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CLINICAL STATEMENTS AND GUIDELINES Circulation. 2024;149:e1–e156. DOI: 10.1161/CIR.0000000000001193 January 2, 2024 e23 Joglar et al 2023 Guideline for the Diagnosis and Management of Atrial Fibrillation and right ventricular (RV) pressure. Left ventricular ejection fraction (LVEF) impacts decisions for antiarrhythmic drug therapy and whether to prioritize other rhythm control therapies, including catheter ablation. Additionally, strain imaging may suggest an underlying infiltrative cardiomyopathy, such as amyloidosis.1 Echocardiography also provides information on LA size and function. Altered LA compliance is known to be associated with AF11 and progression toward persistent-type AF.2 In a meta-analysis, AF recurrence after ablation was associated with a lower LA strain,3 while LA volume was a stronger predictor of recurrence after ablation than the characterization of AF as paroxysmal or persistent.4 Laboratory testing can detect other medical conditions that are associated with AF and would impact therapeutic decision-making, such as CKD,5 liver dysfunction,6 and hyperthyroidism.7,12 Laboratory testing may also reveal electrolyte abnormalities, including from medications such as diuretics. Laboratory testing is also needed to determine stroke risk and bleeding risk factors, which will guide management decisions. When clinical suspicion exists, additional testing might be needed to evaluate for potentially related conditions, such as significant valvular disease. 2. The presence of AF itself should not prompt rou- tine protocolized testing for myocardial ischemia, ACS, or PE, in the absence of signs or symptoms to suggest those diseases. A retrospective analysis of asymptomatic patients with AF compared with age- and sex-matched controls that were referred for myocardial stress imaging found no difference in mean summed stress score or rate of abnormal studies.8 A retrospective analysis of 1700 asymptomatic AF patients (no chest pain or dyspnea) found that 4.6% had >5% ischemic myocardium, and the yield to detect ischemia that resulted in revascularization was only 0.4%.9 Among patients suspected of PE, a retrospective analysis showed that the presence of AF did not increase the probability of PE.10 Certainly, this would not preclude from evaluating patients with signs and/or symptoms of ischemia and PE. 4.2.2 Rhythm Monitoring Tools and Methods Recommendations for Rhythm Monitoring Tools and Methods Referenced studies that support the recommendations are summarized in the Online Data Supplement. COR LOE Recommendations 1 B-NR 1 Among individuals without a known history of AF, it is recommended that an initial AF diagnosis be made by a clinician using visual interpretation of the electrocardiographic signals, regardless of the type of rhythm or monitoring device.1–5 1 B-NR 2 In patients with an intracardiac rhythm device capable of a diagnosis of AF, such as from an atrial pacemaker lead, a diagnosis of AF should only be made after it is visually confirmed by reviewing intracardiac tracings to exclude signal artifacts and other arrhythmias.6–9 2a B-R 3 For patients who have had a systemic thromboembolic event without a known history of AF and in whom maximum sensitivity to detect AF is sought, an implantable cardiac monitor is reasonable.10,11 2a B-NR 4 Among patients with a diagnosis of AF, it is reason- able to infer AF frequency, duration, and burden using automated algorithms available from electrocardiographic monitors, implantable cardiac monitors, and cardiac rhythm devices with an atrial lead, recognizing that periodic review can be required to exclude other arrythmias.1,4,5,12 2a B-R 5 Among patients with AF in whom cardiac monitor- ing is advised, it is reasonable to recommend use of a consumer-accessible electrocardiographic device that provides a high-quality tracing to detect recurrences.13 Synopsis Monitoring options for AF include a standard 12-lead ECG, continuously recording or loop-recording electrocardiographic monitors using separate electrodes or as patches, implantable cardiac monitors (sometimes referred to as implantable loop recorders), cardiac rhythm management devices with an atrial lead (eg, pacemakers and defibrillators), handheld ECGs, and smartwatches. Photoplethysmography has been used to infer AF from irregular pulse patterns using a variety of devices, predominately smartphone cameras14 and smartwatches.15–18 Electrocardiographic monitors often deploy automated algorithms for AF detection, but due to variable accuracy,1–5 the initial diagnosis should rely on a health care professional’s examination of the electrocardiographic tracing. Although photoplethysmography monitors may alert individuals to obtain an electrocardiographic tracing, it is not sufficiently reliable to establish an AF diagnosis.14–18 AF detected from an atrial lead has been validated versus surface ECGs6,7 and independently predicts stroke.8,9 RCTs have demonstrated that implantable cardiac monitors exhibit the highest sensitivity in detecting AF compared with external ambulatory monitors, likely related to the longer duration of monitoring.10,11 Automated algorithms to analyze electrocardiographic devices have generally been found to be sufficiently reliable to infer the frequency, duration, and burden of AF among those with an AF diagnosis.1,4,5,12 A randomized trial showed that a handheld electrocardiographic monitor resulted in earlier detection of recurrent AF.13 Recommendations for Rhythm Monitoring Tools and Methods (Continued) COR LOE Recommendations Downloaded from http://ahajournals.org by on October 7, 2026