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CLINICAL STATEMENTS AND GUIDELINES

January 2, 2024 Circulation. 2024;149:e1–e156. DOI: 10.1161/CIR.0000000000001193 e112

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

remain poorly characterized, such as dementia and valvular insufficiency. 3.	 Better goal and outcome definition: Historically, ablation failure has been defined as having 30 seconds of AF identified during a follow-up period. However, that number might be too simplistic because AF burden may be a more important metric and because the 30-second metric might not reflect significant burden reduction that may be observed in many patients. Patient-oriented outcomes would also be more important, such as QOL. 4.	 Role of risk modifiers in AF stroke prevention: Great variation exists in risk of stroke depending on nonbinary or dynamic risk factors. Yet it is unclear how to best manage patients accordingly. For example, how should risk of stroke be assessed in a person with hypertension in whom the BP is very well controlled? Or, perhaps, how do we incorporate AF burden on the risk calculation? 5.	 Individualization of AF and stroke risk: Although some studies have demonstrated an effective role of biomarkers in predicting AF and stroke, how to incorporate these findings into clinical practice remains elusive. Similarly, how to incorporate other clinical markers of atrial cardiopathy into clinical practice must be better defined, as well as clarification as to how these nontraditional risk factors help better stratify patient risk. 6.	 Incorporating other stroke risk scores: The ubiquitous nature and simplicity of the CHA2DS2-VASc score have diminished with consideration of other scores of potential utility, better c-statistics, and with potential advantages in particular populations. Additional studies are needed to better take advantage of scores for specific groups, scores that could potentially be incorporated into the electronic medical record, and perhaps some with the potential benefit of better discriminating the true low-risk patients. 7.	 Surgical exclusion and LAAO: Increasingly available evidence has demonstrated the benefit of surgical LAA exclusion for stroke prevention, but the most scientifically rigorous trials included patients who received concomitant anticoagulation. More evidence is needed on the magnitude of benefit of LAA exclusion in preventing stroke in patients who have contraindications to anticoagulation and how to best manage those patients around rhythm-control interventions, such as cardioversion. Clinicians would also like to see additional data on pLAAO, particularly peri-implant stroke management and longer-term outcomes in patients in whom periprocedure anticoagulation is not possible. 8.	 Subclinical AF: What magnitude of AF burden

mandates stroke prevention therapy in patients with subclinical AF must be better defined. Certainly, large general risk categories have been identified, and general guidelines exist, but extensive practice variations remain, and more precise recommendations for the community are needed. In addition, the role and impact on outcomes of AF screening in general and poststroke should be better defined. 9.	 Use and applicability of consumer-based wear-

able heart monitoring devices: These devices are now widespread and are used to diagnose and monitor response to therapy in patients with AF. Validation on the accuracy of the most common available technologies is needed. How to best use these devices in practice, including for AF screening, must be better defined. 10.	 Standardization of ablation procedures: Great practice variation exists on how AF ablation procedures are performed, either as first or repeat procedures. Large registries and more data are required to better define standards of care in this field. Many interventions, such as extra ablation lines, are still performed despite limited data demonstrating efficacy, whereas the best approaches to persistent AF and repeat ablation are poorly defined. 11.	 Candidates for ablation: We must better identify clinical markers to better identify when catheter ablation is unlikely to benefit patients and define specific criteria for candidacy for first time and repeat procedures. 12.	 Artificial intelligence for AF management: Artificial intelligence could potentially be used to better tailor therapy to the individual patient, taking into consideration numerous factors that may better select candidates for therapeutic approaches, such as anticoagulation versus LAAO, rhythm versus rate control, catheter ablation versus medical therapy, modification of risk factors, genetics, and others. 13.	 Strategies for anticoagulation: Ongoing clini-

cal trials are assessing different strategies for oral anticoagulation in persons who have undergone catheter ablation, including the OCEAN (Optimal AntiCoagulation for Enhanced-Risk Patients Post-Catheter Ablation for Atrial Fibrillation) trial (NCT02168829)1 and ODIn-AF (Prevention of Silent Cerebral Thromboembolism by Oral Anticoagulation With Dabigatran After Pulmonary Vein Isolation for Atrial Fibrillation) (NCT02067182)2 trial, because it is unclear in whom anticoagulation can be discontinued after successful ablation. Several studies also have investigated the use of intermittent or continuous rhythm monitoring to guide oral anticoagulation in persons with AF, including those who have undergone ablation.3,4 These so-called “PITP” or “electrocardiographic-guided” approaches are investigational. Ongoing clinical trials like REACT-AF (Rhythm Evaluation for Anticoagulation

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