The "2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation" provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation.A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate.Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" and the "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed. 

2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines.

Atrial fibrillation (AF) is the most common cardiac arrhythmia despite substantial efforts to understand the pathophysiology of the condition and develop improved treatments. Identifying the underlying causative mechanisms of AF in individual patients is difficult and the efficacy of current therapies is suboptimal. Consequently, the incidence of AF is steadily rising and there is a pressing need for novel therapies. Research has revealed that defects in specific molecular pathways underlie AF pathogenesis, resulting in electrical conduction disorders that drive AF. The severity of this so-called electropathology correlates with the stage of AF disease progression and determines the response to AF treatment. Therefore, unravelling the molecular mechanisms underlying electropathology is expected to fuel the development of innovative personalized diagnostic tools and mechanism-based therapies. Moreover, the co-creation of AF studies with patients to implement novel diagnostic tools and therapies is a prerequisite for successful personalized AF management. Currently, various treatment modalities targeting AF-related electropathology, including lifestyle changes, pharmaceutical and nutraceutical therapy, substrate-based ablative therapy, and neuromodulation, are available to maintain sinus rhythm and might offer a novel holistic strategy to treat AF. Atrial fibrillation (AF) is the most common cardiac arrhythmia and is increasing in prevalence as populations age. This Primer provides an overview of AF epidemiology, the mechanisms underlying electropathology in AF, and the diagnostic approaches and treatments, and highlights important directions to improve understanding and management of AF in co-creation with patients. 

Atrial fibrillation

The “2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Patients With Atrial Fibrillation” provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation. A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate. Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the “2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation” and the “2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation” have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed. 

2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines.

Importance Early-onset atrial fibrillation (AF) can be the initial manifestation of a more serious underlying inherited cardiomyopathy or arrhythmia syndrome. Objective To examine the results of genetic testing for early-onset AF. Design, Setting, and Participants This prospective, observational cohort study enrolled participants from an academic medical center who had AF diagnosed before 66 years of age and underwent whole genome sequencing through the National Heart, Lung, and Blood Institute’s Trans-Omics for Precision Medicine program. Participants were enrolled from November 23, 1999, to June 2, 2015. Data analysis was performed from October 24, 2020, to March 11, 2021. Exposures Rare variants identified in a panel of 145 genes that are included on cardiomyopathy and arrhythmia panels used by commercial clinical genetic testing laboratories. Main Outcomes and Measures Sequencing data were analyzed using an automated process followed by manual review by a panel of independent, blinded reviewers. The primary outcome was classification of rare variants using American College of Medical Genetics and Genomics criteria: benign, likely benign, variant of undetermined significance, likely pathogenic, or pathogenic. Disease-associated variants were defined as pathogenic/likely pathogenic variants in genes associated with autosomal dominant or X-linked dominant disorders. Results Among 1293 participants (934 [72.2%] male; median [interquartile range] age at enrollment, 56 [48-61] years; median [interquartile range] age at AF diagnosis, 50 [41-56] years), genetic testing identified 131 participants (10.1%) with a disease-associated variant, 812 (62.8%) with a variant of undetermined significance, 92 (7.1%) as heterozygous carriers for an autosomal recessive disorder, and 258 (20.0%) with no suspicious variant. The likelihood of a disease-associated variant was highest in participants with AF diagnosed before the age of 30 years (20 of 119 [16.8%; 95% CI, 10.0%-23.6%]) and lowest after the age of 60 years (8 of 112 [7.1%; 95% CI, 2.4%-11.9%]). Disease-associated variants were more often associated with inherited cardiomyopathy syndromes compared with inherited arrhythmias. The most common genes wereTTN(n = 38),MYH7(n = 18),MYH6(n = 10),LMNA(n = 9), andKCNQ1(n = 8). Conclusions and Relevance In this cohort study, genetic testing identified a disease-associated variant in 10% of patients with early-onset AF (the percentage was higher if diagnosed before the age of 30 years and lower if diagnosed after the age of 60 years). Most pathogenic/likely pathogenic variants are in genes associated with cardiomyopathy. These results support the use of genetic testing in early-onset AF.

/pdf/early-onset-atrial-fibrillation-and-the-prevalence-of-rare-3q8ub7sicq.pdf

Early-Onset Atrial Fibrillation and the Prevalence of Rare Variants in Cardiomyopathy and Arrhythmia Genes

Background: Epidemiological studies have established obesity as an independent risk factor for atrial fibrillation (AF), but the underlying pathophysiological mechanisms remain unclear. Reduced car...

https://www.ahajournals.org/doi/pdf/10.1161/CIRCEP.120.008296?download=true

Ion Channel and Structural Remodeling in Obesity-Mediated Atrial Fibrillation.

Prevalence of disease-associated cardiomyopathy gene variants in ethnic minorities with atrial fibrillation

Introduction: Atrial fibrillation (AF) guidelines rely on the severity of symptoms experienced by patients to select a rate or rhythm control treatment strategy. While the severity of symptoms is v...

Abstract 16130: Race-Ethnicity Modulates Atrial Fibrillation Symptom Burden and Quality of Life

Clinical characteristics including family history between early-onset and late-onset lone atrial flutter across race-ethnicity


 Introduction:
 Studies in Whites of European descent have shown that atrial fibrillation (AF) have a strong genetic component especially in probands with early-onset (EO) AF. However, the role of family history in the pathogenesis of EO atrial flutter (EOAFL) across race-ethnicity remains unclear. Here, we sought to determine if African American, European American, and Hispanic/Latino probands with EOAFL have a higher rate of arrhythmia recurrence in first-degree family members than ethnically-matched patients with late-onset AFL (LOAFL).
 
 
 Methods:
 In this cohort study, 917 adults with AFL were identified between 2015 and 2021 across 3 sites in the Chicagoland area. EOAFL was defined as AFL occurring before 60 years of age. Primary analysis of reported family history in first-degree relatives with sensitivity analysis restricted to those in whom a family history was confirmed by medical record review and electrocardiogram was done.
 
 
 Results:
 Those with EOAFL were more overweight, Black or White, and had more comorbidities (
 Table 1
 ). Multivariate analysis showed that BMI ≥ 40 kg/m
 2
 (odds ratio [OR]: 5.4; 95% confidence interval [CI]: 3.2-9.4,
 p
 <0.001) and a family history (OR: 3.7; 95% CI: 2.1-6.9,
 P
 <0.001) carried the highest adjusted odds of EOAFL followed by alcohol use (OR: 2.1; 95% CI: 1.5-3.0,
 P
 <0.001), Black race (OR: 1.6; 95% CI: 1.1-2.3,
 P
 =0.021), and heart failure (OR: 1.4; 95% CI: 1-1.9,
 P
 =0.03). Adjusting for effect modification on the association of family history and race, among Whites, the odds of EOAFL in patients with family history was 6.1 (95% CI: 2.1-22.3,
 P
 =0.002) comparative to those with no family history, and among Blacks, it was 4.9 (95% CI: 1.6-6.1,
 P
 =0.021).
 
 
 Conclusion:
 Obesity and family history were strongly associated with EOAFL. Whites with EOAFL were more likely to have a first-degree relative with AF/AFL when compared to Blacks or Hispanics/Latinos. These findings support genetic predisposition to EOAFL across all 3 races.
 
 
 


Abstract 12110: The Multi-Racial Clinical and Familial Characteristics of Early and Late Onset Atrial Flutter

Association between smoking history and response to anti-arrhythmic therapy in atrial fibrillation patients across race-ethnicity

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