevention thereof by anticoagulants was only established decades later. Today it is clear that the major cause of morbidity and mortality in atrial fibrillation is its association with embolic stroke and that anticoagulation can largely prevent that. With the development of non-vitamin K antagonists or NOACs, anticoagulation in such patients has become easier and is more commonly used. Currently, at least four NOACs are available. ‘The 2018 European Heart Rhythm Association Practical Guide on the use of non-vitamin K antagonist oral anticoagulants in patients with atrial fibrillation’ by Jan Steffel of the ESC Scientific Document Group is a timely document for practising cardiologists. NOACs are an increasingly preferred alternative to vitamin K antagonists, particularly in patients just started on anticoagulation. However, many unresolved questions on how to use these agents optimally in specific clinical situations remain. A writing group of the European Heart Rhythm Association identified 20 clinical scenarios for which, based on available evidence, practical answers are presented.
Lüscher TF. Eur Heart J. 2018;39:1317-1321.