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CLINICAL STATEMENTS AND GUIDELINES Circulation. 2024;149:e1–e156. DOI: 10.1161/CIR.0000000000001193 January 2, 2024 e25 Joglar et al 2023 Guideline for the Diagnosis and Management of Atrial Fibrillation associated with increased risk, and smoking cessation is associated with decreased risk of incident AF.4 The presence of either type 1 or type 2 diabetes increases AF risk,5,32 with evidence that worse glucose control correlates with a higher probability of developing AF.33 Hypertension is the risk factor with the highest attributable risk for AF10; intensive BP control lowers the risk of incident AF in observational and randomized data.6 Effective strategies to manage risk factors and prevent CVD have been reported elsewhere.12,13 5.2 Secondary Prevention: Management of Comorbidities and Risk Factors 5.2.1 Weight Loss in Individuals Who Are Overweight or Obese Recommendation for Weight Loss in Individuals Who Are Overweight or Obese Referenced studies that support the recommendation are summarized in the Online Data Supplement. COR LOE Recommendation 1 B-R 1 In patients with AF who are overweight or obese (with body mass index [BMI] >27 kg/m2), weight loss is recommended, with an ideal target of at least 10% weight loss to reduce AF symptoms, burden, recurrence, and progression to persistent AF.1–4 Synopsis Obesity is associated with the development and progression of AF.5 It results in direct changes to the atrial myocardium forming the substrate for AF.6–8 In addition, obesity is also associated with several comorbidities that have been independently associated with the development of AF.9,10 Obesity has a significant adverse impact on attempts to maintain sinus rhythm, with each 5-unit increase in BMI being associated with a 10% and 13% greater risk of postoperative and postablation AF, respectively.5,11,12 Management of weight is important in the prevention and treatment of AF. Recommendation-Specific Supportive Text 1. In an RCT in overweight and obese individuals with BMI >27 kg/m2 and AF, weight loss, as part of a comprehensive LRFM program, was associated with reduction in arrhythmia symptoms, recurrence, and burden.1 Observational studies demonstrated graded responses commensurate with the degree of weight loss, with achievement of at least 10% weight loss associated with greater maintenance of sinus rhythm,2 improved ablation outcomes,3 and reversal of AF type.4 In observational studies, bariatric surgery in Class III obese individuals (BMI ≥40 kg/m2) with AF was associated with improved sinus rhythm maintenance after catheter ablation13,14 and reversal of AF type.15 The greater number of risk factors managed associated with likelihood of maintaining sinus rhythm.16 However, a small observational study in individuals with obesity (BMI ≥30 kg/m2) with long-lasting persistent AF observed no difference in symptoms or sinus rhythm maintenance despite significant weight loss, suggesting that there may be extreme substrates in which a weight loss strategy may not be effective.17 Structured programs with regular review of prog- ress facilitate achievement of weight loss and appear essential, as demonstrated by inability to reduce AF burden in a small RCT that achieved only 4.5% weight loss in the intervention arm. 5.2.2 Physical Fitness Recommendation for Physical Fitness Referenced studies that support the recommendation are summarized in the Online Data Supplement. COR LOE Recommendation 1 B-R 1 In individuals with AF,* moderate-to-vigorous exercise training to a target of 210 minutes per week is recommended to reduce AF symptoms1–3 and burden,2,3 increase maintenance of sinus rhythm,3–5 increase functional capacity, and improve QOL.3,5,6 *In patients without AF related to excessive exercise training. Synopsis Randomized trials provide evidence that prescribed aerobic exercise interventions may reduce arrhythmia burden in those with nonpermanent AF2 and improve functional capacity and health-related QOL in both permanent1,6 and nonpermanent AF.2 In the ACTIVE-AF (An Exercise and Physical Activity Program in Patients With Atrial Fibrillation) study, an exercise intervention combining home and supervised aerobic exercise over 6 months resulted in greater freedom from arrhythmia recurrence, reduced burden, and improved QOL.3 Recommendation-Specific Supportive Text 1. In patients with nonpermanent AF, aerobic exercise training may contribute to a reduction in AF burden and improve maintenance of sinus rhythm.2–5 Aerobic exercise interventions reduce severity of AF symptoms, increase functional capacity, and improve health-related QOL among patients with both nonpermanent and permanent AF.1,3,6 Initiation of or continuing regular exercise after development of AF was associated with a lower risk of HF and mortality in a population-based cohort study.7 Exercise training should be moderate- to vigorousintensity aerobic exercise, with a target of 210 minutes per week, and should be prescribed to reduce the frequency and duration of AF episodes, while improving cardiorespiratory fitness and symptom severity.3 Exercise prescription may be further modified to patient comorbidities, such as obesity, hypertension, and diabetes.4 Caution should be applied to ensure adequate ventricular rate control during exercise training and absence of atrial Downloaded from http://ahajournals.org by on October 7, 2026