Summary and general discussion 169 reduced thrombo-embolic protective effect (15). Consequently, we do not expect that factor XIa inhibitors will be introduced for AF management in clinical practice in the short term. Besides developments in novel oral anticoagulants, a major technological improvement in the past few years is the introduction of pulsed field ablation (PFA). PFA is a non-thermal cardio selective energy source and thus reduces collateral damage (e.g., phrenic nerve palsy, oesophageal damage). The ease of use and increased procedural efficiency has rendered PFA an interesting ablation modality. However, the first large RCT (ADVENT) had only demonstrated that PFA was noninferior to conventional thermal energy sources (cryoablation, radiofrequency) (16). The coming years will determine whether PFA will replace conventional energy sources. In addition to cardioversion, ablation, anticoagulation, and antiarrhythmic drugs, it is crucial to address underlying modifiable risk factors to improve the outcome of AF management. These risk factors include obesity, hypertension, smoking, excessive alcohol, OSA, and lack of exercise (17). Obesity is a major societal problem with a dire impact on the health system. Weight loss and risk factor management is associated with a significant reduction of AF burden and the maintenance of sinus rhythm (LEGACY, ARREST-AF) (12, 18). Unfortunately, in daily practice it is arduous to establish a sustained change in lifestyle adaptation (RACE-3) (19). Furthermore, many patients and treating caregivers are insufficiently appreciative that certain risk factors, such as OSA are present. We demonstrated that 38% of patients undergoing AF ablation had undiagnosed OSA. To improve the detection, management and treatment of modifiable risk factors in patients with AF, the establishment of integrated AF care initiatives proved to be a valuable strategy (20). To further develop AF care, it is also crucial to implement regional AF care to homogenize the treatment of AF patients. This is also in accordance with the Integral Care Agreement which promotes appropriate care at the right location (21). Since AF ablation is only possible in centers with thoracic surgical backup in the Netherlands, clear indications for invasive rhythm management should be made in this regional collaboration. Finally, we anticipate that the novel indication of the GLP1 agonists (e.g., semaglutide) in AF patients with obesity promises to play a significant role in their 10
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