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CLINICAL STATEMENTS AND GUIDELINES January 2, 2024 Circulation. 2024;149:e1–e156. DOI: 10.1161/CIR.0000000000001193 e106 Joglar et al 2023 Guideline for the Diagnosis and Management of Atrial Fibrillation 10.11 Hyperthyroidism Recommendation for Hyperthyroidism Referenced studies that support the recommendation are summarized in the Online Data Supplement. COR LOE Recommendation 1 B-NR 1 In patients with hyperthyroidism and AF who have an elevated risk of stroke based on a standard clinical risk score, anticoagulation is recommended until thyroid function has returned to normal and sinus rhythm can be maintained.1,2 Synopsis Hyperthyroidism, defined as elevated blood levels of thyroid hormone with reduced levels of thyroid- stimulating hormone, is relatively common and may not lead to overt symptoms of thyrotoxicosis.3,4 Patients with hyperthyroidism are at increased risk of developing AF,5 which resolves in most cases after the restoration of the euthyroid state with effective antithyroid treatment.6,7 Excess thyroid hormone increases sensitivity to catecholamines,3,8 and beta blockers reduce symptoms and tachycardia in patients with hyperthyroidism.9–12 Nonselective beta blockers may reduce the systemic symptoms of hyperthyroidism a bit more than beta-1–selective agents do, and propranolol reduces the peripheral conversion of T4 to T3.10,13 Although it is uncertain whether hyperthyroidism is an independent risk factor for stroke, many patients have other risk factors that elevate stroke risk, and anticoagulation reduces risk of stroke to a similar extent among patients with and without hyperthyroidism.1,2,14 Restoration of sinus rhythm is unlikely until a euthyroid state has been achieved15 and, in 1 study, spontaneous reversion to sinus rhythm occurred at a median of 1 to 3 weeks after thyroid hormone levels returned to normal.6 Recommendation-Specific Supportive Text 1. Patients with hyperthyroidism often have labora- tory findings that suggest hypercoagulability,16 but it is uncertain whether this translates into a higher risk of stroke.1,17 Nevertheless, patients with hyperthyroidism are commonly at elevated risk of stroke due to other clinical factors, so anticoagulation should be considered using the framework in Section 6.3.1 (“Antithrombotic Therapy”). A Danish national registry study found that patients with thyrotoxicosis and AF had a lower overall risk of thromboembolic events but a similar reduction in the risk of thromboembolic events from anticoagulation compared with patients who did not have a secondary cause of AF.5 In a large, randomized trial of apixaban versus warfarin, patients with a history of hyperthyroidism or hypothyroidism had risk of stroke similar to that of patients with no history of thyroid disease, and the effectiveness of apixaban in reducing stroke was consistent across subgroups with and without a history of thyroid disease.16 10.12 Pulmonary Disease Recommendations for Pulmonary Disease Referenced studies that support the recommendations are summarized in the Online Data Supplement. COR LOE Recommendations 2a B-R 1 In patients with AF and COPD, it is reasonable to use cardioselective beta blockers for rate control of AF, especially where other indications exist (eg, MI and HF).1–3 2a B-NR 2 In patients with pulmonary hypertension (PH) with pulmonary vascular disease and AF or AFL, a rhythm-control strategy is reasonable to improve functional status and potentially prolong survival.4–12 Synopsis Pulmonary disease is commonly associated with arrhythmias. AF is common in COPD and is associated with an increased risk of mortality and bleeding.13 The combination of AF and asthma is less common, and beta blockers are generally avoided to prevent bronchospasm. A bidirectional relationship is seen between AF and pulmonary embolus (PE), although it is little studied. The risk of PE is increased in patients with AF.14 AF may also complicate acute PE, where it is a marker of increased risk of mortality.15 Whether AF in the setting of PE should influence the intensity or duration of anticoagulation, or is associated with future AF recurrence, is unknown. AF and other supraventricular arrhythmias are important causes of decompensation in patients with PH, which is especially well described in World Health Organization groups 1 and 4. A successful rhythm-control strategy is associated with better outcomes in these patients. Recommendation-Specific Supportive Text 1. AF is common in patients with COPD, with a prevalence of 11% in a large European registry.16 Furthermore, patients with COPD often have other concomitant heart disease. Because beta-2 agonists can be used for the treatment of COPD, there has been a reluctance to prescribe beta blockers in case these would antagonize beta-2 agonists or precipitate bronchospasm.17 However, a systematic review and meta-analysis of observational studies found that beta-blocker use, for diverse indications including HF and CAD, was associated with a significantly reduced risk of mortality in patients with COPD.1 Another meta-analysis of RCTs assessing the effect of cardioselective beta blockers on respiratory function and symptoms did not find any change in these parameters or in response to beta-2 agonists.2 An RCT of patients with advanced COPD at risk of severe exacerbation, but without an indication for beta-blocker treatment, found no difference in the time to first exacerbation but did find an increased risk of severe exacerbation.3 Therefore, although other agents can be used for rate control of AF (Section 7, “Rate Control”), beta blockers, Downloaded from http://ahajournals.org by on October 7, 2026