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CLINICAL STATEMENTS AND GUIDELINES

January 2, 2024 Circulation. 2024;149:e1–e156. DOI: 10.1161/CIR.0000000000001193 e104

Joglar et al 2023 Guideline for the Diagnosis and Management of Atrial Fibrillation

10.10 Acute Medical Illness or Surgery

(Including AF in Critical Care) Recommendations for Acute Medical Illness or Surgery (Including AF in Critical Care) Referenced studies that support the recommendations are summarized in the Online Data Supplement. COR LOE Recommendations

1 B-NR 1 Patients with AF who are identified in the setting

of acute medical illness or surgery should be counseled about the significant risk of recurrent AF after the acute illness is resolved.1–6

2a B-NR 2 In patients with AF who are identified in the setting

of acute medical illness or surgery, outpatient followup for thromboembolic risk stratification and decision-making on OAC initiation or continuation, as well as AF surveillance, can be beneficial given a high risk of AF recurrence.4–9

2b B-NR 3 In patients with AF who are identified in the setting

of critical illness due to sepsis, the benefits of anticoagulation during critical illness for stroke prevention are uncertain.10,11

Synopsis AF identified in the setting of hospitalization for acute noncardiac illness (acute AF), including patients who are critically ill, may represent new-onset AF that has been detected and treated for the first time. Incidence ranges from 1% to 46% in medical illness,1,12–14 with 6% to 22% in severe sepsis,15 and 3% to 16% after noncardiac surgery.16 AF can be an incidental finding during low-risk procedures but can occur associated with a range of conditions, including critical illness or sepsis. A combination of underlying arrhythmogenic substrate and triggers related to the acute illness likely contribute to acute AF. Acute AF can be paroxysmal or persistent, with or without symptoms, and is associated with higher risk of AF recurrence.1–3 Acute AF is also associated with prolonged hospitalization13,14 as well as increased morbidity12,15 and mortality.13,15 Management of acute AF is directed toward detection and treatment of potential triggers, optimizing hemodynamics, rate and/or rhythm control, and reducing in-hospital and long-term risk of stroke. Rate- or rhythm-control strategy should be individualized, balancing the impact of rapid rates and atrioventricular dyssynchrony on hemodynamics with ability to tolerate treatment. Decisions regarding initiating anticoagulation should be based on risk stratification of patient substrate and comorbidities, and the timing should take into consideration bleeding risks and the complexity of the acute illness.

Recommendation-Specific Supportive Text 1.	 In patients who develop or are discovered to

have AF in the setting of acute medical illness and noncardiac surgery, recurrent AF was noted in 42% to 68%1,2 and 39%,3 respectively, during 5-year follow-up. Regardless of presence of an initial precipitant, recurrent AF was associated with increased risks of HF (HR, 2.74 [95% CI, 2.39- 3.15]; P<0.001), stroke (HR, 1.57 [95% CI, 1.30- 1.90]; P<0.001), and mortality (HR, 2.96 [95% CI, 2.70-3.24]; P<0.001).2

2 In 10 723 patients with newly diagnosed AF

(67.9±–9.9 years, 41% women) identified from a longitudinal database, 19% of patients had an acute AF precipitant, the most common being cardiac surgery (22%), pneumonia (20%), and noncardiac surgery (15%). AF recurrence at 5 years was 41% among those with a precipitant versus 52% in those without one (adjusted HR, 0.75 [95% CI, 0.69-0.81]; P<0.001) (Figure 27).3 Regardless of a precipitant, recurrent AF was associated with increased risk of HF (HR, 2.74 [95% CI, 2.39-3.15]; P<0.001), stroke (HR, 1.57 [95% CI, 1.30-1.90]; P<0.001), and death (HR, 2.96 [95% CI, 2.70-3.24]; P<0.001). In patients with acute AF after cardiac surgery, observational studies show that those who underwent continuous rhythm monitoring had a higher detection of AF.4–6 No randomized clinical trial has specifically compared different monitoring strategies for outpatient follow-up of patients with acute AF. However, parallels could be drawn from studies like the CRYSTAL-AF8 and SEARCH-AF (Post-Surgical Enhanced Monitoring for Cardiac Arrhythmias and Atrial Fibrillation)9 trials, which showed increased sensitivity for AF detection with long-term monitoring. Close outpatient follow-up with consideration of heart rhythm monitoring and thromboembolic risk stratification is important considering the high risk of AF recurrence in these patients, especially in those who underwent noncardiac surgery and with risk factors for stroke in whom the AF is likely to recur (Figure 28). The optimal frequency, duration, and type of rhythm monitoring for patients with acute AF remain unclear and need further study. 3.	 In a retrospective cohort study of 38 582 patients

with AF and sepsis admitted to US hospitals from July 1, 2010, to June 30, 2013, 13 611 patients (35.3%) received parenteral anticoagulation for AF. The CHA2DS2-VASc score was a poor predictor of acute stroke risk, and parenteral anticoagulation did not reduce stroke risk (1.3% versus 1.4%; RR, 0.94 [95% CI, 0.77-1.15]) and was associated with an increased risk of clinically significant bleeding (8.6% versus 7.2%; RR, 1.21 [95% CI, 1.10-1.32]). Risk of stroke did not differ whether patients had preexisting AF and new onset AF.10 In a retrospective cohort study of 102 patients ≥65 years of age who were hospitalized with sepsis and with new-onset AF, 28% received

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