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CLINICAL STATEMENTS AND GUIDELINES January 2, 2024 Circulation. 2024;149:e1–e156. DOI: 10.1161/CIR.0000000000001193 e28 Joglar et al 2023 Guideline for the Diagnosis and Management of Atrial Fibrillation 5.2.9 Sleep Recommendation for Sleep Referenced studies that support the recommendation are summarized in the Online Data Supplement. COR LOE Recommendation 2b B-NR 1 Among patients with AF, it may be reasonable to screen for obstructive sleep apnea, given its high prevalence in patients with AF, although the role of treatment of sleep-disordered breathing (SDB) to maintain sinus rhythm is uncertain.1–13 Synopsis SDB is a risk factor for the development of incident AF, and more severe SDB acutely increases the risk of a discrete AF episode.14–18 Independent of SDB, poor sleep quality is associated with an increased risk of developing incident AF.19–21 When formal testing for SDB is used, the disease is frequently observed in >20% of patients with an AF diagnosis.1–5 Observational studies suggest that treatment of SDB may reduce the risk of AF recurrence and AF burden, but RCTs have not been adequately powered to reveal a relationship between treating SDB and reduced AF.6–13 Recommendation-Specific Supportive Text 1. The prevalence of SDB is remarkably and consis- tently high in patients with AF (generally substantially >20% and sometimes >50% regardless of the type of AF population assessed), is often undetected, and, as conventional symptoms of SDB may be absent, may require formal study to establish a diagnosis of SDB.1–5,11 Multiple observational studies have described fewer recurrences of AF and a reduction in AF burden, including after cardioversion and catheter ablation procedures, among those undergoing treatment for SDB compared with those not treated for their SDB.6–11,22 However, small trials randomizing patients with AF and SDB treatment versus usual care have not shown significant differences in AF burden or AF recurrence, including after cardioversion or PVI ablation,12,13,22 although studies tended to exclude patients who might benefit most from SDB treatment (eg, those who had more symptomatic sleep apnea [Epworth Sleepiness Scale score >10 or 15], severe cardiovascular disease [LVEF <40% or 45%], or severe obesity). 5.2.10 Comprehensive Care Recommendations for Comprehensive Care Referenced studies that support the recommendations are summarized in the Online Data Supplement. COR LOE Recommendations 1 A 1 Patients with AF should receive comprehensive care addressing guideline-directed LRFM, AF symptoms, risk of stroke, and other associated medical conditions to reduce AF burden, progression, or consequences.1–3 2a B-R 2. In patients with AF, use of clinical care pathways, such as nurse-led AF clinics, is reasonable to promote comprehensive, team-based care and to enhance adherence to evidence-based therapies for AF and associated conditions.4–6 Synopsis Almost all patients with AF have multiple conditions that either increase AF risk or are exacerbated by AF. Patients with AF are also at risk of developing thromboembolism, stroke, and HF, so a comprehensive approach tailored to the needs of the individual patient should improve outcomes. Randomized trials have shown that interventions aimed at AF risk factors, such as alcohol use, overweight, and HF, reduce AF burden. Clinical care pathways and algorithms for AF management, including LRFM, have shown promise in randomized trials through coordinating care and facilitating comprehensive AF management. Although comprehensive care of the multiple conditions associated with AF is logical, it is unclear whether integrated care by a multidisciplinary team leads to better outcomes than comprehensive care by a single clinician applying an evidence-based AF clinical care algorithm or pathway. Nevertheless, coordination of care among multiple clinicians should also improve care, even though it has not been evaluated rigorously.7 Recommendation-Specific Supportive Text 1. Randomized trials have shown the efficacy of many individual components of patient-centered care for AF, as discussed earlier in this section. Several randomized and nonrandomized studies have utilized comprehensive programs for patients with AF.2,8,9 The RACE 3 (Rate Control versus Electrical cardioversion for persistent atrial fibrillation) trial3 found that multifaceted treatment for patients with AF and early HF (with mineralocorticoid receptor antagonists, statins, ACE inhibitors and/or angiotensin receptor blockers [ARBs], and cardiac rehabilitation) improved maintenance of sinus rhythm. 2. Various clinical care pathways, algorithms, and electronic clinical decision support systems for the care of patients with AF have been tested in clinical trials, with mixed results. Care provided by specialty nurses using a clinical support system aimed at enhancing adherence to guideline-directed therapies improved cardiovascular outcomes in a single center study4 but not in the subsequent multicenter RACE 4 trial, where results were associated with experience of the center, although adherence to guideline-based recommendations was still greatly improved.10 In a cluster randomized trial of elderly patients with AF where integrated care intervention consisting of (a) quarterly AF check-ups by trained nurses in primary care, also focusing on comorbidities, (b) monitoring of anticoagulation therapy in primary care, and finally (c) easy-access availability of consultations from cardiologists and anticoagulation clinics, the patients assigned to integrated care experienced a 45% reduction in all-cause mortality when compared with usual care.11 In another study (SAFETY [Standard versus Atrial Fibrillation specific management study]), a posthospital discharge Downloaded from http://ahajournals.org by on October 7, 2026