JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY VOL. -, NO.

-, 2023
ª 2023 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION
PUBLISHED BY ELSEVIER

SOCIETAL STATEMENT

2023 Atrial Fibrillation

Barbara S. Wiggins, PHARMD, FACC, on behalf of the ACC Solution Set Oversight Committee
Morgane Cibotti-Sun, MPH
Mykela M. Moore, MPH

INTRODUCTION TOP 10 TAKE-HOME MESSAGES

The 2023 ACC/AHA/ACCP/HRS Guideline for the The following Top 10 Take-Home Messages are taken
Diagnosis and Management of Atrial Fibrillation (ACC/ directly from the ACC/AHA/ACCP/HRS Atrial Fibrilla-
AHA/ACCP/HRS Atrial Fibrillation Guideline) provides tion Guideline.1 Messages in bold were selected as key
guidance for clinicians on the management of patients themes for this Guideline-at-a-Glance because they
with atrial fibrillation (AF).1 The guideline emphasizes represent the most impactful changes in these rec-
a rhythm control strategy similar to what is recom- ommendations compared with previous guidelines
mended in the most recent atrial fibrillation guideline and address known gaps in clinical practice.
from the European Society of Cardiology (ESC). 2 The 1. Stages of atrial fibrillation (AF): The previous
recommendations also highlight the need for lifestyle classification of AF, which was based only on
and risk factor modification in addition to medical arrhythmia duration, although useful, tended to
treatment. In this Guideline-at-a-Glance, practice- emphasize therapeutic interventions. The new
changing recommendations from the guideline are proposed classification, using stages, recognizes
highlighted to accelerate adoption into clinical AF as a disease continuum that requires a variety
practice. of strategies at the different stages, from pre-
The dissemination of ACC Guidelines is an vention, lifestyle and risk factor modification,
organization-wide effort overseen by the Solution Set screening, and therapy.
Oversight Committee, whose goal it is to ensure that 2. AF risk factor modification and prevention: This
guideline content is integrated throughout the ACC’s guideline recognizes lifestyle and risk factor
clinical policy, education, registry, membership, and modification as a pillar of AF management to
advocacy efforts. The clinical tools presented here are prevent onset, progression, and adverse out-
part of a larger ACC dissemination strategy to facili- comes. The guideline emphasizes risk factor
tate the implementation of key changes in practice. management throughout the disease continuum
Three of the top 10 take-home messages from the and offers more prescriptive recommendations,
ACC/AHA/ACCP/HRS Atrial Fibrillation Guideline are accordingly, including management of obesity,
presented here to provide a framework for initial weight loss, physical activity, smoking cessation,
dissemination. The 3 selected messages are focused alcohol moderation, hypertension, and other
on the new stages of atrial fibrillation (take-home comorbidities.
message 1), the importance of early rhythm control 3. Flexibility in using clinical risk scores and
(take-home message 5), and the use of catheter abla- expanding beyond CHA 2DS2-VASc for prediction
tion as first-line therapy in select patients (take-home of stroke and systemic embolism: Recommenda-
message 6). These messages are emphasized in tions for anticoagulation are now made based on
various ACC clinician tools: the JACC Central yearly thromboembolic event risk using a vali-
Illustrations, as well as comparison tables to high- dated clinical risk score, such as CHA2DS 2-VASc.
light the changes between the new ACC/AHA/ACCP/ However, patients at an intermediate annual risk
HRS Atrial Fibrillation Guideline and the previous score who remain uncertain about the benefit of
version as well as the relevant 2020 ESC guideline. anticoagulation can benefit from consideration of

ISSN 0735-1097/$36.00 https://doi.org/10.1016/j.jacc.2023.10.021

C E N T R A L IL LU ST R A T I O N ACC/AHA/ACCP/HRS Atrial Fibrillation Guideline

Wiggins BS, et al. J Am Coll Cardiol. November 30, 2023. 10.1016/j.jacc.2023.10.021.

AF ¼ atrial fibrillation.
JACC VOL. -, NO. -, 2023 Wiggins et al 3
-, 2023:-–- 2023 Atrial Fibrillation Guideline-at-a-Glance

TABLE 1 Select Differences Between the 2014/2019 Guidelines and the 2023 ACC/AHA/ACCP/HRS Atrial Fibrillation Guideline

2014/2019 5,8 2023 1

Stages of atrial AF is defined in 5 terms: Atrial arrhythmia progression is split up into 4 stages:
fibrillation n Paroxysmal AF 1. At risk for AF
n Persistent AF 2. Pre-AF (evidence of structural or electrical findings pre-
n Long-standing persistent AF disposing a patient to AF)
n Permanent AF 3. AF (including paroxysmal, persistent, long-standing
n Nonvalvular AF persistent, and successful AF ablation)
Each term is defined in Table 4. Definitions 4. Permanent AF
of AF: A Simplified Scheme. Each stage is defined in Figure 4. AF Stages: Evolution of Atrial
Arrhythmia Progression, and special considerations across
stages are listed, including treating modifiable risk factors
throughout the entire atrial arrythmia progression.

Early rhythm control A heart rate control (resting heart rate <80 beats/min) strategy In patients with reduced LV function and persistent (or high
is reasonable for symptomatic management of AF (COR 2a). burden) AF, a trial of rhythm control should be recommended
to evaluate whether AF is contributing to the reduced LV
function (COR 1).

Catheter ablation of AF In patients with recurrent symptomatic paroxysmal AF, catheter In selected patients (generally younger with few comorbidities)
as first-line therapy in ablation is a reasonable initial rhythm-control strategy before with symptomatic paroxysmal AF in whom rhythm control is
selected patients therapeutic trials of antiarrhythmic drug therapy, after weighing desired, catheter ablation is useful as first-line therapy to
the risks and outcomes of drug and ablation therapy (COR 2a). improve symptoms and reduce progression to persistent AF
(COR 1).

Colors in the table align with the classification system found in Table 2, “Applying American College of Cardiology/American Heart Association Class of Recommendation and Level of
Evidence to Clinical Strategies, Interventions, Treatments, or Diagnostic Testing in Patient Care” in the 2023 ACC/AHA/ACCP/HRS Atrial Fibrillation Guideline.1
ACC ¼ American College of Cardiology; AF ¼ atrial fibrillation; AHA ¼ American Heart Association; COR ¼ Class of Recommendation; LV ¼ left ventricular.

other risk variables to help inform the decision, or the 8. Recommendations have been updated for device-
use of other clinical risk scores to improve prediction, detected AF: In view of recent studies, more pre-
facilitate shared decision making, and incorporate scriptive recommendations are provided for patients
into the electronic medical record. with device-detected AF that consider the interaction
4. Consideration of stroke risk modifiers: Patients with between episode duration and the patient’s underly-
AF at intermediate to low (<2%) annual risk of ing risk for thromboembolism. This includes consid-
ischemic stroke can benefit from consideration of erations for patients with AF detected via implantable
factors that might modify their risk of stroke, such as devices and wearables.
the characteristics of their AF (eg, burden), non- 9. Left atrial appendage occlusion devices receive higher
modifiable risk factors (sex), and other dynamic or level Class of Recommendation: In view of additional
modifiable factors (blood pressure control) that may data on safety and efficacy of left atrial appendage
inform shared decision-making discussions. occlusion devices, the Class of Recommendation has
5. Early rhythm control: With the emergence of new been upgraded to 2a compared with the 2019 AF
and consistent evidence, this guideline emphasizes Focused Update for use of these devices in patients
the importance of early and continued management with long-term contraindications to anticoagulation.
of patients with AF that should focus on maintaining 10. Recommendations are made for patients with AF
sinus rhythm and minimizing AF burden. identified during medical illness or surgery (pre-
6. Catheter ablation of AF receives a Class 1 indication cipitants): Emphasis is made on the risk of recurrent
as first-line therapy in selected patients: Recent AF after AF is discovered during noncardiac illness or
randomized studies have demonstrated the superi- other precipitants, such as surgery.
ority of catheter ablation over drug therapy for
rhythm control in appropriately selected patients. In
view of the most recent evidence, we upgraded the JACC ILLUSTRATIONS
Class of Recommendation.
7. Catheter ablation of AF in appropriate patients with Central Illustration: Management Strategies for New
heart failure with reduced ejection fraction receives a Classification of Atrial Fibrillation
Class 1 indication: Recent randomized studies have An important message of the most recent guideline is the
demonstrated the superiority of catheter ablation new classification system of AF. The previous classifica-
over drug therapy for rhythm control in patients with tion system was based on arrythmia duration and focused
heart failure and reduced ejection failure. In view of primarily on therapeutic interventions. The new classifi-
the data, we upgraded the Class of Recommendation cation identifies AF as a disease continuum that requires a
for this population of patients. variety of strategies at different stages—from prevention
4 Wiggins et al JACC VOL. -, NO. -, 2023
2023 Atrial Fibrillation Guideline-at-a-Glance -, 2023:-–-

TABLE 2 AF Classification and Treatment Strategies: Select Comparison of ACC/AHA/ACCP/HRS Guideline and ESC Guideline

ESC Guideline 2 ACC/AHA/ACCP/HRS Guideline 1

Stages of AF Classification of AF split up into 5 AF patterns: Atrial arrhythmia progression is split up into 4 stages:
n First diagnosed 1. At risk for AF
n Paroxysmal 2. Pre-AF (evidence of structural or electrical findings predisposing
n Persistent a patient to AF)
n Long-standing persistent 3. AF (including paroxysmal, persistent, long-standing persistent,
n Permanent and successful AF ablation)
Each stage is split up according to pattern of AF 4. Permanent AF
and risk factors are not included. Each stage is defined in Figure 4. AF Stages: Evolution of Atrial
Arrhythmia Progression, and special considerations across stages are
listed, including treating modifiable risk factors throughout the entire
atrial arrythmia progression.

Early rhythm control Rhythm control therapy is recommended for symptom In patients with reduced LV function and persistent (or high burden) AF,
and QoL improvement in symptomatic patients with AF a trial of rhythm control should be recommended to evaluate whether
(COR 1). AF is contributing to the reduced LV function (COR 1).

Catheter ablation of AF AF catheter ablation for PVI should/may be considered as In selected patients (generally younger with few comorbidities) with
as first line therapy in first-line rhythm control therapy to improve symptoms symptomatic paroxysmal AF in whom rhythm control is desired,
selected patients in selected patients with symptomatic: paroxysmal AF catheter ablation is useful as first-line therapy to improve symptoms
episodes (COR 2a). and reduce progression to persistent AF (COR 1).
.or persistent AF without major risk factors for AF
recurrence (COR 2b), as an alternative to AAD class I or III,
considering patient choice, benefit, and risk.

Colors in the table align with the classification system found in Table 2, “Applying American College of Cardiology/American Heart Association Class of Recommendation and Level of
Evidence to Clinical Strategies, Interventions, Treatments, or Diagnostic Testing in Patient Care,” in the 2023 ACC/AHA/ACCP/HRS Atrial Fibrillation Guideline.1
AAD ¼ antiarrhythmic drug; ACC ¼ American College of Cardiology; AF ¼ atrial fibrillation; AHA ¼ American Heart Association; COR ¼ Class of Recommendation; ESC ¼ European
Society of Cardiology; LV ¼ left ventricular; PVI ¼ pulmonary vein isolation; QOL ¼ quality of life.

to lifestyle and risk factor modification, screening, and understanding which patients are more likely to benefit
therapy. This new classification system parallels the idea from catheter ablation as first-line therapy for rhythm
of disease continuum in other guidelines3,4 with a goal to control. The tool is accessible at https://www.jacc.org/
prevent the progression of AF. guidelines/AtrialFibrillation/interactive.
The JACC Central Illustration for the ACC/AHA/ACCP/ This interactive clinician tool focuses on Take-Home
HRS Atrial Fibrillation Guideline focuses on the impor- Messages 5, 6, and 7 and represents a change in clinical
tance of AF as a disease continuum in the new classifi- practice. Within the interactive tool, clinicians can select
cation system of AF. This clinician tool focuses on Top 10 groupings of clinical variables that best describe the pa-
Take-Home Message 1 and aims to change clinical prac- tient. The corresponding guideline recommendations are
tice. The educational tool is intended to communicate presented to help determine if the selected clinical vari-
information quickly and memorably from the guideline, ables favor a rhythm or rate control strategy and if the
especially related to modifiable risk factors that must be patient is likely to benefit from catheter ablation as first-
treated throughout atrial arrythmia progression. For line therapy. Within the interactive tool, clinicians can
additional information, see Section 2.2.1 of the guideline, select groups of clinical variables to help understand their
“AF classification.” 1 impact on recommendations for treatment.
For additional information, see the guideline Section
Interactive Illustration: Catheter Ablation as First-Line Therapy 8.4, “AF Catheter Ablation,” Section 9.2, “Management of
for Rhythm Control AF in Patients With Heart Failure,” and Section 8.1, “Goals
of Therapy With Rhythm Control.” 1
Another important message of the guideline is the supe-
riority of catheter ablation over pharmacologic therapy COMPARISON TO PREVIOUS ACC/AHA/ACCP/
for rhythm control in select patients. The guideline HRS GUIDELINES
updated the Class of Recommendation from a 2a (mod-
erate) in the 2014 AHA/ACC/HRS Atrial Fibrillation The scope of the ACC/AHA/ACCP/HRS Atrial Fibrillation
Guideline 5 to a Class of Recommendation 1 (strong) in Guideline 1 includes and updates content previously
1
2023. Evidence from the EARLY-AF (Early Aggressive covered in 2 other guidelines.5,8 Table 1 outlines changes
6
Invasive Intervention for Atrial Fibrillation) and STOP AF on the classification of AF, rhythm control strategies, and
First (Cryoballoon Catheter Ablation in an Antiarrhythmic catheter ablation between the 2019 AHA/ACC/HRS
Drug Naive Paroxysmal Atrial Fibrillation)7 trials are the Focused Update of the 2014 AHA/ACC/HRS Guideline for
foundation for this change. the Management of Patients With Atrial Fibrillation
The JACC Interactive Illustration for the AHA/ACC/ and the 2023 ACC/AHA/ACCP/HRS Atrial Fibrillation
ACCP/HRS Atrial Fibrillation Guideline focuses on Guideline.
JACC VOL. -, NO. -, 2023 Wiggins et al 5
-, 2023:-–- 2023 Atrial Fibrillation Guideline-at-a-Glance

Information for Table 1 can be found in the following atrial fibrillation.2 The comparison table is focused on Top
2023 ACC/AHA/ACCP/HRS Atrial Fibrillation Guideline 10 Take-Home Messages 1, 5, and 6.
sections: Information for Table 2 can be found in the following
2023 ACC/AHA/ACCP/HRS Atrial Fibrillation Guideline
 Stages of atrial fibrillation (Top 10 Take-Home Message
sections:
1): Section 2.2.1, “AF Classification”;
 Recommendations for early rhythm control (Top 10  Section 2.2.1, “AF Classification”;
Take-Home Message 5): Section 8.1, “Goals of Therapy  Section 8.1, “Goals of Therapy with Rhythm Control”;
with Rhythm Control”;  Section 8.4, “AF Catheter Ablation.”
 Recommendations for catheter ablation of AF as first
Information can also be found in the following 2020
line therapy in selected patients (Top 10 Take Take-
ESC Atrial Fibrillation Guideline sections:
Home Message 6): Section 8.4, “AF Catheter
Ablation.”  Section 6.1, “Classification of Atrial Fibrillation”;
 Section 10.2.2, “Rhythm Control”;
 Section 10.2, “‘B’-Better Symptom Control.”
ACC/AHA/ACCP/HRS GUIDELINE COMPARISON
TO ESC GUIDELINE ACKNOWLEDGMENTS The authors thank the ACC Solu-
tion Set Oversight Committee: Nicole M. Bhave, MD,
The ESC published an atrial fibrillation clinical practice FACC, Chair; Niti R. Aggarwal, MD, FACC; Katie Bates,
guideline in 2020. Table 2 highlights the subtle differ- ARNP, DNP; Biykem Bozkurt, MD, PhD, FACC; John P.
ences in classification, rhythm vs rate control, and cath- Erwin III, MD, FACC; Dharam J. Kumbhani, MD, SM,
eter ablation recommendations between the 2023 ACC/ FACC; Gurusher S. Panjrath, MBBS, FACC; David E.
AHA/ACCP/HRS Atrial Fibrillation Guideline 1 and the Winter, MD, MS, FACC; Megan Coylewright, MD, MPH,
2020 ESC guidelines for the diagnosis and management of FACC—Ex Officio.

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