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CLINICAL STATEMENTS AND GUIDELINES

Circulation. 2024;149:e1–e156. DOI: 10.1161/CIR.0000000000001193 January 2, 2024 e27

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

risk3–6 or a reduced risk of incident AF.3,5,7–9Also, Mendelian randomization studies examining caffeine metabolism-related genetic variants as instrumental-variable surrogates of caffeine consumption have not shown either a harmful or protective effect related to incident AF.8,11 Several case reports have described a relationship between excessive consumption of caffeine (involving overdoses or highly caffeinated energy drinks)12,13 and AF in young, healthy individuals. Individuals should not begin or increase their caffeine consumption with the intent of reducing their AF risk.Patients often report that caffeine triggers their AF,10,14 although this has neither been supported by nor extensively studied in an objective manner. Current studies cannot exclude the possibility of individual-level idiosyncratic relationships between caffeine and AF. It is also possible that caffeine exacerbates symptoms of AF, or causes similar symptoms of palpitations, or enhances heart rhythm awareness. 5.2.6. Diet and Dietary Supplementation Promoting a healthy diet is an effective strategy for prevention of cardiovascular disease. The evidence pertaining to the prevention of AF using dietary supplements is inconsistent, complicated by substantial misclassification and difficulties controlling for potential confounding factors associated with dietary interventions. Several studies have evaluated the role of omega-3 fatty acids and AF, demonstrating an inverse relationship between plasma omega-3 polyunsaturated fatty acid levels and prevalent AF.1,2 However, with supplementation there has been no effect or a potential for greater AF.3–7 Although vitamin D supplementation is not useful on a population basis,8,9 its use in the perioperative period in deficient individuals reduces AF.10 Similarly, ascorbic acid has been beneficial in reducing postoperative AF in some studies, although not uniformly.11 The importance of weight management on AF symptoms, burden, and recurrence is increasingly recognized,12,13 leading to various dietary interventions. Although evidence on diets is still evolving, analyses of the ARIC (Atherosclerosis Risk in Communities) study caution using low-carbohydrate diets, which were found to increase the risk of incident AF, regardless of the type of protein or fat used to replace carbohydrate.14 5.2.7. Diabetes AF and diabetes are associated with increased risk of cardiovascular mortality and sudden death.1 In patients with diabetes, vascular mortality was lower in patients treated with DOACs compared with warfarin.2 In patients with AF and diabetes undergoing catheter ablation, optimal glycemic control preablation may lessen the risk of AF recurrence postablation.3 5.2.8 Treatment of Hypertension

Recommendation for the Treatment of Hypertension Referenced studies that support the recommendation are summarized in the Online Data Supplement. COR LOE Recommendation

1 B-NR 1 For patients with AF and hypertension, optimal BP

control is recommended to reduce AF recurrence and AF-related cardiovascular events.1–7

Synopsis Renal denervation and mineralocorticoid receptor antagonists (MRAs) have been associated with decreased AF burden in clinical trials.1,2 The only randomized trial singularly targeting BP control as a mechanism to reduce the recurrence of AF8 showed no significant difference in the primary outcome of recurrent symptomatic atrial arrhythmia beyond 3 months’ postablation among the 2 groups. However, clinical trials of integrated comprehensive LRFM programs in conjunction with rhythm control therapies for AF have resulted in longer arrhythmia-free survival and decreased AF burden.3,5,9 Among patients with AF, treating elevated BP to guideline-directed goals reduces major cardiovascular events.9 Recommendation-Specific Supportive Text 1.	 In patients with AF, treatment of hypertension

should aim for current BP guidelines to reduce stroke, bleeding, and other adverse outcomes.5,10 An RCT of patients with paroxysmal AF and hypertension noted fewer recurrences among participants treated with renal denervation and pulmonary vein isolation (PVI) compared with PVI alone.2 Randomized studies of mineralocorticoid receptor antagonists for hypertension have been shown to reduce AF burden, and ACE inhibitors and angiotensin II receptor blockers have been associated with lower AF incidence in secondary analyses of RCTs (see Section 8.3.4, “Upstream Therapy”). In addition, several integrated LRFM programs that have resulted in a decrease in BP have been associated with a decreased recurrence of AF.3,11The SMAC (Substrate Modification With Aggressive Blood Pressure Control) AF trial randomized hypertensive patients scheduled for AF ablation to standard or aggressive BP treatment with a systolic BP target of 120 or 140 mm Hg.8 No significant difference was shown in recurrent symptomatic atrial arrhythmia beyond 3 months postablation (median follow-up, 14 months), and this is the only RCT to date singularly targeting BP control as a mechanism to reduce AF recurrence.8 Post hoc analyses of DOAC clinical trials to reduce the risk of stroke in patients with AF have consistently found lower rates of stroke in patients with controlled BP.6,7

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