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CLINICAL STATEMENTS AND GUIDELINES Circulation. 2024;149:e1–e156. DOI: 10.1161/CIR.0000000000001193 January 2, 2024 e99 Joglar et al 2023 Guideline for the Diagnosis and Management of Atrial Fibrillation Synopsis Patients with class III obesity (BMI ≥40 kg/m2) are underrepresented in the major clinical trials evaluating the efficacy and safety of DOACs in patients with AF. Post hoc analyses of major DOAC trials in AF and large observational studies have shown comparable efficacy and safety of DOACs compared with warfarin across weight groups, including patients with class III obesity.1–5 Thus, DOACs are preferred over warfarin for stroke risk prevention in patients with class III obesity and AF. Little evidence is available that evaluates the pharmacokinetics, efficacy, and safety of DOACs in patients with AF who have undergone bariatric surgery. Thus, warfarin may be reasonable to choose over DO- ACs to reduce stroke risk in this population until further data become available. Recommendation-Specific Supportive Text 1. Post hoc analyses of the ARISTOTLE (apixaban versus warfarin), ROCKET AF (rivaroxaban versus warfarin), and ENGAGE AF-TIMI 48 (edoxaban versus warfarin) demonstrated consistent efficacy (stroke and systemic embolism) and safety (major bleeding) of DOACs compared with warfarin across weight groups in patients with AF.3–5 A meta-analysis including these trials and RE-LY (dabigatran versus warfarin) again showed similar efficacy and safety of DOACs compared with warfarin, although the outcome differences were attenuated in obese patients.2 A large retrospective observational study including 36 094 patients compared risk of ischemic stroke, significant bleeding, and mortality in patients receiving a DOAC or warfarin, stratified by BMI group.1 For all 3 endpoints, better outcomes were observed with DOACs across BMI groups. In patients with a BMI ≥40 kg/m2, a relative risk reduction of 25% for ischemic stroke (adjusted HR, 0.75 [95% CI, 0.64-0.87]; P<0.001), 57% for significant bleeding (adjusted HR, 0.43 [95% CI, 0.20-0.94]; P<0.001), and 34% for all-cause mortality (adjusted HR, 0.66 [95% CI, 0.56-0.77]; P<0.001) was observed with DOACs compared with warfarin. 2. Although case reports exist that demonstrate expected factor Xa trough levels in patients taking a DOAC who undergo bariatric surgery, a metaanalysis of cohort studies, case series, and case reports has shown that 42% of patients who have undergone bariatric surgery had peak drug levels below the expected range.6,7 Patients who have undergone bariatric surgery are not well represented in any of the major trials comparing DOACs with warfarin, and few observational data support DOAC use in this population. Warfarin’s therapeutic effect can be routinely monitored. Thus, in patients with AF who have undergone bariatric surgery, warfarin may be a reasonable choice over DOACs for stroke risk reduction at this time. 10.5 AF and VHD VHD and AF commonly coexist. AF independently predicts the risk of cerebrovascular events among patients with valve disease.1 This risk may be addressed with the use of oral anticoagulation, percutaneous and surgical LAAO, and surgical ablation as described in Sections 6.5.1 (“Percutaneous Approaches to Occlude the LAA”), 6.5.2 (“Cardiac Surgery—LAA Exclusion/Excision”), and 6.8.5 (“AF in VHD”). 10.6 WPW and Preexcitation Syndromes Recommendations for WPW and Preexcitation Syndromes Referenced studies that support the recommendations are summarized in the Online Data Supplement. COR LOE Recommendations 1 B-NR 1 Patients with AF with rapid anterograde conduction (preexcited AF), and hemodynamic instability should be treated with electrical cardioversion.1,2 1 B-NR 2 For patients with AF with rapid anterograde conduction (preexcited AF), catheter ablation of accessory pathways (APs) is recommended.3–7 1 C-LD 3 In patients with AF with rapid anterograde conduction (preexcited AF) and hemodynamic stability, pharmacological cardioversion with intravenous ibutilide or intravenous procainamide is recommended as an alternative to elective cardioversion.1,8,9 3: Harm B-NR 4 For patients with AF with anterograde accessory pathway conduction (preexcited AF), pharmacological agents that block atrioventricular nodal conduction (verapamil, diltiazem, amiodarone, digoxin, adenosine, or beta blockers) are contraindicated due to risk of precipitating VF or hemodynamic deterioration.10–14 Synopsis WPW and preexcitation syndromes refer to the presence of extra-atrioventricular nodal connection(s) between atrium and ventricle; such APs are comprised of atrial tissue.15 AF occurs in approximately 15% of persons with WPW and although the mechanism(s) remain unclear, the faster conduction properties of atrial tissue compared with the atrioventricular node allow for rapid rates in preexcited AF.15–17 The risk of preexcited AF is higher for those with multiple pathways and short antegrade pathway refractory period (<250 ms), which allows rapid conduction and predisposes to VF and sudden death.1,18,19 Moreover, AF in young persons without evidence of comorbid conditions may be associated with an AP, and pathway ablation is definitive therapy for AF and SVT in these persons.1 For those who cannot undergo ablation, preventive pharmacological therapy is directed to slowing pathway conduction.20,21 Downloaded from http://ahajournals.org by on October 7, 2026