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CLINICAL STATEMENTS AND GUIDELINES

January 2, 2024 Circulation. 2024;149:e1–e156. DOI: 10.1161/CIR.0000000000001193 e24

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

Recommendation-Specific Supportive Text 1.	 Although automated algorithms in various devices

are generally reliable, health care professional overread of electrocardiographic tracings remains necessary given the imperfect test characteristics of those algorithms.1–5 Similarly, while algorithms utilizing photoplethysmography signals (derived using smartphones or smartwatches) to infer irregular heart rates can discriminate AF from normal sinus rhythm, these are not sufficiently reliable to establish an AF diagnosis.14–18

2 Cardiac rhythm devices with an atrial lead have

been shown to detect AF validated against conventional surface electrocardiographic tracings.6–8 In addition, both the presence and duration of AF detected solely by these devices predict stroke in a manner that would be expected of AF.8,9 It is still essential that the intracardiac tracings are reviewed for confirmation because false-positives are possible. The duration of AF that mandates intervention with anticoagulation will be discussed in Section 6.4.1 (“Oral Anticoagulation for Device-Detected Atrial High-Rate Episodes Among Patients Without a Previous Diagnosis of AF”). 3.	 The more frequent and longer monitoring for AF

is deployed, the greater the sensitivity in detecting AF.10,19 Randomized trials, predominately among cryptogenic stroke patients, have revealed that implantable cardiac monitors exhibit the highest sensitivity in detecting AF in view of extended monitoring periods compared with external monitors.10,11

4 It is often not feasible to manually review all elec-

trocardiographic strips from various monitoring devices, either due to inaccessibility or time and resource constraints on health care professionals. Although variability in accuracy across different devices may be present, the validity demonstrated in automated algorithms is generally sufficient to infer frequency, duration, and burden of AF using electrocardiographic devices such as continuously wearable monitors, implantable cardiac monitors, and cardiac rhythm devices with an atrial lead.1,4,5,12

5 Cardiac monitoring may be advised to AF patients

for various reasons, such as for detecting recurrences, screening, or response to therapy. Among patients with AF who are undergoing cardioversion or AF ablation, a single-center, randomized trial demonstrated that use of a self-administered handheld ECG resulted in earlier detection of recurrent AF13 and possibly improvement in survey-determined AF-related QOL20 compared with usual care. 5 LIFESTYLE AND RISK FACTOR

MODIFICATION (LRFM) FOR AF MANAGEMENT

5.1 Primary Prevention

Recommendation for Primary Prevention Referenced studies that support the recommendation are summarized in the Online Data Supplement. COR LOE Recommendation

1 B-NR 1 Patients at increased risk of AF should receive com-

prehensive guideline-directed LRFM for AF, targeting obesity,1 physical inactivity,2 unhealthy alcohol consumption,3 smoking,4 diabetes,5 and hypertension.6

Synopsis The clinical, family history, and genetic risk factors for AF are well established (Table 3), and risk prediction models (Section 4.1, “Risk Stratification and Population Screening”) for AF have been reported and replicated.7–9 Multiple reports have established that maintenance of optimal risk factors and ideal cardiovascular health are associated with substantially reduced risk of AF10,11 onset and complications (Section 5, “Lifestyle and Risk Factor Modification [LRFM] for AF Management”). To reduce risk of AF onset, individuals in the general population, particularly those at increased risk of AF, should receive comprehensive integrated LRFM, including maintenance of ideal weight and weight loss if overweight or obese1,12; pursue a physically active lifestyle,2 particularly if sedentary; receive smoking cessation counseling and/or medications4; moderate (≤1 standard alcoholic drink/day) or abstain from alcohol and avoidance of binge drinking3; control diabetes5; and control BP in accordance with GDMT.6,13 There is also an association of cannabis, cocaine, methamphetamine, or opiate use with increased incidence of AF.14

Recommendation-Specific Supportive Text 1.	 Most cardiovascular risk factors are associated

with increased risk of new-onset AF. Observational studies have demonstrated that obesity and physical inactivity each independently increase the risk of newly diagnosed AF.1,2,12,15–20 However, caution should be considered in pursuing years of regular, high-volume (≥3 h/day) high-intensity endurance training given observational data linking it with increased AF risk21–23 in men and similar “J” curve risk curve observed for high or vigorous activity in both men and women in another study.24 Alcohol consumption enhances the risk of AF in a fairly linear fashion, with clear evidence that binge drinking heightens the risk.3,25–29 Uncertainty persists regarding harms or benefits of no more than 1 regular drink per day.28,29 Self-reported,4 biomarkerverified,30 and genetically predicted31 smoking is

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