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CLINICAL STATEMENTS AND GUIDELINES

January 2, 2024 Circulation. 2024;149:e1–e156. DOI: 10.1161/CIR.0000000000001193 e20

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

2.5 Addressing Health Inequities and Barriers

to AF Management Recommendation to Address Health Inequities and Barriers to AF Management Referenced studies that support the recommendation are summarized in the Online Data Supplement. COR LOE Recommendation

1 B-NR 1 Patients with AF, regardless of sex1 and gender

diversity, race and ethnicity,2 or adverse social determinants of health (SDOH),3,4* should be equitably offered guideline-directed stroke risk reduction therapies as well as rate or rhythm control strategies and LRFM as indicated to improve quality of life (QOL) and prevent adverse outcomes.

*Including lower income, lower education, inadequate or lack of insurance coverage, or rurality.3–5 Synopsis Inequities in AF care and outcomes in individuals who are women, from underrepresented racial and ethnic groups (UREGs),2 or who have adverse SDOH have been documented.3,4 Sex differences in AF treatment have been described with respect to anticoagulation6,7 and rhythm control therapy approaches.7–9 Racial and ethnic differences in clinical presentation, management, and prognosis, including stroke, HF, and death, in patients with AF are widely reported.2,10 To avoid guidelines having the unintended consequence of widening inequities in clinical care and outcomes in individuals with AF, it is essential to longitudinally measure the receipt of AF GDMT and outcomes at the clinical practice and health system levels stratified by specific populations who have historically experienced inequitable care. If inequities are identified, barriers to GDMT should be eliminated. Data are needed to assess the impact of addressing SDOH in patients with AF on process measures, health care utilization, costs, and clinical outcomes.11 In other health contexts, there are observational and randomized data12 that screening and addressing SDOH leads to improved medication adherence,13 risk factor control,14 and clinical outcomes.15

Recommendation-Specific Supportive Text 1.	 Despite the elevated risk of stroke in women and

several UREGs, many are less likely to be treated with stroke risk reduction therapies.6,7 Although women and individuals from UREGs with AF are more symptomatic and report worse QOL than their counterparts, they also are less likely to be referred to an electrophysiologist7 and receive catheter ablation.2,7–9,16 Women are referred for ablation later in the disease course and at older ages than men.7,17,18 These differences or delays in therapy may result in worse outcome given early rhythm control of AF improves outcomes1,19 in select patients. In addition, in the Catheter

Figure 8. Contemporary Summary of the Role of the ANS in AF. Original figure created by the 2023 Atrial Fibrillation Guideline Writing Committee. AF indicates atrial fibrillation; ANS, autonomic nervous system; HRV, heart rate variability; and LA, left atrium.

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