Prognia
Back to Guidelines
American Heart AssociationCardiology2023advanced

Management of Patients With Atrial Fibrillation

Published by American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines · ACC/AHA Class of Recommendation and Level of Evidence

30Tables
28Figures
Read Full Guideline

Summary

AI-generated

This guideline provides comprehensive, evidence-based recommendations for the diagnosis and management of atrial fibrillation. It emphasizes a new staging classification, lifestyle and risk factor modifications, stroke risk assessment, and strategies for both rate and rhythm control.

atrial fibrillationACC/AHAHRScardiologyguidelinesrate controlrhythm controlcatheter ablation

Key Takeaways

  • 1
    Stages of atrial fibrillation (AF): The new proposed classification, using stages, recognizes AF as a disease continuum.
  • 2
    AF risk factor modification and prevention: This guideline recognizes lifestyle and risk factor modification as a pillar of AF management.
  • 3
    Flexibility in using clinical risk scores and expanding beyond CHA2DS2-VASc for prediction of stroke and systemic embolism.
  • 4
    Consideration of stroke risk modifiers: Patients with AF at intermediate to low (<2%) annual risk of ischemic stroke can benefit from consideration of stroke risk modifiers.
  • 5
    Early rhythm control: This guideline emphasizes the importance of early and continued management of patients with AF focusing on maintaining sinus rhythm.
  • 6
    Catheter ablation of AF receives a Class 1 indication as first-line therapy in selected patients.
  • 7
    Catheter ablation of AF in appropriate patients with heart failure with reduced ejection fraction receives a Class 1 indication.
  • 8
    Recommendations have been updated for device-detected AF, providing more prescriptive recommendations.
  • 9
    Left atrial appendage occlusion devices receive higher level Class of Recommendation (upgraded to 2a).
  • 10
    Recommendations are made for patients with AF identified during medical illness or surgery (precipitants).

What's New in This Version

Introduced a new classification of AF by stages as a disease continuum; emphasized early rhythm control and lifestyle risk factor modification (LRFM); upgraded catheter ablation to a Class 1 recommendation for first-line therapy in select patients and those with HFrEF; upgraded left atrial appendage occlusion (LAAO) devices to a Class 2a recommendation; provided updated guidance on device-detected AF and AF discovered during acute medical illness/surgery.

Key Recommendations

4.2.1. Basic Clinical Evaluation

  • rec_1

    In patients with newly diagnosed AF, a transthoracic echocardiogram to assess cardiac structure, laboratory testing to include a complete blood count, metabolic panel, and thyroid function, and when clinical suspicion exists, targeted testing to assess for other medical conditions associated with AF are recommended to determine stroke and bleeding risk factors, as well as underlying conditions that will guide further management.

    Class 1Evidence: B-NRDiagnostic
  • rec_2

    In patients with newly diagnosed AF, protocolized testing for ischemia, acute coronary syndrome (ACS), and pulmonary embolism (PE) should not routinely be performed to assess the etiology of AF unless there are additional signs or symptoms to indicate those disorders.

    Class 3: No benefitEvidence: B-NRDiagnostic

5.1. Primary Prevention

  • rec_3

    Patients at increased risk of AF should receive comprehensive guideline-directed LRFM for AF, targeting obesity, physical inactivity, unhealthy alcohol consumption, smoking, diabetes, and hypertension.

    Class 1Evidence: B-NRPrevention

6.1. Risk Stratification Schemes

  • rec_4

    Patients with AF should be evaluated for their annual risk of thromboembolic events using a validated clinical risk score, such as CHA2DS2-VASc.

    Class 1Evidence: B-NRRisk Assessment

6.3.1. Antithrombotic Therapy

  • rec_5

    For patients with AF and an estimated annual thromboembolic risk of ≥2% per year (eg, CHA2DS2-VASc score of ≥2 in men and ≥3 in women), anticoagulation is recommended to prevent stroke and systemic thromboembolism.

    Class 1Evidence: ATreatment
  • rec_6

    In patients with AF who do not have a history of moderate to severe rheumatic mitral stenosis or a mechanical heart valve, and who are candidates for anticoagulation, DOACs are recommended over warfarin to reduce the risk of mortality, stroke, systemic embolism, and ICH.

    Class 1Evidence: ATreatment

7.2.1. Acute Rate Control

  • rec_7

    In patients with AF with rapid ventricular response who are hemodynamically stable, beta blockers or nondihydropyridine calcium channel blockers (verapamil, diltiazem; provided that EF >40%) are recommended for acute rate control.

    Class 1Evidence: B-RTreatment

8.4. AF Catheter Ablation

  • rec_8

    In selected patients (generally younger with few comorbidities) with symptomatic paroxysmal AF in whom rhythm control is desired, catheter ablation is useful as first-line therapy to improve symptoms and reduce progression to persistent AF.

    Class 1Evidence: ATreatment

Scope & Objectives

Clinical Topic

Atrial Fibrillation

Objectives

Provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation.

Target Patient Population

Patients with or at risk of developing atrial fibrillation

Diagnostic Criteria

Irregular R-R intervals (when atrioventricular conduction is present), absence of distinct P waves, and irregular atrial activity (fibrillatory waves) documented by ECG.

Target Providers

CardiologistsCardiac ElectrophysiologistsSurgeonsPharmacistsPrimary Care Clinicians

Patient Criteria & Setting

Therapeutic Area

Cardiovascular Disease

Guideline Scope

DiagnosisManagementPrevention

Care Settings

InpatientOutpatientEmergency DepartmentCritical CareSurgical

Special Populations

Heart FailureAthletesObesityValvular Heart DiseaseAdult Congenital Heart Disease (ACHD)Hypertrophic CardiomyopathyHyperthyroidismPulmonary DiseasePregnancyCancer/Cardio-OncologyChronic Kidney DiseaseLiver Disease

Evidence Grading

System: ACC/AHA Class of Recommendation and Level of Evidence

Evidence Levels

Level AHigh-quality evidence from more than 1 RCT, meta-analyses of high-quality RCTs, or 1+ RCTs corroborated by high-quality registry studies.
Level B-R(Randomized) Moderate-quality evidence from 1 or more RCTs or meta-analyses of moderate-quality RCTs.
Level B-NR(Nonrandomized) Moderate-quality evidence from 1 or more well-designed, well-executed nonrandomized studies, observational studies, registry studies, or meta-analyses thereof.
Level C-EO(Expert Opinion) Consensus of expert opinion based on clinical experience.
Level C-LD(Limited Data) Randomized or nonrandomized observational or registry studies with limitations of design or execution, meta-analyses thereof, or physiological/mechanistic studies in human subjects.

Recommendation Strength

Class 2b (Weak)Benefit >= Risk. Suggested phrases: May/might be reasonable, may/might be considered, usefulness/effectiveness is unknown/unclear/uncertain or not well-established.
Class 1 (Strong)Benefit >>> Risk. Suggested phrases: Is recommended, is indicated/useful/effective/beneficial, should be performed/administered/other.
Class 2a (Moderate)Benefit >> Risk. Suggested phrases: Is reasonable, can be useful/effective/beneficial.
Class 3: Harm (Strong)Risk > Benefit. Suggested phrases: Potentially harmful, causes harm, associated with excess morbidity/mortality, should not be performed/administered/other.
Class 3: No Benefit (Moderate)Benefit = Risk. Suggested phrases: Is not recommended, is not indicated/useful/effective/beneficial, should not be performed/administered/other.

Safety & Contraindications

Contraindications

  • DOACs in moderate to severe rheumatic mitral stenosis or mechanical heart valves
  • Nondihydropyridine calcium channel blockers in severe LV systolic dysfunction (HFrEF)
  • Class IC agents in prior MI or significant structural heart disease
  • Dronedarone in recent decompensated heart failure or severe LV dysfunction

Monitoring Guidance

Includes routine INR monitoring for warfarin, DOAC laboratory monitoring based on renal and hepatic function, and QT interval/electrolyte monitoring for specific antiarrhythmic drugs like dofetilide, ibutilide, and sotalol.

Authors & Contributors

José A. JoglarMina K. ChungAnastasia L. ArmbrusterEmelia J. BenjaminJanice Y. ChyouEdmond M. CroninAnita DeswalLee L. EckhardtZachary D. GoldbergerRakesh GopinathannairBulent GorenekPaul L. HessMark HlatkyGail HoganChinwe IbehJulia H. IndikKazuhiko KidoFred KusumotoMark S. LinkKathleen T. LintaGregory M. MarcusPatrick M. McCarthyNimesh PatelKristen K. PattonMarco V. PerezJonathan P. PicciniAndrea M. RussoPrashanthan SandersMegan M. StreurKevin L. ThomasSabrina TimesJames E. TisdaleAnne Marie ValenteDavid R. Van Wagoner

Guideline Features

Dosing informationFlowcharts includedBased on systematic reviewMultidisciplinaryPatient involvementDrug interactions discussed

Learning Context

Difficulty

advanced

Exam Relevance

Cardiology BoardsClinical Cardiac Electrophysiology BoardsInternal Medicine Boards

Learning Paths

Atrial Fibrillation ManagementCardiologyElectrophysiologyStroke PreventionRhythm ControlRate ControlAnticoagulationCatheter Ablation