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CLINICAL STATEMENTS AND GUIDELINES January 2, 2024 Circulation. 2024;149:e1–e156. DOI: 10.1161/CIR.0000000000001193 e26 Joglar et al 2023 Guideline for the Diagnosis and Management of Atrial Fibrillation myopathy related to excessive exercise training. To date, there is little evidence that high-intensity aerobic exercise may be favorable over moderateintensity activities,8 and extreme levels of exercise have been associated with higher incidence of AF.9,10 Exercise training may be delivered as a stand-alone intervention or as a component of multidisciplinary cardiac rehabilitation. Exercise-based cardiac rehabilitation improves QOL and functional capacity among patients with AF undergoing ablation,11,12 although available studies have not been adequately powered to assess AF-specific outcomes, such as arrhythmia recurrence.13 There is mixed evidence for a reduction in hospitalization or all-cause mortality with exercise training or exercise-based cardiac rehabilitation.12,14,15 5.2.3 Smoking Cessation Recommendation for Smoking Cessation Referenced studies that support the recommendation are summarized in the Online Data Supplement. COR LOE Recommendation 1 B-NR 1 Patients with a history of AF who smoke cigarettes should be strongly advised to quit smoking and should receive GDMT for tobacco cessation1,2 to mitigate increased risks of AF-related cardiovascular complications and other adverse outcomes.3–6 Synopsis Observational data support that cigarette smoking in individuals with AF is associated with worse cardiovascular outcomes and death and that individuals with AF who quit smoking are less likely to develop stroke or die. Despite the benefits of smoking cessation, individuals with AF are less likely to receive smoking cessation management than counterparts without AF.7,8 Patients with AF should be strongly advised to quit cigarette smoking9 and should receive GDMT for tobacco cessation, including behavioral interventions10,11 and pharmacotherapy.2 Recommendation-Specific Supportive Text 1. In individuals with AF, cigarette smoking was asso- ciated with poorer outcomes. For individuals who have undergone AF catheter ablation, current cigarette smoking was associated with increased risk for AF recurrence.12,13 Cigarette smoking was associated with less time in therapeutic range for patients on warfarin.14 Although some heterogeneity exists, the preponderance of studies have reported that individuals with AF who smoked cigarettes had increased risks of stroke,3,4 HF,5 hospitalization,6 and death.6,15 Of concern, studies have reported that individuals with AF (versus those without) were less likely to receive smoking cessation interventions.7,8 Observational studies suggest that compared with current smokers, individuals with AF who quit smoking after AF diagnosis were less likely to experience CVD,3 stroke,3,16 and allcause mortality.16 5.2.4 Alcohol Consumption Recommendation for Alcohol Consumption Referenced studies that support the recommendation are summarized in the Online Data Supplement. COR LOE Recommendation 1 B-R 1 Patients with AF seeking a rhythm-control strategy should minimize or eliminate alcohol consumption to reduce AF recurrence and burden.1–3 Synopsis Among patients with a diagnosis of AF, randomized trials have demonstrated a reduction in AF burden on assignment to abstinence,1 that alcohol acutely changes human electrophysiology in a fashion that renders the atria more prone to fibrillate,2 and suggest that avoiding alcohol can reduce the risk of a near-term AF event.3 Recommendation-Specific Supportive Text 1. Among patients with AF, a case-crossover study revealed a higher risk of a discrete AF episode hours after objectively confirmed alcohol consumption.4 In the context of a structured comprehensive management of risk factors, alcohol abstinence1 or reduction to ≤3 standard drinks per week has been demonstrated to reduce AF symptoms,5 AF burden,6,7 and progression of AF from paroxysmal to persistent.8 5.2.5 Caffeine Consumption Recommendation for Caffeine Consumption Referenced studies that support the recommendation are summarized in the Online Data Supplement. COR LOE Recommendation 3: No Benefit B-NR 1 For patients with AF, recommending caffeine abstention to prevent AF episodes is of no benefit, although it may reduce symptoms in patients who report caffeine triggers or worsens AF symptoms.1–9 Synopsis A randomized N-of-1 trial,2 as well as longitudinal, observational studies, have generally found that caffeine consumed within normal limits is either associated with no heightened risk3–6 or a reduced risk of incident AF.3,5,7–9 Patients often report caffeine as a trigger of AF,10 although this has not been supported by objective data. Recommendation-Specific Supportive Text 1. A randomized trial of caffeine failed to show any difference in postoperative AF risk,1 and paroxysmal AF patients experienced no detectable difference in AF episodes when exposing themselves to versus avoiding caffeine in randomized N-of-1 trials.2 Longitudinal, observational studies have generally found that caffeine consumed in usual amounts is either associated with no heightened Downloaded from http://ahajournals.org by on October 7, 2026