p.21 抽出テキスト
CLINICAL STATEMENTS AND GUIDELINES Circulation. 2024;149:e1–e156. DOI: 10.1161/CIR.0000000000001193 January 2, 2024 e21 Joglar et al 2023 Guideline for the Diagnosis and Management of Atrial Fibrillation Ablation versus Antiarrhythmic Drugs in AF trial, individuals from UREGs treated with catheter ablation had a 72% relative reduction in the allcause mortality rate.20 Therefore, ensuring timely and equitable referral of women, individuals from UREG, and those with adverse SDOH for rhythm control therapy is important. In patients with AF, indicators of lower socioeconomic status were associated with lower oral anticoagulation rates,21 lower rate of adherence during direct oral anticoagulant (DOAC) initiation,22 specialty care,21,23 and less use of cardioversion4,21 and catheter ablation.4,21,24 Indicators of socioeconomic disadvantages, such as increased risk of hospitalization,25 stroke,4,21 HF,4,21,26 and death, were also associated with complications in patients with AF.4,21,27 3 SHARED DECISION-MAKING (SDM) IN AF MANAGEMENT Recommendation for SDM in AF Management Referenced studies that support the recommendation are summarized in the Online Data Supplement. COR LOE Recommendation 2b B-R 1 In patients with AF, the use of evidence-based decision aids might be useful to guide stroke reduction therapy treatment decisions throughout the disease course to improve engagement, decisional quality, and patient satisfaction.1–4 Synopsis There are wide variations in how SDM is implemented in clinical care settings.5,6 Decision aids may provide standardization of SDM approaches for better informing patients about stroke reduction therapies and improve patient-reported measures but to date have not consistently been developed with recommended frameworks, have rarely been tested in systemically disadvantaged populations (low health literacy, UREGs, low socioeconomic status, rural geography, older adults), and have had variable impact on adherence and clinical outcomes.1–8 Ongoing work will measure health and digital literacy and strengthen the evidence for the impact of decision aids on decisional quality, adherence to treatment, and health outcomes.9 Symptom severity strongly correlates with QOL; thus, minimizing symptoms is an essential component of patient-centered AF management decisions. Rhythm control strategies improve QOL, particularly when maintenance of sinus rhythm or low AF burden is achieved.10 Notably, few SDM decision aids are focused on rate or rhythm control treatment options, and few have measured QOL as an outcome.3,5 Recommendation-Specific Supportive Text 1. Recently, 2 comprehensive reviews of deci- sion aids for stroke reduction therapies were conducted to determine the impact of these tools on patient-reported measures of decisional quality, while considering other important outcomes including oral anticoagulant (OAC) uptake, medication adherence, and the effect on bleeding and stroke.3,4 Most decision aids focused on patientreported measures, and few underwent rigorous pilot testing or correlated the aid with clinical outcomes, such as stroke and bleeding. Decision aids consistently demonstrate improvements in patient knowledge. The pooled analysis by Song et al noted lower decisional conflict using decision aids and enhanced OAC uptake (risk ratio, 1.03 [95% CI, 1.01-1.05]).4 Decision aids have historically shown marginal improvement in 3-month measures of adherence, and the 2 largest randomized trials to date showed no improvement in adherence between decision aids and usual care at 1 year.1,2 There is a paucity of data on the impact of decision aids on stroke, thromboembolic events, or bleeding, and when assessed the benefit has been minimal or neutral.4,11 Despite the US Centers for Medicaid & Medicare Services coverage decision requirement for SDM for percutaneous left atrial appendage occlusion (LAAO), only 1 tool was identified that incorporated this option (Table 5).5 4 CLINICAL EVALUATION 4.1 Risk Stratification and Population Screening There are >20 risk prediction models for incident AF in the community.1 The most widely replicated risk prediction model for newly diagnosed AF is CHARGE-AF (Cohorts for Heart and Aging Research in Genomic Epidemiology model for atrial fibrillation; Table 6),2 while the C2HEST score (coronary artery disease or chronic obstructive pulmonary disease [1 point each]; hypertension [1 point]; elderly [age ≥75 years, 2 points]; systolic HF [2 points]; Table 5. Publicly Available Decision Aids Agency Website Focus Area American College of Cardiology Colorado Program for Patient Centered Decisions https://patientdecisionaid.org/icd/ atrial-fibrillation/ Stroke risk reduction therapies Anticoagulation Choice Decision Aid https://anticoagulationdecisionaid. mayoclinic.org/ Stroke risk reduction therapies Ottawa Hospital Research Institute Developer Healthwise https://decisionaid.ohri.ca/AZlist. html AF ablation Stroke risk reduction Stanford https://afibguide.com/ Stroke risk reduction therapies Downloaded from http://ahajournals.org by on October 7, 2026