Clinical Review & Education

JAMA Clinical Guidelines Synopsis

Management of Atrial Fibrillation

GUIDELINE TITLE 2023 ACC/AHA/ACCP/HRS Guideline for the • Direct oral anticoagulants (DOACs) are recommended to
Diagnosis and Management of Atrial Fibrillation lower stroke risk in most patients with AF who have a
calculated annual stroke risk of at least 2% (1-A). Individuals
DEVELOPERS American College of Cardiology (ACC) and with moderate to severe mitral stenosis or mechanical heart
American Heart Association (AHA), in collaboration with valves should receive warfarin instead of DOACs (1-B).
American College of Clinical Pharmacy (ACCP) and Heart Percutaneous left atrial appendage occlusion (LAAO) devices
Rhythm Society (HRS) may be considered for patients with elevated stroke risk and
contraindication to long-term anticoagulation (2a-B).
RELEASE DATE November 30, 2023
• Antiplatelet drugs such as aspirin or P2Y12 inhibitors
PRIOR VERSION 2019 AHA/ACC/HRS Focused Update of the
(eg, clopidogrel, prasugrel, or ticagrelor) are not
2014 AHA/ACC/HRS Guideline for the Management of recommended as alternatives to DOACs or warfarin
Patients With Atrial Fibrillation (recommendation strength 3-B for harm/no benefit).
• For patients with AF and chronic coronary artery disease (ⱖ1
FUNDING SOURCE ACC/AHA year after revascularization or not requiring revascularization)
without history of stent thrombosis, antiplatelet agents can be
TARGET POPULATION Patients with atrial fibrillation (AF) stopped in favor of DOAC monotherapy (1-B).
• Before patients develop long-standing persistent AF, rhythm
SELECTED RECOMMENDATIONS control is preferred over rate control alone (2a-B). Catheter
• Patients with AF should be encouraged to participate in ablation is recommended for rhythm control therapy in
moderate to vigorous exercise training to a target of 210 patients with few comorbidities and symptomatic
min/wk (recommendation strength 1; level of evidence B), paroxysmal AF (1-A) and in patients with heart failure with
stop smoking tobacco (1-B), minimize or eliminate alcohol reduced ejection fraction (1-A).
consumption (1-B), and reduce weight by 10% (if body mass
index is >27) (1-B).

Summary of the Clinical Problem to recurrent AF among those randomized to an abstinence strategy
Atrial fibrillation has a lifetime prevalence of 15% to 40% and pre- vs those who continued their usual alcohol consumption (median, 139
disposes patients to stroke and cardiac dysfunction.1 This JAMA vs 62 days; P = .005).2 In an RCT of patients with AF and body mass
Clinical Guidelines Synopsis focuses on recommendations for long- index of 27 or higher (calculated as weight in kilograms divided by
term management of AF, including new paradigms for rhythm con- height in meters squared), a physician-led weight loss program re-
trol and stroke risk reduction. sulted in greater reductions in a composite measure of AF fre-
quency, duration, and severity than general lifestyle advice (P < .001).3
Characteristics of the Guideline Source
The ACC/AHA Task Force on Clinical Practice Guidelines writing Stroke Risk
committee included members with wide scopes of practice and To reduce stroke risk, DOACs (apixaban, dabigatran, edoxaban, or
expertise related to AF.1 Mem- rivaroxaban) should be prescribed for most individuals with AF who
bers were required to disclose have a 2% or higher annual risk of stroke based on a validated risk
Supplemental content
all industry relationships and assessment (such as CHA2DS2-VASc, ATRIA, or GARFIELD-AF).
could not participate in sec- Standard-dose DOACs, compared with warfarin, were associated
CME at jamacmelookup.com with fewer strokes and systemic emboli (3.0% vs 3.7%; hazard ra-
tions of this guideline that
directly involved medications or products associated with indus- tio, 0.81; 95% CI, 0.74-0.89) and lower rates of all-cause death (7.8%
try relationships (eTable in the Supplement). vs 8.4%; hazard ratio, 0.92; 95% CI, 0.87-0.97) in a network meta-
analysis of 4 RCTs (29 362 participants).4 Percutaneous LAAO de-
Evidence Base vices may be considered for patients with high bleeding risk such
Modifiable Risk Factors as gastrointestinal tract lesions refractory to treatment, spontane-
In a randomized clinical trial (RCT) of 120 patients with AF, those ran- ous intracerebral or intraspinal bleeding, or severe bleeding from re-
domized to supervised exercise training were less likely to have AF at current falls when the cause of falls is not treatable. In an RCT of 402
12 months compared with controls (40% vs 20%; P = .002) and had patients at high risk of both thromboembolism and gastrointesti-
lower symptom severity.1 An RCT of 140 patients with AF who con- nal bleeding, those assigned to percutaneous LAAO devices or
sumed 10 or more standard drinks per week showed increased time DOACs had the same 2.6% annual rate of thromboembolic events.5

jama.com (Reprinted) JAMA Published online November 14, 2024 E1

© 2024 American Medical Association. All rights reserved, including those for text and data mining, AI training, and similar technologies.
Downloaded from jamanetwork.com by guest on 11/14/2024
 Clinical Review & Education JAMA Clinical Guidelines Synopsis

Warfarin is recommended for patients with AF and moderate tially rate control for 96% of patients (3.9 vs 5.0 events per 100 per-
to severe mitral stenosis or mechanical heart valves. In an RCT of son-years; P = .005).8 For many patients, particularly younger in-
4565 participants with AF and rheumatic heart disease, those re- dividuals with symptomatic paroxysmal AF, ablation is now
ceiving rivaroxaban had a higher yearly risk of stroke, systemic em- recommended as first-line treatment for rhythm control. In an RCT
bolism, myocardial infarction, or death due to cardiovascular or un- of 303 patients (mean age, 59 [SD, 11] years) with symptomatic par-
known causes compared with warfarin (8.2% vs 6.5%; P < .001). Two oxysmal AF, those assigned to ablation were less likely to develop
RCTs of DOACs vs warfarin in patients with AF and mechanical valves persistent AF over 3 years vs antiarrhythmic drug therapy alone (1.9%
were stopped early due to increased thromboembolic and bleed- vs 7.4%; hazard ratio, 0.25; 95% CI, 0.09-0.70).9 Ablation is also rec-
ing events attributable to DOACs.1 ommended for patients with heart failure and reduced ejection frac-
Patients with AF who require aspirin in addition to a P2Y12 in- tion (ⱕ35%). An RCT of 363 patients with heart failure and symp-
hibitor and DOAC after percutaneous coronary interventions (PCI) tomatic AF reported that those assigned to ablation had fewer deaths
should stop aspirin after 1 to 4 weeks. In an RCT of 4614 partici- and hospitalizations for worsening heart failure compared with medi-
pants with AF and recent acute coronary syndrome or PCI (median cal therapy (28.5% vs 44.6%; P = .007).10
time, 6 days [IQR, 3-10 days]), early cessation of aspirin resulted in
fewer significant bleeding events (9.0% vs 16.1%; P < .001) with- Potential Harms
out a difference in ischemic events.6 Using a DOAC without anti- Antiarrhythmic drug therapy is associated with a high rate of ad-
platelet therapy is now recommended for patients with AF and coro- verse drug events (1%-7% yearly rate in recent trials), and ablation
nary artery disease 1 year after revascularization (or in chronic carries procedural risk (1.3% vascular complication, 0.8% pericar-
coronary artery disease not requiring coronary revascularization). dial effusion or tamponade, 0.2% stroke or transient ischemic attack,
In an RCT of patients with AF and coronary artery disease who did 0.06% procedure-related mortality). Up to 50% of patients re-
not require revascularization or were enrolled at least 1 year after PCI quire repeated ablation procedures for durable rhythm control.8,9
or coronary artery bypass graft surgery, rivaroxaban monotherapy Percutaneous LAAO devices also have procedural risks (1% rate of
was noninferior to rivaroxaban plus a single antiplatelet agent for procedure- or device-related death and 3.5% rate of combined peri-
combined stroke, systemic embolism, myocardial infarction, un- cardial effusion, device embolization, or vascular complications).5
stable angina, or death due to any cause (4.1% per patient-year for
monotherapy vs 5.8% for combined therapy; P < .001 for noninfe- Discussion
riority), and monotherapy decreased risk of major bleeding (1.6% vs The 2023 AF guideline emphasizes stroke risk assessment and treat-
2.8% per patient-year; P = .01).7 ment. For arrhythmia management, the guideline states that rhythm
control is the preferred initial strategy, with ablation as the pre-
Management of Symptoms and AF Burden ferred method to slow overall AF progression.8-10 The guideline also
Rhythm control is currently preferred for most patients with AF to emphasizes lifestyle and risk factor modification to mitigate ad-
reduce cardiovascular morbidity and progression to persistent AF. verse outcomes from AF. Future work is needed to expand the evi-
In an RCT of 2789 patients with AF within 1 year of diagnosis and high dence base to more diverse populations of trial participants with AF,
risk features (age >75 years, previous transient ischemic attack or which could encourage broader application of the guidelines to re-
stroke, or ⱖ2 other risk factors), those randomized to early rhythm duce current treatment disparities within and among communities
control with antiarrhythmic drugs or ablation had lower incidence and countries. More clarity is needed on the role of screening in
of cardiovascular death, stroke, heart failure, or hospitalization for asymptomatic persons with risk factors for AF, including screening
acute coronary syndrome compared with usual care, which was ini- at a population level with wearable technology.

ARTICLE INFORMATION and management of atrial fibrillation. J Am Coll 6. Lopes RD, Heizer G, Aronson R, et al.
Author Affiliations: Department of Medicine, Cardiol. 2024;83(1):109-279. doi:10.1016/j.jacc.2023. Antithrombotic therapy after acute coronary
University of Chicago, Chicago, Illinois. 08.017 syndrome or PCI in atrial fibrillation. N Engl J Med.
2. Voskoboinik A, Kalman JM, De Silva A, et al. 2019;380(16):1509-1524. doi:10.1056/
Corresponding Author: Gaurav A. Upadhyay, MD, NEJMoa1817083
University of Chicago Medicine, 5758 S Maryland Alcohol abstinence in drinkers with atrial fibrillation.
Ave, Chicago, IL 60637 (gupadhyay@ N Engl J Med. 2020;382(1):20-28. doi:10.1056/ 7. Yasuda S, Kaikita K, Akao M, et al.
uchicagomedicine.org). NEJMoa1817591 Antithrombotic therapy for atrial fibrillation with
3. Abed HS, Wittert GA, Leong DP, et al. Effect of stable coronary disease. N Engl J Med. 2019;381(12):
Section Editor: David L. Simel, MD, MHS, Associate 1103-1113. doi:10.1056/NEJMoa1904143
Editor. weight reduction and cardiometabolic risk factor
management on symptom burden and severity in 8. Kirchhof P, Camm AJ, Goette A, et al. Early
Published Online: November 14, 2024. patients with atrial fibrillation. JAMA. 2013;310(19): rhythm-control therapy in patients with atrial
doi:10.1001/jama.2024.19565 2050-2060. doi:10.1001/jama.2013.280521 fibrillation. N Engl J Med. 2020;383(14):1305-1316.
Conflict of Interest Disclosures: Dr Upadhyay 4. Carnicelli AP, Hong H, Connolly SJ, et al. Direct doi:10.1056/NEJMoa2019422
reported receipt of personal fees from Abbott, oral anticoagulants versus warfarin in patients with 9. Andrade JG, Deyell MW, Macle L, et al.
Biotronik, Boston Scientific, Medtronic, GE atrial fibrillation. Circulation. 2022;145(4):242-255. Progression of atrial fibrillation after cryoablation or
Healthcare, Philips, Rhythm Science, and Zoll doi:10.1161/CIRCULATIONAHA.121.056355 drug therapy. N Engl J Med. 2023;388(2):105-116.
Medical and grants from Biotronik. No other doi:10.1056/NEJMoa2212540
disclosures were reported. 5. Osmancik P, Herman D, Neuzil P, et al. Left atrial
appendage closure versus direct oral anticoagulants 10. Marrouche NF, Brachmann J, Andresen D, et al.
REFERENCES in high-risk patients with atrial fibrillation. J Am Coll Catheter ablation for atrial fibrillation with heart
Cardiol. 2020;75(25):3122-3135. doi:10.1016/j.jacc. failure. N Engl J Med. 2018;378(5):417-427. doi:10.
1. Joglar JA, Chung MK, Armbruster AL, et al. 2023 2020.04.067 1056/NEJMoa1707855
ACC/AHA/ACCP/HRS guideline for the diagnosis

E2 JAMA Published online November 14, 2024 (Reprinted) jama.com

© 2024 American Medical Association. All rights reserved, including those for text and data mining, AI training, and similar technologies.
Downloaded from jamanetwork.com by guest on 11/14/2024