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CLINICAL STATEMENTS AND GUIDELINES

January 2, 2024 Circulation. 2024;149:e1–e156. DOI: 10.1161/CIR.0000000000001193 e98

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

12 of 13 patients who underwent slow pathway ablation without PVI had no recurrence of AF after a mean follow-up of 21 months.3

2 A prospective observational cohort study in patients

with AF diagnosed before the age of 66 years and who had sequencing of genes typically found in ion channelopathy and cardiomyopathy panels reported that among 1293 patients studied, 10% (131) were found to have a disease-associated variant, primarily in cardiomyopathy-related genes.4 In 1 study of 23 unrelated patients with onset of AF at <45 years of age who had a normal echocardiogram and no other readily identifiable causes of AF, 24% had a pathogenic or likely pathogenic variant identified. Most of these were also in cardiomyopathy-related genes.5

10.2 Athletes

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

2a B-NR 1 In athletes who develop AF, catheter ablation with

PVI is a reasonable strategy for rhythm control because of its effectiveness and low risk of detrimental effect on exercise capacity.1,2

Synopsis Engaging in moderate levels of exercise has several cardiovascular benefits and, in some studies, has been associated with a lower incidence of AF.3,4 However, high-volume endurance athleticism, defined here as exercise of >45 metabolic equivalent-hours per week, has been associated with a higher prevalence of AF,5 particularly in young athletes.6 The mechanisms behind this association are not well established but may be related to atrial myopathy from exercise-induced stretch or perhaps inflamation.7,8 No studies have prospectively studied the effects of detraining on AF burden, but some have proposed that moderation of exercise may be considered, although it is unclear whether changes are reversible.9 Nevertheless, athletes will often choose to continue sport participation, and aggressive rhythm control strategies are often sought. Because many of these patients are young, medications are often not tolerated or preferred. PVI has been shown to be safe and effective in this population without resulting in a significant reduction in exercise capacity1 and has been shown to significantly improve QOL.2 Recommendation-Specific Supportive Text 1.	 In a prospective cohort study of 144 athletes, AF

ablation with PVI, including multiple procedures, resulted in freedom from AF at 1 year in 86% of athletes with paroxysmal AF and 68% of athletes with persistent AF over a median follow-up of 3 years.1 Athletes underwent cardiopulmonary exercise stress testing before and after ablation and, although the sinus rate increased on average 10 bpm after ablation (which may bother some athletes and thus should be discussed before the procedure), no significant changes were observed in maximum metabolic equivalents on exercise treadmill testing. In a retrospective cohort study of 133 competitive athletes who underwent catheter ablation for AF with 10-year follow-up, 83% of athletes did not have recurrent events and had significantly improved QOL scores.2

10.3 Management Considerations in Patients

With AF and Obesity Obesity is a strong risk factor for AF.1 In the Framingham Study, overweight and obesity increased the risk of incident AF, with a 4% increase in AF risk per unit increase in BMI in men and women. Adjusted HRs for AF associated with obesity were 1.52 (95% CI, 1.09-2.13; P=0.02) and 1.46 (95% CI, 1.03-2.07; P=0.03) for men and women, respectively, compared with individuals with normal BMI. In that study, the excess risk of AF associated with obesity appeared to be mediated through LA dilatation.2 Other studies suggest that the risk of AF with obesity is mediated through epicardial and abdominal fat, or structural changes in the atria.1,3 Obesity is also associated with other comorbidities, including hypertension, HF, and sleep apnea, which themselves predispose to an increased incidence of AF. Further, higher BMI and obesity are associated with an increase in the burden of AF, including progression from paroxysmal to permanent AF, and an increased risk of AF recurrence after AF ablation.4 Special considerations for the management of AF in patients with obesity include the role of weight loss in the primary and secondary prevention of AF (Section 5, “Lifestyle and Risk Factor Modification for AF Management”), as well as anticoagulation in patients with severe or class III obesity in this section and in Section 10.4 (“Anticoagulation Considerations in Patients With Class III Obesity”).

10.4 Anticoagulation Considerations in Patients

With Class III Obesity Recommendations for Anticoagulation Considerations in Patients With Class III Obesity Referenced studies that support the recommendations are summarized in the Online Data Supplement. COR LOE Recommendations

2a B-NR 1 In patients with AF and class III obesity (BMI ≥

40 kg/m2), DOACs are reasonable to choose over warfarin for stroke risk reduction.1–5

2b C-LD 2 In patients with AF who have undergone bariatric

surgery, warfarin may be reasonable to choose over DOACs for stroke risk reduction in view of concerns about DOAC drug absorption.6,7

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