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CLINICAL STATEMENTS AND GUIDELINES

January 2, 2024 Circulation. 2024;149:e1–e156. DOI: 10.1161/CIR.0000000000001193 e22

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

thyroid disease [hyperthyroidism, 1 point]) was derived and validated in Asian cohorts (Table 7).3,4 Screening for AF has been investigated, mostly in patients >65 years of age, using various protocols that include both 1-time electrocardiographic recordings, recurring intermittent ECGs (including consumer-based devices), or continuous electrocardiographic external monitors. Most screening trials have shown higher AF detection using intermittent or continuous electrocardiographic recordings5 and higher AF detection in patients with higher predicted risk for AF.6 A recent study also showed that an AI algorithm able to risk-stratify a relatively uniform population (eg, older adults at risk for stroke) to detect undiagnosed AF during short-term cardiac monitoring was associated with increased AF.7 Conversely, mass population screening with a smartwatch app only rarely detected a new diagnosis of AF.8 Ultimately, for risk stratification models and screening programs to be useful, they would need to improve outcomes and be cost-effective.9 It is not yet established that patients at high risk of developing AF by a validated risk score benefit from screening and interventions to improve rates of ischemic stroke, systemic embolism, and survival.

4.2 Basic Evaluation

4.2.1 Basic Clinical Evaluation

Recommendations for Basic Clinical Evaluation Referenced studies that support the recommendations are summarized in the Online Data Supplement. COR LOE Recommendations

1 B-NR 1 In patients with newly diagnosed AF, a transthoracic

echocardiogram1–4 to assess cardiac structure, laboratory testing to include a complete blood count, metabolic panel, and thyroid function,5–7 and when clinical suspicion exists, targeted testing to assess for other medical conditions associated with AF are recommended to determine stroke and bleeding risk factors, as well as underlying conditions that will guide further management.

3: No benefit B-NR 2 In patients with newly diagnosed AF, protocolized

testing for ischemia, acute coronary syndrome (ACS), and pulmonary embolism (PE) should not routinely be performed to assess the etiology of AF unless there are additional signs or symptoms to indicate those disorders.8–10

Synopsis The initial clinical evaluation of the patient with newly diagnosed or suspected AF should be focused on confirming the diagnosis and identifying relevant clinical factors that will impact management. A targeted history and physical examination should be performed at the initial assessment and repeated during periodic follow-up, especially given the evolving risk of thromboembolism and the cadence of symptoms in response to therapy (see Section 11, “Future Research Needs”). An ECG can assess other electrical abnormalities, including possible substrates such as Wolff-Parkinson-White (WPW) syndrome, coexisting atrial arrhythmias, as well as abnormalities that may affect decision-making in pharmacological management (eg, bradycardia, QT duration). Basic laboratory tests should be performed to determine if other clinically relevant disorders are present and impact on management, particularly with respect to stroke and bleeding risk. A transthoracic echocardiogram provides information on chamber size, thickness, function, and the presence of valvular pathology. Additional testing, including multimodality advanced imaging and further ambulatory electrocardiographic monitoring, may be pursued based on the results of these initial evaluations. AF itself does not increase the likelihood of myocardial ischemia, ACS or PE, and therefore routine testing for these disorders in the absence of signs or symptoms is of no benefit. Recommendation-Specific Supportive Text 1.	 A transthoracic echocardiogram is essential to

evaluate chamber size and function, valve function,

Table 6.  CHARGE-AF Risk Score for Detecting Incident AF*

Variable (X) Estimated β Coefficient (SE) HR (95% CI) Age (per 5-y increment) 0.508 (0.022) 1.66 (1.59-1.74) White race 0.465 (0.093) 1.59 (1.33-1.91) Height (per 10-cm increment) 0.248 (0.036) 1.28 (1.19-1.38) Weight (per 15-kg increment) 0.115 (0.033) 1.12 (1.05-1.20) Systolic BP (per 20-mm Hg increment) 0.197 (0.033) 1.22 (1.14-1.30) Diastolic BP (per 10-mm Hg increment) –0.101 (0.032) 0.90 (0.85-0.96) Smoking (current versus former/never) 0.359 (0.063) 1.42 (1.25-1.60) Diabetes (yes) 0.237 (0.073) 1.27 (1.64-2.48) Myocardial infarction (yes) 0.496 (0.089) 1.64 (1.38-1.96) Table 6 does not encompass all complications. *Five-year risk is given by: 1 – 0.9718412736exp(ΣβX – 12.4411305), where β is the regression coefficient (column 2) and X is the level of each variable risk factor.2 AF indicates atrial fibrillation; BP, blood pressure; CHARGE-AF, Cohorts for Heart and Aging Research in Genomic Epidemiology model for atrial fibrillation; HR, hazard ratio; and SE, standard error.

Table 7.  C2HEST Risk Score for Detecting Incident AF* Acronym Risk Factor Points C2 CAD/COPD 1-2 H Hypertension 1 E Elderly (age ≥75 y) 2 S Systolic heart failure 2 T Thyroid disease (hyperthyroidism) 1 *Total points 0-8. For the C2HEST score, the C statistic was 0.749, with 95% CI of 0.729–0.769.10 The incident rate of AF increased significantly with higher C2HEST scores. AF indicates atrial fibrillation; CAD, coronary artery disease; C2HEST, coronary artery disease or chronic obstructive pulmonary disease [1 point each]; hypertension [1 point]; elderly [age ≥75 y, 2 points]; systolic HF [2 points]; thyroid disease [hyperthyroidism, 1 point]; and COPD, chronic obstructive pulmonary disease.

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