Atrial fibrillation.

# Atrial fibrillation *The Lancet 2026* Seminar Atrial fibrillation Deirdre A Lane, Jason G Andrade, Elena Arbelo, Giuseppe Boriani, Jeroen M Hendriks, So-Ryoung Lee, Gregory Y H Lip, Jonathan Mant, Melissa E Middeldorp Lancet 2026; 407: 1000–13 Atrial fibrillation affects approximately 37·6 million people worldwide, with the prevalence predicted to double over the Department of Cardiovascular next 35 years. The ubiquitous use of wearable devices and other technologies with inbuilt diagnostic algorithms allows and Metabolic Medicine, greater detection of atrial fibrillation among the general public than previously. Atrial fibrillation increases the risk of Institute of Life Course and stroke and thromboembolism, heart failure, and death, and is associated with reductions in quality of life. Patients with Medical Sciences, University of atrial fibrillation frequently have comorbidities, and the accumulation of risk factors, including lifestyle factors Liverpool, Liverpool, UK (Prof D A Lane PhD, associated with poorer health outcomes, and increasing age, often adds to the complexity of managing such patients. All Prof G Y H Lip MD); Liverpool major clinical guidelines advocate that stroke prevention, symptom relief, identification of risk factors, and optimisation Centre for Cardiovascular of risk factor management, incorporated into an integrated care approach, with multidisciplinary input as required, are Sciences, University of essential elements of atrial fibrillation management. Avoidance of stroke with oral anticoagulation remains the default Liverpool, Liverpool John Moores University and for most patients with atrial fibrillation and, more recently, catheter ablation has been reconsidered as an initial Liverpool Heart and Chest treatment option for symptom relief. The dynamic nature of risk factors requires early identification and appropriate Hospital, Liverpool, UK management of new and existing risk factors to optimise atrial fibrillation care. Patient-centred care and better health (Prof D A Lane, Prof G Y H Lip); literacy can empower patients to take a more active role in their atrial fibrillation management. Department of Clinical Medicine, Aalborg University, Aalborg, Denmark Introduction with atrial fibrillation affects quality of life. The cost of (Prof D A Lane, Prof G Y H Lip); Atrial fibrillation is a common cardiac arrhythmia atrial fibrillation varies substantially by country and Centre for Cardiovascular characterised by an irregular heart rhythm. Globally, an health-care system. In Europe, atrial fibrillation has been Innovation, Vancouver General Hospital, Vancouver, BC, estimated 37·6 million people have atrial fibrillation, estimated to account for 1–2% of total health-care Canada (J G Andrade MD); with a projected doubling in prevalence by 2060 resulting expenditure, with a median annual direct medical cost of Montreal Heart Institute, from increasing longevity, higher awareness and better €9409 per patient, mainly due to hospitalisations.3 Université de Montréal, Montreal, QC, Canada detection by means of wearable devices and other Associated comorbidities and risk factors are (J G Andrade); Arrhythmia innovative technology, and greater burden of risk factors important drivers of atrial fibrillation onset and Section, Cardiology (ie, comorbidities and lifestyle factors).1 Approximately progression. The central tenets of atrial fibrillation Department, Hospital Clínic, one in three people are expected to develop atrial management are stroke prevention, symptom control, Universitat de Barcelona, Barcelona, Spain fibrillation over the course of their lives.2 Women have a and comorbidity and risk factor optimisation. However, (Prof E Arbelo PhD); Institut lower age-adjusted risk than men and prevalence is the focus of recent European guidelines has shifted to d’Investigació August Pi i greater in White populations than in non-White initially prioritise comorbidity and risk factor Sunyer, Barcelona, Spain populations, and among those with more risk factors.2 management (as with all cardiovascular disorders) (Prof E Arbelo); Centro de Investigación Biomédica en Atrial fibrillation is associated with high rates of via the AF-CARE approach and timely identification and Red de Enfermedades hospitalisation and increased risk of stroke and other re-evaluation of individual risk, with renewed emphasis Cardiovasculares, Madrid, thromboembolic events, heart failure, cognitive on empowering patients to actively engage in managing Spain (Prof E Arbelo); European impairment and dementia, and death. Atrial fibrillation- their health.4 Reference Network for Rare and Low Prevalence and related morbidity, including symptom burden and The AF-CARE framework aligns with other global Complex Diseases of the Heart, severity, and the likelihood of multimorbidity in patients guidelines that have promoted a holistic treatment Barcelona, Spain (Prof E Arbelo); approach, such as the Atrial Fibrillation Better Care Cardiology Division, (ABC) pathway5 (ie, anticoagulation for stroke prevention, Department of Biomedical Metabolic and Neural Sciences, Search strategy and study selection criteria symptom management with rate or rhythm control, and University of Modena and management of cardiovascular comorbidities and For the literature review for this Seminar, we searched Reggio Emilia, Modena, Italy PubMed and Embase for international guidelines, meta- lifestyle factors) and the SOS6 approach (ie, stroke (Prof G Boriani PhD); prevention, management of other comorbidities, and Department of Nursing, analyses, and landmark clinical trials published between Maastricht University Medical Jan 10, 2010, and Sept 30, 2025. Priority for inclusion was rate or rhythm control; figure 1). Only the ABC pathway Centre, Maastricht, given to high-quality evidence, including systematic reviews, is currently supported by trial and real-world evidence.13,14 Netherlands This Seminar provides a comprehensive overview of (Prof J M Hendriks PhD); large cohort studies, and consensus statements from leading the latest advances in the detection and management of Department of Health Services professional societies. Only articles published in English and Research, Care and Public pertaining to humans were considered. The selection of atrial fibrillation, with a view to supporting health-care Health Research Institute, professionals in delivering guideline-adherent care and studies and guidelines was based on relevance, Maastricht University, improving patients outcomes. Although many of the Maastricht, Netherlands methodological quality, and clinical impact (as per the described associations are supported by large-scale (Prof J M Hendriks); Centre for opinion of the authors) with the aim of providing a Heart Rhythm Disorders, comprehensive and up-to-date overview for clinicians. As this observational studies, the overall level of evidence in University of Adelaide, some areas remains moderate, and conclusions should is a narrative review, a formal systematic review protocol was Adelaide, SA, Australia be interpreted considering potential residual (Prof J M Hendriks, not used. confounding and study design limitations. M E Middeldorp PhD); 1000 Seminar Presentation and diagnosis of atrial fibrillation Atrial fibrillation can present with symptoms such as ABC5 SOS6 AF-CARE4 palpitations, shortness of breath, fatigue, chest pain, syncope, or dizziness. The first presentation can be A S C accompanied by stroke, transient ischaemic attack, or Avoid stroke Stroke risk—assess and treat Comorbidity and risk factor heart failure. Diagnosis requires confirmation with a management 12-lead electrocardiogram (ECG), the gold standard investigation, which shows absence of P waves and B O A irregular RR intervals.4 However, a 12-lead ECG is unlikely Better symptom control Optimise all modifiable Avoid stroke and risk factors thromboembolism to detect paroxysmal atrial fibrillation, which is intermittent and usually spontaneously terminates within 48 h. If paroxysmal atrial fibrillation is suspected, further C S R investigation is required by use of other ECG monitoring Cardiovascular and other Symptom management Reduce symptoms by rate comorbidities (risk factors) and rhythm control devices (eg, ambulatory ECG monitor, event recorder, management ECG patch monitor, or hand-held single lead ECGs); single-lead ECGs can be difficult to read accurately.15 Atrial fibrillation can also be diagnosed in the absence of E Evaluation and dynamic symptoms, either through screening, case finding, or self- reassessment diagnosis with wearable devices. The prognostic significance of atrial fibrillation detected by means of Guidelines Guidelines Guidelines wearable devices is yet to be established, as stroke risk ACCP (2018),7 ESC (2020),8 ACC/AHA/ACCP/HRS (2023)6 ESC (2024)4 appears to be associated with atrial fibrillation burden (ie, APHRS (2021),9 China (2024),10 RCT evidence RCT evidence the amount of time a person is in atrial fibrillation), and a and KHRS (2018)11 None None RCT evidence continuously worn device will detect low burden atrial mAF-II (2020),12 fibrillation.16 Therefore, the utility of oral anticoagulation MIRACLE-AF (2025)13 for people with atrial fibrillation detected with a wearable Stroke prevention Symptom management Comorbidity and risk factor management device remains to be established. Evaluation and dynamic reassessment Evidence Figure 1: Atrial fibrillation management frameworks Screening for atrial fibrillation ABC=Atrial Fibrillation Better Care pathway. ACC=American College of Cardiology. ACCP=American College of Given the strong association between stroke and atrial Chest Physicians. AHA=American Heart Association. APHRS=Asia Pacific Heart Rhythm Society. ESC=European fibrillation and the effectiveness of oral anticoagulation in Society of Cardiology. HRS=Heart Rhythm Society. KHRS=Korean Heart Rhythm Society. RCT=randomised controlled trial. SOS=stroke risk, optimise risk factor management, and symptom management. reducing stroke risk,17 European guidelines4 recommend screening for atrial fibrillation during health-care visits for everyone 65 years or older, and prolonged screening (ie, fibrillation reduces stroke risk. Factors contributing to Department of Internal 72 h or longer) if the person has additional risk factors for this uncertainty include low power, exacerbated by lower- Medicine, Seoul National atrial fibrillation, or is 75 years or older. Although single- than-anticipated stroke rates, low uptake of screening,21 University Hospital, Seoul, South Korea (S-R Lee PhD); timepoint screening has been shown to be effective in and low initiation of oral anticoagulants.22 Larger trials (~ Department of Internal detecting new-onset atrial fibrillation when compared with 82 000 participants) are underway,23 which will hopefully Medicine, Seoul National usual care in the SAFE trial,18 this effectiveness has not provide additional clarity. University College of Medicine, Seoul, South Korea (S-R Lee); been confirmed by more recent trials (appendix pp 2–3).19 Primary Care Unit, Department The most likely explanation for the negative results of Detection and management of subclinical atrial of Public Health & Primary Care, contemporary studies is that more atrial fibrillation fibrillation University of Cambridge, detection is now done in routine care than when the SAFE Cardiac implantable electronic devices with atrial sensing Cambridge, UK (Prof J Mant MD) trial was conducted in 2000–03. In the control groups of (eg, pacemakers, implantable cardioverter-defibrillators, Correspondence to: recent trials, detection of atrial fibrillation varied between cardiac resynchronisation therapy devices, and implantable Prof Deirdre Lane, Department of Cardiovascular and Metabolic 1·37% and 1·59%,20,21 compared with 1·04% in the SAFE loop recorders) can detect atrial tachyarrhythmias through Medicine, Institute of Life Course trial.18 To the best of our knowledge, no trials of single- continuous monitoring.24,25 The term atrial high-rate and Medical Sciences, University timepoint screening have been done to establish whether episodes refers to atrial tachyarrhythmias detected by of Liverpool, Liverpool L7 8TX, UK this screening method has an effect on stroke. Therefore, cardiac implantable electronic devices diagnostics in a deirdre.lane@liverpool.ac.uk such screening is not recommended by national screening patient with no history or symptoms of atrial fibrillation, See Online for appendix committees. and absence of atrial fibrillation on 12-lead ECG, if noise or In contrast to single-timepoint screening, there is artifacts are excluded by analysis of device memory.8 The strong trial evidence that prolonged screening can detect term subclinical atrial fibrillation has been widely used more atrial fibrillation than usual care, at least in the synonymously.26 In 2024, the term device-detected short term (ie, within 1 year of screening; appendix subclinical atrial fibrillation was proposed for atrial pp 2–3). Collectively, these studies20,21 do not give a clear fibrillation detected by cardiac implantable electronic answer as to whether prolonged screening for atrial devices and consumer-based wearable monitors.4 Seminar Up to 30% of patients with a cardiac implantable and CHADS₂-65 is mainly used in Canada. In a electronic device can present with atrial high-rate episodes subanalysis of ARTESiA, the risk–benefit ratio of of 5–6 min duration or longer, especially those aged anticoagulation was positive in patients with a 65 years or older.27 Atrial high-rate episodes are associated CHA₂DS₂-VASc score of more than 4,33 in those with with an approximately doubled risk of stroke (compared previous transient ischaemic attack or stroke,34 and in with the five-fold increase associated with clinical atrial those with vascular disease according to a combined fibrillation), with an annual risk of stroke or ARTESiA–NOAH-AFNET 6 analysis (appendix pp 4–5).35 thromboembolism of 1·24–1·50% per patient-year, Additionally, decision making should consider the reported in the control group of recent trials.26,28,29 Two dynamicity of atrial fibrillation, given that progression to randomised controlled trials (RCTs), ARTESiA and clinical atrial fibrillation or long-duration atrial high-rate NOAH-AFNET 6,28,29 assessed the risk–benefit of oral episodes occurs in around 10% of patients annually anticoagulation in subclinical atrial fibrillation or atrial worldwide.26,36 Advanced age, male sex, left atrial dilatation, high-rate episodes (appendix pp 4–5). The two RCTs and clinical factors such as heart failure, diabetes, and a differed in several aspects, including the duration of atrial duration of atrial high-rate episodes or device-detected high-rate episodes for study enrolment, primary endpoint, atrial fibrillation of more than 1 h are associated with an and control group treatment. Results were positive in increased risk of progression from subclinical to clinical ARTESiA,28 whereas NOAH-AFNET 6 was terminated atrial fibrillation or long duration episodes and should prematurely for futility and safety concerns over bleeding therefore be taken into account in decision making for risk.29 However, the study-level meta-analysis30 clearly prophylactic anticoagulation.37 showed that oral anticoagulation reduced risk of ischaemic stroke by 32% (relative risk [RR] 0·68 [95% CI 0·50–0·92]). Prevention of stroke and thromboembolism In both studies, oral anticoagulation significantly Stroke prevention is one of the pillars of atrial fibrillation increased major bleeding (1·62 [1·05–2·50]),30 a finding management. Guidelines globally recommend oral that should be evaluated from a risk–benefit perspective, anticoagulation for patients who are at moderate-to-high taking into account that fatal bleeding and deaths were not risk of stroke (appendix pp 6–7). The risk of stroke in increased by oral anticoagulation and that disabling or patients with atrial fibrillation is heterogenous and fatal strokes (43% incidence in control group) were halved dependent on the presence of stroke risk factors, the by apixaban in ARTESiA (appendix pp 4–5).28,30 Accordingly, most common and validated of which have been used to oral anticoagulation should be considered in patients with formulate risk-stratification scores. The most widely atrial high-rate episodes or subclinical atrial fibrillation, used score is CHA₂DS₂-VASc. Some contemporary with shared decision making, considering the patient evidence from Europe reported that the female–male profile and the CHA₂DS₂-VA or CHA₂DS₂-VASc scores, differential in stroke risk is non-significant;38 hence the or CHADS₂-65.4,31,32 CHA₂DS₂-VASc is globally accepted, CHA₂DS₂-VA score has been proposed (figure 2). CHA₂DS₂-VA is endorsed by 2024 European guidelines, However, European data might not reflect all populations Stroke risk factors Bleeding risk factors CHADS-VASc or Modifiable risk factors* Potentially modifiable risk Non-modifiable bleeding Biomarkers 2 2 CHADS-VA score factors* risk factors 2 2 • Congestive heart failure (1) • Uncontrolled hypertension • Severe frailty or high falls • Age >65 years • GDF-15 • Hypertension (1) or elevated systolic blood risk¶ • Previous major bleeding • Markers of renal function • Age ≥75 years (2) pressure • Suboptimal vitamin K • End-stage kidney disease (eg, cystatin C, eGFR) • Diabetes (1) • Poor international antagonist management requiring dialysis or renal • High-sensitivity cardiac • Stroke, thromboembolism, normalised ratio control (ie, • Anaemia replacement therapy troponin T or transient ischaemic <2·0 or >3·0) and time in • Thrombocytopenia or • Severe hepatic disease • von Willebrand factor and attack therapeutic range (<65%)‡ platelet dysfunction (cirrhosis) markers of haemostatic • Vascular disease (1) • Concomitant antiplatelet • Severe renal impairment • Malignancy activation (plus other • Age 65–74 years therapy or NSAID use (creatinine clearance • Genetic factors (eg, CYP2C9 coagulation markers) • Sex† (female; 1) • Excessive alcohol intake <30 mL/min) polymorphisms) • Non-adherence to oral • Previous stroke or small anticoagulation vessel disease • Hazardous activities or • Diabetes occupations • Cognitive impairment or • Use of bridging therapy dementia with oral anticoagulation§ Figure 2: Stroke and bleeding risk factors assessment for patients with atrial fibrillation Adapted from Lip et al,7 by permission of the authors. Numbers in parentheses indicate the point weights assigned to each component of the score. NSAIDs=non- steroidal anti-inflammatory drugs. *Increased international normalised ratio monitoring, dedicated oral anticoagulation clinics, self-monitoring or self-management, educational or behavioural interventions. †Sex is not included as a category in the CHADS-VA score. ‡For patients receiving vitamin K antagonist treatment. §Dose 2 2 based on patient’s age, bodyweight, and serum creatinine concentration. ¶Walking aids and appropriate footwear, home review to remove trip hazards, and neurological assessment where appropriate. 1002 Seminar globally. Retaining female sex as a component of the non-significant reduction in major bleeding (RR 0·86, CHA₂DS₂-VASc score improved the net reclassification 0·73–1·00; p=0·06).17 High-dose direct oral anticoagulants of stroke events in Asian patients with atrial fibrillation, (150 mg dabigatran twice per day, 20 mg rivaroxaban and female sex remained an important stroke risk once per day, and 60 mg edoxaban once per day) were modifier.39 also associated with a higher risk of gastrointestinal In the 2024 European Society of Cardiology guidelines, bleeding than warfarin.17 the CHA₂DS₂-VA score was recommended for use “in All direct oral anticoagulants have some degree of renal the absence of other locally validated alternatives”, given dependency for their excretion, and in large phase 3 that “the inclusion of gender complicates clinical trials,17 patients with severe renal impairment (ie, practice…[and] omits individuals who identify as non- Cockcroft–Gault creatinine clearance <30 mL/min for all binary, transgender, or are undergoing sex hormone direct oral anticoagulants or <25 mL/min for apixaban) therapy”.4 Other risk scores, such as CHADS-65, have were excluded. The US Food and Drug Administration also been recommended in Canadian guidelines,32 has approved oral factor Xa inhibitors for patients with although some evidence suggests that the patient creatinine clearance of 15 mL/min or more, and apixaban subgroup for whom oral anticoagulation is not and rivaroxaban for patients undergoing dialysis, with recommended on the basis of CHADS-65 might not be, scarce evidence from clinical trials showing their safety in fact, at low risk.40 Stroke risk is dynamic, changing compared with vitamin K antagonists.46 In patients with with ageing and incident comorbidities. The change in atrial fibrillation who have prosthetic mechanical heart CHA₂DS₂-VASc over time predicts stroke risk better than valves or moderate-to-severe mitral stenosis (so-called baseline risk and, therefore, reassessment is needed.41 valvular atrial fibrillation), vitamin K antagonists are the Bleeding risk should be assessed to identify and correct oral anticoagulation of choice; poorer outcomes were modifiable bleeding risk factors (figure 2) and to identify evident in trials where direct oral anticoagulants were individuals at high risk of bleeding for early review and used, compared with vitamin K antagonists.47 follow-up. Bleeding risk results from the interaction of Recent data48 also show that use of an early rhythm modifiable and non-modifiable risk factors; focusing control strategy (ie, antiarrhythmic drugs or catheter exclusively on modifiable bleeding risk factors is an ablation within 1 year of atrial fibrillation diagnosis) in inferior strategy to use of a validated, structured bleeding patients with incident atrial fibrillation is associated with risk assessment.42 Many bleeding risk scores have been a lower risk of stroke, compared with patients who do not proposed and, in a systematic review and evidence receive such a strategy. Furthermore, management of appraisal,43 the HAS-BLED score performed best; more comorbidities and lifestyle factors is associated with a recent evidence44 shows the utility of the HAS-BLED reduction in stroke, mortality, and other major adverse score in patients being treated with direct oral cardiovascular events.49 The combination of early rhythm anticoagulants. A high bleeding risk score should not be control and healthy lifestyle behaviours has an additive used as an excuse to withhold oral anticoagulation. effect on reducing stroke.50 Hence, although oral Current oral anticoagulation options include vitamin K anticoagulation remains the cornerstone of stroke antagonists (eg, warfarin) or the direct oral anticoagulants prevention for most patients with atrial fibrillation, (eg, direct thrombin inhibitors [such as dabigatran] or guidelines recommend that it is complemented by other factor Xa inhibitors [such as rivaroxaban, apixaban, and components of holistic atrial fibrillation management edoxaban]), which are used for patients with atrial (figure 1). Despite the strong evidence for oral fibrillation without prosthetic mechanical heart valves or anticoagulation, adherence can be suboptimal, with moderate-to-severe mitral stenosis (previously called evidence of poor time in the therapeutic range for those non-valvular atrial fibrillation). Evidence from historical being treated with a vitamin K antagonist, or under- trials45 showed that dose-adjusted warfarin significantly dosing of direct oral anticoagulants.51 reduced the risk of stroke (by 64%, 95% CI 49–74) and Nevertheless, long-term oral anticoagulation is all-cause mortality (by 26%, 3–43) compared with placebo contraindicated for some patients. In such cases, left atrial or control. Aspirin did not significantly reduce stroke or appendage closure might be an option for reduction of the death compared with placebo or control,45 hence aspirin risk of stroke;52 however, patients undergoing left atrial is not recommended for stroke prevention in patients appendage closure might still require oral anticoagulation with atrial fibrillation.4 Based on the data from large for the first 45 days or longer after the procedure.52 In the RCTs,17 direct oral anticoagulants are now the preferred LAAOS III trial, patients with atrial fibrillation who were oral anticoagulants for atrial fibrillation, as they reduce treated with oral anticoagulation and underwent cardiac the risk of stroke and systemic embolism (RR 0·81, surgery for another indication and received concomitant 95% CI 0·73–0·91; p<0·0001) and risk of death (RR 0·90, left atrial appendage closure during the surgery had a 0·85–0·95; p=0·0003) compared with warfarin.17 Direct lower risk of ischaemic stroke or stystemic embolism oral anticoagulants were associated with a significant (hazard ratio [HR] 0·67, 95% CI 0·53–0·85; p=0·001) reduction in intracranial bleeding compared with compared with those who did not have left atrial warfarin (RR 0·48, 0·39–0·50; p<0·0001) and a appendage closure.53 The OPTION trial54 showed that left Seminar atrial appendage closure was associated with a lower risk default strategy for patients with newly diagnosed atrial of major or clinically relevant non-major bleeding than fibrillation. oral anticoagulation, and was non-inferior for a composite However, antiarrhythmic drugs have only modest of death from any cause, stroke, or systemic embolism at efficacy at maintaining sinus rhythm (less than a third of 36 months follow-up. Ongoing studies are investigating patients maintain sinus rhythm after 1 year of follow- the effect of different antithrombotic regimes after left up).59 Moreover, pharmacotherapy with antiarrhythmic atrial appendage closure.52 drugs is associated with high rates of discontinuation due to cardiac and non-cardiac side-effects (OR 1·6–2·9), Symptom reduction by rate and rhythm control and adverse events including pro-arrhythmia (4·1–6·8) Atrial fibrillation is often associated with symptoms such and increased mortality (OR 2·73, 95% CI 1·00–7·41, as palpitations, dyspnoea, and effort intolerance. p=0·049 for amiodarone and 4·32, 95% CI 1·59–11·70, Objectively, the impairment in quality of life felt by p=0·013 for sotalol).60 patients with atrial fibrillation is similar to that of patients Catheter ablation, targeting electrical isolation of living with heart failure or coronary artery disease, with a pulmonary vein triggers, has been shown in multiple disease burden similar to chronic haemodialysis.55 RCTs to be superior to antiarrhythmic drug therapy in Accordingly, a major component of atrial fibrillation maintaining sinus rhythm when antiarrhythmic drugs management is centred on symptom relief (figure 1) and have been ineffective, contraindicated, or poorly quality-of-life improvement, which are best achieved tolerated.61 through interventions targeting the rhythm disorder. Over the past 5 years, the role of catheter ablation as an Traditionally, this approach has been dichotomised into initial therapy has been reconsidered. Three recent restoration and maintenance of sinus rhythm (ie, rhythm RCTs62–64 have shown that an initial treatment strategy of control) or acceptance of atrial fibrillation with control of catheter ablation in patients with treatment-naive atrial the ventricular response (ie, rate control). Both can be fibrillation significantly improved arrhythmia outcomes, accomplished pharmacologically or through invasive produced clinically meaningful improvements in patient- procedures (eg, catheter ablation). reported outcomes (eg, symptoms and quality of life), For the past 30 years, pharmacological rate control has and significantly reduced subsequent health-care been the default strategy for patients with atrial resource use (appendix p 9).65 Importantly, these studies fibrillation, largely based on trial data showing no suggested that catheter ablation is associated with a statistically significant difference between rate control similar or lower risk of adverse cardiovascular outcomes and rhythm control in terms of mortality (odds ratio [OR] compared with antiarrhythmic drugs, challenging the 0·87 [95% CI 0·74–1·02]; p=0·09) or stroke (0·5 dogma that antiarrhythmic drugs should be the default [0·14–1·83]; p=0·30).56 Consequently, the choice to treatment.65 pursue rhythm control in patients with atrial fibrillation Indeed, the procedural risk associated with catheter was individualised on the basis of atrial fibrillation ablation has decreased substantially as techniques and symptoms and response to rate control. technologies have evolved, with contemporary estimates Further studies have shown that early rhythm control suggesting severe complications occur in less than 2% of is associated with improved cardiovascular outcomes. patients.66 Moreover, several recent studies have expanded The EAST-AFNET 4 trial57 compared early rhythm the use of catheter ablation to high risk patient cohorts, control (ie, antiarrhythmic drugs, atrial fibrillation such as those with advanced cardiomyopathy (appendix catheter ablation, or cardioversion) with usual care (ie, pp 10–12). Catheter ablation in individuals with heart rate-control therapy without rhythm-control strategies failure and reduced ejection fraction has also been shown initially) in patients with newly diagnosed atrial to reduce arrhythmia recurrence and increase ejection fibrillation (diagnosed within 12 months). The trial fraction, and has been associated with reduced rates of found a significant reduction in cardiovascular death heart failure hospitalisation and mortality (class I (1·0% per year in patients receiving early rhythm control indication for arrhythmia-induced cardiomyopathy and vs 1·3% per year those receiving usual care; HR 0·72 class IIa for other cardiomyopathies).4 [95% CI 0·52–0·98]) and stroke (0·6% per year in Over the past 40 years, percutaneous catheter ablation patients receiving early rhythm control vs 0·9% per year has evolved from prolonged interventional procedures in those receiving usual care; 0·65 [0·44–0·97]). designed to recreate the surgical maze procedure, to Subsequent studies, mainly examining large population focal ablation of discrete triggers within the pulmonary datasets (appendix p 8), have confirmed these findings, vein, and more recently to circumferential ablation of the showing that early rhythm control is associated with left atrial myocardium outside of the tubular veins with a significant reductions in cardiovascular death (HR 0·83 goal of large circumferential electrical pulmonary vein [95% CI 0·70–0·99]), ischaemic stroke (0·81 isolation, a procedure that targets the initiating triggers [0·69–0·94]), and hospitalisation due to heart failure of atrial fibrillation within the pulmonary veins and the (0·90 [0·88–0·92]).58 Given these findings, recent electrically active pulmonary venous antral tissue capable guidelines4,6 recommend early rhythm control as a of perpetuating atrial fibrillation. This contemporary 1004 Seminar approach can be performed with focal point-by-point reduces cardiovascular events in patients with radiofrequency catheters, dedicated thermal (radio- hypertension and atrial fibrillation. Lifestyle inter- frequency, cryothermal, or laser) balloon or ventions, such as dietary changes (eg, reduced sodium multi-electrode catheters, or specialised pulsed field intake), increased physical activity, and weight loss, energy catheters.67 Pulsed field ablation uses intermittent further enhance outcomes in hypertensive individuals high-intensity electrical discharges to induce pore with atrial fibrillation.71,75 formation in cell membranes, minimising the risk of collateral damage and avoiding many of the negative Heart failure effects of thermal energy. Current evidence suggests that Heart failure commonly coexists with atrial fibrillation, pulsed field ablation is a promising alternative to and their bidirectional relationship often complicates traditional thermal atrial fibrillation ablation methods, management.76 Suboptimal atrial fibrillation rate control offering advantages in procedural efficiency and safety.68 can also result in arrhythmia-induced cardiomyopathy.77 However, more extensive RCTs are necessary to confirm Optimal treatment focuses on both conditions, including these benefits and establish long-term outcomes. acute management of rate control. β blockers (especially bisoprolol and carvedilol) improve mortality in patients Management of comorbidities with heart failure while controlling atrial fibrillation Identification and management of comorbidities and ventricular rate.78 For patients with reduced ejection lifestyle factors is essential for the optimisation of atrial fraction, renin–angiotensin–aldosterone system fibrillation care and to reduce adverse outcomes. inhibitors, mineralocorticoid receptor antagonists, and Guideline-recommended strategies4 for optimisation of sodium–glucose co-transporter 2 (SGLT2) inhibitors are comorbidities and lifestyle modification are summarised pivotal in preventing cardiac remodelling.79 If rhythm in figure 3, with studies detailed in the appendix control is necessary, cardioversion is an initial option (appendix pp 13–54). The list included is not exhaustive. (recommended if patients are haemodynamically Research has increasingly emphasised the role of unstable). Catheter ablation might also offer superior modifiable lifestyle factors in atrial fibrillation prevention outcomes compared with antiarrhythmic drugs.80 In and management. Studies such as ACTIVE-AF,69 patients with newly diagnosed heart failure (ie, diagnosed ARREST-AF,70 and LEGACY71 have shown that sustained within 12 months) associated with atrial fibrillation and weight loss and increased physical activity can tachycardia, successful rhythm control could lead to significantly reduce atrial fibrillation burden and improve recovery of left ventricular function, especially if other atrial fibrillation freedom and ablation outcomes. causes of left ventricular systolic dysfunction are Structured, risk factor-based management programmes addressed.81 Oral anticoagulation to prevent thrombo- that include lifestyle optimisation have shown improved embolic events is vital due to the high risk of stroke in rhythm control and quality of life in patients with atrial patients with atrial fibrillation who have heart failure;4 fibrillation.70–72 direct oral anticoagulants are often preferred over warfarin unless contraindications exist.4 Hypertension Hypertension is an important risk factor for atrial Diabetes fibrillation and is strongly associated with increased risk Diabetes substantially increases the risk of atrial fibrillation of stroke and other cardiovascular events.73 Strict and its related complications, including stroke.82 Glucose- blood pressure control is crucial to reduce atrial lowering medications have had variable effects on atrial fibrillation-related complications. The use of renin– fibrillation and more evidence of their efficacy is required.83 angiotensin–aldosterone system inhibitors (eg, ACE Metformin remains the first-line therapy for type 2 inhibitors or angiotensin receptor blockers) is favoured diabetes and is commonly used in patients with coexisting due to their potential benefits in preventing atrial atrial fibrillation, with observational data suggesting a remodelling.4 β blockers and calcium channel blockers reduced risk of atrial fibrillation.84 Glycaemic control, (such as diltiazem or verapamil) can also help control through agents such as SGLT2 inhibitors and GLP-1 ventricular rate.4 Evidence from trials such as SPRINT74 receptor agonists (eg, liraglutide or semaglutide), offers supports intensive blood pressure lowering cardiovascular benefits in type 2 diabetes, reducing risk of (<130/80 mm Hg) to reduce hard cardiovascular heart failure and possibly lowering the risk of atrial outcomes such as myocardial infarction, heart failure, fibrillation.85 Optimal anticoagulation remains the and cardiovascular death. Although SPRINT did not cornerstone of stroke prevention in patients with atrial focus specifically on patients with atrial fibrillation, its fibrillation who have diabetes. Direct oral anticoagulants findings reinforce the broader cardiovascular benefits of offer advantages in this population, including lower rates optimal blood pressure control. Targeting a blood of major and intracranial bleeding compared with pressure of less than 130/80 mm Hg is recommended warfarin, and more predictable pharmacokinetics.86 In for patients with atrial fibrillation, with evidence patients with atrial fibrillation who have diabetes, supporting that intensive blood pressure lowering aggressive management of cardiovascular risk factors, Seminar such as dyslipidaemia and hypertension, alongside glucose Coronary artery disease control, further reduces the risk of adverse outcomes.71,75 Coronary artery disease frequently coexists with atrial fibrillation, complicating anticoagulation strategies due to Valvular heart disease the risk of both thromboembolism and bleeding. In Valvular heart disease, particularly mitral stenosis and patients with atrial fibrillation who have stable coronary regurgitation, increases the risk of atrial fibrillation due artery disease, monotherapy with a direct oral anticoagulant to atrial dilation and pressure overload.87 Management of is generally favoured due to its efficacy in preventing atrial fibrillation in the context of valvular heart disease thromboembolic events while minimising bleeding risk focuses on anticoagulation to mitigate stroke risk.4,6 In compared with warfarin.91 After percutaneous coronary patients with moderate-to-severe mitral stenosis, intervention or acute coronary syndrome, the preferred warfarin remains the anticoagulant of choice, with a strategy is dual therapy with a direct oral anticoagulant and target international normalised ratio of 2·0–3·0.88 In P2Y12 inhibitor (clopidogrel) to balance stroke prevention non-rheumatic valvular heart disease, direct oral and bleeding risk.4 Long-term direct oral anticoagulant anticoagulants are now favoured, based on studies monotherapy is recommended for patients with atrial showing better outcomes compared with warfarin.17,89 fibrillation who have stable coronary artery disease.91 Rate control is crucial, often achieved with β blockers or β blockers are favoured for heart rate control with non-dihydropyridine calcium channel blockers. Valve aggressive secondary prevention, including high-intensity intervention, such as percutaneous repair or replacement, statins and lifestyle modification (eg, smoking cessation or is indicated in symptomatic patients or those with severe exercise), which remains key to reduce the risk of adverse valve dysfunction90 and could improve atrial fibrillation events and to improve cardiovascular outcomes in patients control in appropriately selected patients. with atrial fibrillation who have coronary artery disease.92 Heart failure Hypertension Diabetes Overweight or Sleep apnoea Physical activity Smoking Alcohol intake Mental health obesity Treatment with Blood pressure Effective Weight loss Management Tailored Complete Reduce alcohol Assess anxiety diuretics to lowering glycaemic of 10% or of obstructive exercise cessation intake to no and depression alleviate treatment, control with more if sleep apnoea programme more than with a congestion, target diet and overweight to minimise aiming for three standard validated appropriate blood pressure medication or obese apnoeic regular units patient- medical 120–129/ (BMI episodes moderate per week reported therapy 70–79 mm Hg ≥27 kg/m2) or vigorous outcome for reduced in most adults activity measure LVEF, and (or as low as SGLT2 reasonably inhibitors achievable) for all LVEF Continuous Refer to positive airway psychologist pressure for when anxiety moderate or or depression severe symptoms obstructive affect sleep apnoea wellbeing Weight loss Proactively and lifestyle incorporate interventions changes in for all patients treatment plan with to improve obstructive psychological sleep apnoea wellbeing Personalised risk factor management plan focusing on all relevant risk factors with achievable targets Shared decision making and tailored information to support behaviour change Regular review and additional support or treatment change as required Level of evidence Class I recommendation Class IIb recommendation Consensus recommendation Figure 3: Comorbidity and risk factor management for patients with atrial fibrillation Adapted from Van Gelder et al.4 Levels of evidence as defined by European guidelines.4 LVEF=left ventricular ejection fraction. SGLT2=sodium–glucose co-transporter-2. 1006 Seminar Obstructive sleep apnoea also a risk factor for ischaemic stroke.98 Weight loss Obstructive sleep apnoea is a recognised modifiable risk interventions, including dietary changes and physical factor for atrial fibrillation.93 Continuous positive airway activity, have been shown to reduce atrial fibrillation pressure therapy remains the primary treatment for burden and improve outcomes post-ablation.96 Patients obstructive sleep apnoea. Although obstructive sleep should be encouraged to reach and maintain a healthy apnoea is clearly linked to increased atrial fibrillation weight (ie, BMI 21–25 kg/m²) as part of their atrial risk and recurrence,93 particularly after interventions fibrillation management plan. In people with a BMI of such as cardioversion or ablation, European guidelines4 27 kg/m² or more, a dose–response relationship has been acknowledge that RCTs have not shown a consistent reported, with weight loss of 3–9% of their bodyweight reduction in atrial fibrillation recurrence with associated with clinical benefit and weight loss of 10% of continuous positive airway pressure therapy. As a result, their bodyweight or more associated with lower rates although continuous positive airway pressure is atrial fibrillation progression and greater post-ablation recommended by European guidelines4 to improve atrial fibrillation-free survival.71,99 Emerging pharma- symptoms and reduce cardiovascular events in patients cological options, such as GLP-1 receptor agonists with moderate-to-severe obstructive sleep apnoea, its (eg, semaglutide), have shown significant weight specific effects on reducing atrial fibrillation burden reduction and cardiovascular benefit.100 Although their remain uncertain. Weight loss and lifestyle interventions direct effect on atrial fibrillation outcomes remains under are strongly encouraged, as both can improve both atrial investigation, they could constitute a valuable adjunct to fibrillation outcomes and obstructive sleep apnoea lifestyle-based weight management strategies. severity.70 Given the strong association between obstructive sleep apnoea and atrial fibrillation, screening Physical inactivity for obstructive sleep apnoea is recommended in patients Moderate regular physical activity, typically defined as at with atrial fibrillation who have risk factors or symptoms, least 150 min per week of moderate-intensity aerobic particularly when rhythm control strategies such as exercise, has been associated with reduced atrial ablation are being considered.4 Despite definitive fibrillation incidence and improved cardiovascular evidence of efficacy of continuous positive airway outcomes.101 Guideline-recommended physical activity pressure on atrial fibrillation, managing obstructive levels lower atrial fibrillation burden and recurrence after sleep apnoea remains important for patients with atrial rhythm control interventions.69,75,95 However, extreme fibrillation because of its association with broader endurance training could increase atrial fibrillation risk, cardiovascular risk. requiring careful exercise prescription tailored to individual patients.102 Modifiable risk factors Addressing obesity and lifestyle factors such as physical Smoking inactivity, smoking, and alcohol consumption (figure 3; Smoking is a well established risk factor for both atrial appendix pp 47–54) is essential to improve outcomes and fibrillation and stroke; it promotes atrial remodelling and reduce atrial fibrillation burden and recurrence.4 Such thrombogenesis, increasing the likelihood of atrial factors often cluster together, and the presence of multiple fibrillation development and ischaemic stroke in patients “unhealthy health behaviours” increases the risk of with atrial fibrillation.103 Smoking cessation significantly atrial fibrillation-related complications.94 Integrated decreases the risk of new-onset atrial fibrillation and management of atrial fibrillation emphasises the ischaemic stroke in patients with atrial fibrillation.104,105 combination of personalised lifestyle counselling with Clinicians should incorporate smoking cessation medical therapy. Structured programmes that incorporate strategies, such as behavioural counselling and lifestyle interventions—such as weight reduction, regular pharmacological aids, to mitigate these risks effectively. exercise, and healthy dietary habits—alongside pharmacological and procedural strategies, have shown Alcohol consumption improved clinical outcomes.95,96 Moreover, recent Alcohol has a dose-dependent relationship with atrial observational data50 suggest that integrating early rhythm fibrillation risk, with six or more standard drinks per week control with a healthy lifestyle might yield synergistic increasing the risk.106–108 Moderate alcohol consumption effects reducing the incidence of stroke and other major increases the risk of atrial fibrillation and associated stroke atrial fibrillation-related complications. These findings because alcohol promotes atrial dilation, fibrosis, and highlight the crucial role of addressing lifestyle factors arrhythmogenesis.106 Alcohol intake reduction has been within a comprehensive atrial fibrillation management associated with improved outcomes after atrial fibrillation strategy to optimise patient outcomes. catheter ablation.109 In patients with atrial fibrillation, abstinence from alcohol not only reduces atrial fibrillation Obesity burden but also decreases the risk of thromboembolic Obesity is linked to atrial enlargement, systemic events.110,111 Counselling on elimination or restricting inflammation, and atrial fibrillation progression,97 and is alcohol intake is essential. Seminar Caffeine and recreational drugs is common in these patients.117 Various comorbidities tend Although excessive caffeine consumption or heightened to cluster together, with implications for prognosis.118 sensitivity in some patients can act as a trigger for Unsurprisingly, such clinically complex patient arrhythmias, research exploring the association between phenotypes with frailty, multimorbidity, and polypharmacy caffeine intake and the development of atrial fibrillation or are at increased risk of adverse clinical events. outcomes in patients with atrial fibrillation remains scarce Undertreatment and inappropriate prescribing are and yields conflicting results (appendix pp 52–53).112–114 common and, where oral anticoagulation is prescribed for Recreational drugs have been shown to increase the risk stroke prevention, there is a high prevalence of of arrhythmias and stroke; however, there are few studies discontinuation.117 Clinical trial evidence119 for oral specifically linking them to atrial fibrillation.115 These anticoagulation in older, frail patients with atrial substances can lead to hypertensive and arrhythmogenic fibrillation shows that oral anticoagulation treatment is effects, underscoring the importance of complete better than no oral anticoagulation, and where patients on avoidance. a vitamin K antagonist maintain time in therapeutic range of 65% or more, swapping to a direct oral anticoagulant Multimorbidity and frailty gives no advantage, and could potentially be harmful.120 Patients with atrial fibrillation are a heterogenous group Importantly, multimorbidity status changes over time and various characteristics lead to some phenotypes that with ageing; new comorbidities detected have implications define clinical complexity in these patients.116 Older for clinical outcomes.121 Holistic, comprehensive care and patients (65 years or older) with atrial fibrillation are often treatment for patients who are frail with comorbidities is frail and have multiple comorbidities, and polypharmacy needed and should incorporate the ABC pathway; evidence shows such care is associated with better clinical outcomes.122,123 In the multimorbidity analysis from the mAFA-II trial,123 the composite outcome of stroke or Digital health, mobile health, or clinical decision support systems thromboembolism, all-cause death, and rehospitalisation was significantly reduced with the ABC pathway compared with usual care (HR 0·37, 95% CI 0·26–0·53; p<0·001), General practitioner as were rehospitalisations alone (0·42, 0·27–0·64; Psychologist Geriatrician p<0·001).123 The ongoing Horizon Europe projects AFFIRMO124 and EHRA-PATHS125 aim to address the effect of multimorbidity in patients with atrial fibrillation. Pharmacist Haematologist Mental health Depression and anxiety occur in approximately 25–33% of patients with atrial fibrillation,126 and could be both a consequence of, and contributing factor to, atrial Nephrologist Heart failure fibrillation.127 They are associated with poor quality of life, team increased self-reported atrial fibrillation symptom Family or burden, treatment non-adherence, and engagement in caregivers lifestyle behaviours associated with health risk.128 Measurement of emotional functioning in patients with Exercise Electro- physiologist physiologist atrial fibrillation at first diagnosis and once per year after initial diagnosis with validated patient-reported outcome measures is advocated to identify those in need of Patient-centred care support.129 Individually tailored education regarding atrial Cardiac fibrillation (its trajectory, treatment, and management), Neurologist or general surgeons which addresses patients’ concerns, in combination with reassurance from their health-care team, and strategies Atrial fibrillation Emergency that alleviate atrial fibrillation symptoms, can reduce nurse medicine anxiety and depression and improve quality of life.130,131 Cardiologist Psychosocial support is integral to patient-centred atrial fibrillation management.4 The “evaluation and dynamic reassessment” aspect of AF-CARE encourages health- Figure 4: Integrated atrial fibrillation management team care professionals to actively identify and implement The composition of the atrial fibrillation management team is dependent on many factors (eg, clinical status of changes to management strategies that positively patient, their comorbidities, cultural and country specific factors, or organisation of the health-care system). For influence patient wellbeing. A collaborative approach to example, for patients requiring catheter ablation, involvement of an electrophysiologist is required. For patients atrial fibrillation management is needed, with access to where atrial fibrillation is detected after stroke, a stroke physician, neurologist, or geriatrician might be involved in their care. Most patients with atrial fibrillation are managed by their general practitioner or cardiologist. psychologists for patients who require formal 1008 Seminar psychological support; however, the first step is routine personalised and shared decision making on the risk– assessment of emotional wellbeing to identify those at benefit of oral anticoagulation according to the patient’s risk (figure 3). profile is needed, combined with monitoring to detect progression to clinical atrial fibrillation or atrial high-rate Integrated care approach episodes or subclinical atrial fibrillation of long duration. An ageing population and growing prevalence of Contributors multimorbidity increases the complexity of atrial DAL: conceptualisation, project administration, visualisation, writing, fibrillation management and should encourage greater and revising. JGA, EA, GB, JMH, S-RL, GYHL, JM, and MEM: writing, and revising. involvement of patients in their care process. Atrial fibrillation management should be tailored to the needs of Declaration of interests DAL reports investigator-initiated quality improvement grants from each individual rather than based on one-size-fits-all Bristol Myers Squibb and Pfizer (paid to institution); and is a co-applicant approaches, and might therefore require the expertise of on the AFFIRMO project on multimorbidity in atrial fibrillation (grant multiple specialists (figure 4). However, in most health- agreement number 899871), the ARISTOTELES project on artificial care systems, patients with atrial fibrillation are managed intelligence for management of chronic long-term conditions (grant agreement number 101080189), and the TARGET project on digital twins by their general practitioner or cardiologist. Therefore, for personalised management of atrial fibrillation and stroke (grant European guidelines4 recommend a personalised and agreement number 101136244), all of which are funded by the Horizon holistic approach that incorporates the fundamentals of Europe Research and Innovation programme. JGA reports consulting integrated care—a whole systems approach to ensure the fees from Medtronic, Boston Scientific, Johnson & Johnson, and Kardium. EA reports speaker fees from Bristol Myers Squibb, Daiichi patient is placed at the centre of comprehensive care Sankyo, Boston Scientific and Medtronic and consulting fees from delivery, organised based on the patient’s needs and Boston Scientific, Bristol Myers Squibb and Cytokinetics; and is chair of preferences, aligned with the latest evidence, provided by the Data Monitoring Committee of the AFFIRMO project on interdisciplinary teams, and supported by technology.132 multimorbidity in atrial fibrillation (grant agreement number 899871). GB reports speaker fees from Bayer, Boston Scientific, Daiichi Sankyo, Initial trials investigating the effects of integrated care in iRhythm, Lilly, Janssen, and Sanofi outside of the submitted work; and is atrial fibrillation were promising (eg, in terms of the principal investigator of the ARISTOTELES project that received hospitalisation or survival) but showed heterogeneity in funding from the European Union within the Horizon 2020 Research deployment and results;133–136 these trials show the potential and Innovation programme (grant agreement number 101080189). JMH reports speaker fees from Medtronic and Biotronik. S-RL reports economic benefit of such integrated approaches due to speaker fees from Medtronic, Biotronik, Boston Scientific, Abbott, reducing health-care use long term.137 The latest European Biosense Webster, Daiichi Sankyo, Bayer, Bristol Myers Squibb–Pfizer, guidelines4 for the management of atrial fibrillation ChongKunDang, Daewoong Pharmaceutical Co, Samjinpharm, and recommend the AF-CARE pathway (figure 1), which Seers Technology; and participation in advisory board for Medtronic, Daiichi Sankyo, and ChonKunDang; and participation in advisory board incorporates the four fundamentals of integrated care. for Daiichi Sankyo (no fees received personally). GYHL is a National Institute for Health and Care Research (NIHR) Senior Investigator; is Concluding remarks consultant and speaker for Bristol Myers Squibb–Pfizer, Boehringer Global guidelines for the management of atrial Ingelheim, Daiichi Sankyo, and Anthos (no fees received personally); and is co-principal investigator of the AFFIRMO project on multimorbidity in fibrillation recommend an integrated approach to atrial fibrillation (grant agreement number 899871), TARGET project on provide comprehensive, patient-centred care, tailored to digital twins for personalised management of atrial fibrillation and stroke the needs and preferences of patients, aligned with the (grant agreement number 101136244) and ARISTOTELES project on artificial intelligence for management of chronic long term conditions latest evidence, provided by a multidisciplinary team, (grant agreement number 101080189), which are all funded by the and supported by digital and mobile health and wearable Horizon Europe Research and Innovation programme. JM is Chief devices. Crucial components of atrial fibrillation care are Investigator of NIHR funded trial of screening for atrial fibrillation avoidance of stroke with oral anticoagulation, (SAFER), has received honorarium from Bristol Myers Squibb–Pfizer; and is an independent chair of the Data Safety Monitoring Board of the identification and optimal management of comorbidities CRAFT trial (testing different blood pressure targets in atrial fibrillation), and lifestyle risk factors, and reduction or alleviation of with no payment received for this role. MEM declares no competing symptoms. For stroke prevention, the default should be interests. oral anticoagulation, preferably a direct oral References anticoagulant, unless the patient is at low risk of stroke 1 Roth GA, Mensah GA, Johnson CO, et al, and the GBD-NHLBI- JACC Global Burden of Cardiovascular Diseases Writing Group. based on the CHA₂DS₂-VA or CHA₂DS₂-VASc score (no Global burden of cardiovascular diseases and risk factors, oral anticoagulation required), has a mechanical heart 1990–2019: update from the GBD 2019 Study. J Am Coll Cardiol valve or moderate-to-severe mitral stenosis (vitamin K 2020; 76: 2982–3021. antagonist recommended), or creatinine clearance of 2 Elliott AD, Middeldorp ME, Van Gelder IC, Albert CM, Sanders P. Epidemiology and modifiable risk factors for atrial fibrillation. less than 30 min/L. Rhythm control can improve Nat Rev Cardiol 2023; 20: 404–17. symptoms, quality of life, and reduce health-care use, 3 Buja A, Rebba V, Montecchio L, et al. The cost of atrial fibrillation: particularly when pursued with catheter ablation. a systematic review. Value Health 2024; 27: 527–41. 4 Van Gelder IC, Rienstra M, Bunting KV, et al, and the ESC Regular patient review is warranted as risk factors and Scientific Document Group. 2024 ESC Guidelines for the treatment effectiveness can change over time, requiring management of atrial fibrillation developed in collaboration with alterations to the treatment plan. For patients with atrial the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J 2024; 45: 3314–414. high-rate episodes or subclinical atrial fibrillation, Seminar 5 Lip GYH. The ABC pathway: an integrated approach to improve AF 23 Mant J, Modi RN, Dymond A, et al, and the SAFER author group. management. Nat Rev Cardiol 2017; 14: 627–28. Randomised controlled trial of population screening for atrial 6 Joglar JA, Chung MK, Armbruster AL, et al, and the Peer Review fibrillation in people aged 70 years and over to reduce stroke: Committee Members. 2023 ACC/AHA/ACCP/HRS guideline for protocol for the SAFER trial. BMJ Open 2024; 14: e082047. the diagnosis and management of atrial fibrillation: a report of the 24 Kalarus Z, Mairesse GH, Sokal A, et al. Searching for atrial fibrillation: American College of Cardiology/American Heart Association Joint looking harder, looking longer, and in increasingly sophisticated ways. Committee on Clinical Practice Guidelines. Circulation 2024; An EHRA position paper. Europace 2023; 25: 185–98. 149: e1–156. 25 Toennis T, Bertaglia E, Brandes A, et al. The influence of atrial high- 7 Lip GYH, Banerjee A, Boriani G, et al. Antithrombotic therapy for rate episodes on stroke and cardiovascular death: an update. atrial fibrillation: CHEST guideline and expert panel report. Chest Europace 2023; 25: euad166. 2018; 154: 1121–201. 26 Boriani G, Gerra L, Mei DA, et al. Detection of subclinical atrial 8 Hindricks G, Potpara T, Dagres N, et al, and the ESC Scientific fibrillation with cardiac implanted electronic devices: what decision Document Group. 2020 ESC Guidelines for the diagnosis and making on anticoagulation after the NOAH and ARTESiA trials? management of atrial fibrillation developed in collaboration with Eur J Intern Med 2024; 123: 37–41. the European Association for Cardio-Thoracic Surgery (EACTS): 27 Proietti M, Romiti GF, Vitolo M, et al. Epidemiology of subclinical the task force for the diagnosis and management of atrial atrial fibrillation in patients with cardiac implantable electronic fibrillation of the European Society of Cardiology (ESC) developed devices: a systematic review and meta-regression. Eur J Intern Med with the special contribution of the European Heart Rhythm 2022; 103: 84–94. Association (EHRA) of the ESC. Eur Heart J 2021; 42: 373–498. 28 Healey JS, Lopes RD, Granger CB, et al, and the ARTESIA 9 Chao TF, Joung B, Takahashi Y, et al. 2021 focused update of the Investigators. Apixaban for stroke prevention in subclinical atrial 2017 consensus guidelines of the Asia Pacific Heart Rhythm Society fibrillation. N Engl J Med 2024; 390: 107–17. (APHRS) on stroke prevention in atrial fibrillation. J Arrhythm 2021; 29 Kirchhof P, Toennis T, Goette A, et al, and the NOAH-AFNET 6 37: 1389–426. Investigators, and the NOAH-AFNET6 sites and investigators. 10 Wang Y, Guo Y, Qin M, et al, and the Expert Reviewers. Anticoagulation with edoxaban in patients with atrial high-rate 2024 Chinese expert consensus guidelines on the diagnosis and episodes. N Engl J Med 2023; 389: 1167–79. treatment of atrial fibrillation in the elderly, endorsed by 30 McIntyre WF, Benz AP, Becher N, et al. Direct oral anticoagulants Geriatric Society of Chinese Medical Association (Cardiovascular for stroke prevention in patients with device-detected atrial Group) and Chinese Society of Geriatric Health Medicine fibrillation: a study-level meta-analysis of the NOAH-AFNET 6 and (Cardiovascular Branch): executive summary. Thromb Haemost ARTESiA trials. Circulation 2024; 149: 981–88. 2024; 124: 897–911. 31 Lip GY, Nieuwlaat R, Pisters R, Lane DA, Crijns HJ. Refining 11 Joung B, Lee JM, Lee KH, et al, and the KHRS Atrial Fibrillation clinical risk stratification for predicting stroke and Guideline Working Group. 2018 Korean guideline of atrial thromboembolism in atrial fibrillation using a novel risk factor- fibrillation management. Korean Circ J 2018; 48: 1033–80. based approach: the euro heart survey on atrial fibrillation. Chest 12 Guo Y, Lane DA, Wang L, et al, and the mAF-App II Trial 2010; 137: 263–72. Investigators. Mobile health technology to improve care for patients 32 Andrade JG, Aguilar M, Atzema C, et al, and Members of the with atrial fibrillation. J Am Coll Cardiol 2020; 75: 1523–34. Secondary Panel. The 2020 Canadian Cardiovascular Society/ 13 Chu M, Zhang S, Gong J, et al, and the MIRACLE-AF Investigators. Canadian Heart Rhythm Society Comprehensive Guidelines for the Telemedicine-based integrated management of atrial fibrillation in Management of Atrial Fibrillation. Can J Cardiol 2020; village clinics: a cluster randomized trial. Nat Med 2025; 36: 1847–948. 31: 1276–85. 33 Lopes RD, Granger CB, Wojdyla DM, et al. Apixaban vs aspirin 14 Romiti GF, Corica B, Bucci T, et al, and the AF-COMET according to CHADS-VASc score in subclinical atrial fibrillation: Collaborative Group. The ‘Atrial Fibrillation Better Care’ pathway for insights from ART 2 ESi 2 A. J Am Coll Cardiol 2024; 84: 354–64. integrated care of atrial fibrillation: a systematic review and meta- 34 Shoamanesh A, Field TS, Coutts SB, et al, and the ARTESiA study analysis. Thromb Haemost 2026; published online Jan 30. https://doi. investigators. Apixaban versus aspirin for stroke prevention in org/10.1055/a-2787-0186. people with subclinical atrial fibrillation and a history of stroke or 15 Hibbitt K, Brimicombe J, Cowie MR, et al. Reliability of single-lead transient ischaemic attack: subgroup analysis of the ARTESiA electrocardiogram interpretation to detect atrial fibrillation: insights randomised controlled trial. Lancet Neurol 2025; 24: 140–51. from the SAFER feasibility study. Europace 2024; 26: euae181. 35 Schnabel RB, Benezet-Mazuecos J, Becher N, et al. Anticoagulation 16 Chew DS, Li Z, Steinberg BA, et al. Arrhythmic burden and the risk in device-detected atrial fibrillation with or without vascular disease: of cardiovascular outcomes in patients with paroxysmal atrial a combined analysis of the NOAH-AFNET 6 and ARTESiA trials. fibrillation and cardiac implanted electronic devices. Eur Heart J 2024; 45: 4902–16. Circ Arrhythm Electrophysiol 2022; 15: e010304. 36 Linz D, Andrade JG, Arbelo E, et al. Longer and better lives for 17 Ruff CT, Giugliano RP, Braunwald E, et al. Comparison of the patients with atrial fibrillation: the 9th AFNET/EHRA consensus efficacy and safety of new oral anticoagulants with warfarin in conference. Europace 2024; 26: euae070. patients with atrial fibrillation: a meta-analysis of randomised trials. 37 Boriani G, McIntyre WF, Ramasundarahettige C, et al, and the Lancet 2014; 383: 955–62. ARTESiA Investigators. Atrial fibrillation progression in patients 18 Fitzmaurice DA, Hobbs FD, Jowett S, et al. Screening versus with device-detected subclinical atrial fibrillation: insights from the routine practice in detection of atrial fibrillation in patients aged 65 ARTESiA trial. Heart Rhythm 2025; 22: e1260–68. or over: cluster randomised controlled trial. BMJ 2007; 335: 383. 38 Corica B, Lobban T, True Hills M, Proietti M, Romiti GF. Sex as a 19 Lubitz SA, Faranesh AZ, Selvaggi C, et al. Detection of atrial risk factor for atrial fibrillation-related stroke. Thromb Haemost fibrillation in a large population using wearable devices: the Fitbit 2024; 124: 281–85. heart study. Circulation 2022; 146: 1415–24. 39 Cheng WH, Chan YH, Kuo L, et al. Stroke risks in women vs men 20 Svendsen JH, Diederichsen SZ, Højberg S, et al. Implantable loop in Asian patients with atrial fibrillation: a temporal trend analysis recorder detection of atrial fibrillation to prevent stroke and a comparison of the CHADS-VASc and CHADS-VA stroke (The LOOP Study): a randomised controlled trial. Lancet 2021; risk stratification scores. Heart 2 Rh 2 ythm 2025; 22: 25 2 15– 2 23. 398: 1507–16. 40 Lip GY, Nielsen PB, Skjøth F, Rasmussen LH, Larsen TB. Atrial 21 Svennberg E, Friberg L, Frykman V, Al-Khalili F, Engdahl J, fibrillation patients categorized as “not for anticoagulation” Rosenqvist M. Clinical outcomes in systematic screening for atrial according to the 2014 Canadian Cardiovascular Society algorithm fibrillation (STROKESTOP): a multicentre, parallel group, are not “low risk”. Can J Cardiol 2015; 31: 24–28. unmasked, randomised controlled trial. Lancet 2021; 41 Serna MJ, Rivera-Caravaca JM, López-Gálvez R, et al. Dynamic 398: 1498–506. assessment of CHADS-VASc and HAS-BLED scores for predicting 22 Lopes RD, Atlas SJ, Go AS, et al. Effect of screening for ischemic stroke and 2 ma 2 jor bleeding in atrial fibrillation patients. undiagnosed atrial fibrillation on stroke prevention. Rev Esp Cardiol (Engl Ed) 2024; 77: 835–42. J Am Coll Cardiol 2024; 84: 2073–84. 1010 Seminar 42 Guo Y, Zhu H, Chen Y, Lip GYH. Comparing bleeding risk 63 Andrade JG, Wells GA, Deyell MW, et al, and the EARLY-AF assessment focused on modifiable risk factors only versus validated Investigators. Cryoablation or drug therapy for initial treatment of bleeding risk scores in atrial fibrillation. Am J Med 2018; atrial fibrillation. N Engl J Med 2021; 384: 305–15. 131: 185–92. 64 Wazni OM, Dandamudi G, Sood N, et al, and the STOP AF First 43 Borre ED, Goode A, Raitz G, et al. Predicting thromboembolic and Trial Investigators. Cryoballoon ablation as initial therapy for atrial bleeding event risk in patients with non-valvular atrial fibrillation: fibrillation. N Engl J Med 2021; 384: 316–24. a systematic review. Thromb Haemost 2018; 118: 2171–87. 65 Andrade JG, Wazni OM, Kuniss M, et al. Cryoballoon ablation as 44 Esteve-Pastor MA, Rivera-Caravaca JM, Roldán V, et al. Predicting initial treatment for atrial fibrillation: JACC state-of-the-art review. performance of the HAS-BLED and ORBIT bleeding risk scores in J Am Coll Cardiol 2021; 78: 914–30. patients with atrial fibrillation treated with rivaroxaban: 66 Benali K, Khairy P, Hammache N, et al. Procedure-related observations from the prospective EMIR Registry. complications of catheter ablation for atrial fibrillation. Eur Heart J Cardiovasc Pharmacother 2022; 9: 38–46. J Am Coll Cardiol 2023; 81: 2089–99. 45 Hart RG, Pearce LA, Aguilar MI. Meta-analysis: antithrombotic 67 Tzeis S, Gerstenfeld EP, Kalman J, et al. 2024 European Heart therapy to prevent stroke in patients who have nonvalvular atrial Rhythm Association/Heart Rhythm Society/Asia Pacific Heart fibrillation. Ann Intern Med 2007; 146: 857–67. Rhythm Society/Latin American Heart Rhythm Society expert 46 Kaisaier W, Chen Y, Lip GYH, Liu C, Zhu W. Safety and efficacy of consensus statement on catheter and surgical ablation of atrial factor Xa inhibitors in atrial fibrillation patients on dialysis: evidence fibrillation. Europace 2024; 26: euae043. from four randomized controlled trials. Thromb Haemost 2026; 68 Reddy VY, Gerstenfeld EP, Natale A, et al, and the ADVENT 126: 11–22. Investigators. Pulsed field or conventional thermal ablation for 47 Connolly SJ, Karthikeyan G, Ntsekhe M, et al, and the INVICTUS paroxysmal atrial fibrillation. N Engl J Med 2023; 389: 1660–71. Investigators. Rivaroxaban in rheumatic heart disease-associated 69 Elliott AD, Verdicchio CV, Mahajan R, et al. An exercise and physical atrial fibrillation. N Engl J Med 2022; 387: 978–88. activity program in patients with atrial fibrillation: the ACTIVE-AF 48 Chao TF, Chan YH, Chiang CE, et al. Early rhythm control and the randomized controlled trial. JACC Clin Electrophysiol 2023; 9: 455–65. risks of ischemic stroke, heart failure, mortality, and adverse events 70 Pathak RK, Middeldorp ME, Lau DH, et al. Aggressive risk factor when performed early (<3 months): a nationwide cohort study of reduction study for atrial fibrillation and implications for the newly diagnosed patients with atrial fibrillation. Thromb Haemost outcome of ablation: the ARREST-AF cohort study. J Am Coll Cardiol 2022; 122: 1899–910. 2014; 64: 2222–31. 49 Lim WH, Lee SR, Choi EK, et al. Combination of early rhythm 71 Pathak RK, Middeldorp ME, Meredith M, et al. Long-term effect of control and healthy lifestyle on the risk of stroke in elderly patients goal-directed weight management in an atrial fibrillation cohort: with new-onset atrial fibrillation: a nationwide population-based a long-term follow-up study (LEGACY). J Am Coll Cardiol 2015; cohort study. Front Cardiovasc Med 2024; 11: 1346414. 65: 2159–69. 50 Lee SR, Choi EK, Lee SW, Han KD, Oh S, Lip GYH. Clinical impact 72 Chung MK, Eckhardt LL, Chen LY, et al, and the American Heart of early rhythm control and healthy lifestyles in patients with atrial Association Electrocardiography and Arrhythmias Committee and fibrillation. JACC Clin Electrophysiol 2024; 10: 1064–74. Exercise, Cardiac Rehabilitation, and Secondary Prevention 51 Chan YH, Chao TF, Chen SW, et al. Off-label dosing of non-vitamin K Committee of the Council on Clinical Cardiology; Council on antagonist oral anticoagulants and clinical outcomes in Asian patients Arteriosclerosis, Thrombosis and Vascular Biology; Council on with atrial fibrillation. Heart Rhythm 2020; 17: 2102–10. Cardiovascular and Stroke Nursing; and Council on Lifestyle and 52 Potpara T, Grygier M, Häusler KG, et al. Practical guide on left atrial Cardiometabolic Health. Lifestyle and risk factor modification for appendage closure for the non-implanting physician: reduction of atrial fibrillation: a scientific statement from the an international consensus paper. Europace 2024; 26: euae035. American Heart Association. Circulation 2020; 141: e750–72. 53 Whitlock RP, Belley-Cote EP, Paparella D, et al, and the LAAOS III 73 Niiranen TJ, Schnabel RB, Schutte AE, et al. Hypertension and Investigators. Left atrial appendage occlusion during cardiac atrial fibrillation: a frontier review from the AF-SCREEN surgery to prevent stroke. N Engl J Med 2021; 384: 2081–91. International Collaboration. Circulation 2025; 151: 863–77. 54 Wazni OM, Saliba WI, Nair DG, et al, and the OPTION Trial 74 Wright JT Jr, Williamson JD, Whelton PK, et al, and the SPRINT Investigators. Left atrial appendage closure after ablation for atrial Research Group. A randomized trial of intensive versus standard fibrillation. N Engl J Med 2025; 392: 1277–87. blood-pressure control. N Engl J Med 2015; 373: 2103–16. 55 Thrall G, Lane D, Carroll D, Lip GY. Quality of life in patients with 75 Abed HS, Wittert GA, Leong DP, et al. Effect of weight reduction atrial fibrillation: a systematic review. Am J Med 2006; 119: 448.e1–19. and cardiometabolic risk factor management on symptom burden 56 Wyse DG, Waldo AL, DiMarco JP, et al, and the Atrial Fibrillation and severity in patients with atrial fibrillation: a randomized clinical Follow-up Investigation of Rhythm Management (AFFIRM) trial. JAMA 2013; 310: 2050–60. Investigators. A comparison of rate control and rhythm control in 76 Newman JD, O’Meara E, Böhm M, et al. Implications of atrial patients with atrial fibrillation. N Engl J Med 2002; 347: 1825–33. fibrillation for guideline-directed therapy in patients with heart failure: 57 Kirchhof P, Camm AJ, Goette A, et al, and the EAST-AFNET 4 Trial JACC state-of-the-art review. J Am Coll Cardiol 2024; 83: 932–50. Investigators. Early rhythm-control therapy in patients with atrial 77 Zou F, Levine H, Mohanty S, Natale A, Di Biase L. Atrial fibrillation- fibrillation. N Engl J Med 2020; 383: 1305–16. induced cardiomyopathy. Card Electrophysiol Clin 2025; 17: 13–18. 58 Zhu W, Wu Z, Dong Y, Lip GYH, Liu C. Effectiveness of early 78 McDonagh TA, Metra M, Adamo M, et al, and the ESC Scientific rhythm control in improving clinical outcomes in patients with atrial Document Group. 2023 focused update of the 2021 ESC Guidelines fibrillation: a systematic review and meta-analysis. BMC Med 2022; for the diagnosis and treatment of acute and chronic heart failure. 20: 340. Eur Heart J 2023; 44: 3627–39. 59 Andrade JG, Wells GA, Deyell MW, et al, and the EARLY-AF 79 Talha KM, Anker SD, Butler J. SGLT-2 inhibitors in heart failure: Investigators. Cryoablation or drug therapy for initial treatment of a review of current evidence. Int J Heart Fail 2023; 5: 82–90. atrial fibrillation. N Engl J Med 2021; 384: 305–15. 80 Marrouche NF, Brachmann J, Andresen D, et al, and the CASTLE- 60 Freemantle N, Lafuente-Lafuente C, Mitchell S, Eckert L, AF Investigators. Catheter ablation for atrial fibrillation with heart Reynolds M. Mixed treatment comparison of dronedarone, failure. N Engl J Med 2018; 378: 417–27. amiodarone, sotalol, flecainide, and propafenone, for the 81 Schach C, Körtl T, Zeman F, et al. Clinical characterization of management of atrial fibrillation. Europace 2011; 13: 329–45. arrhythmia-induced cardiomyopathy in patients with 61 Calkins H, Reynolds MR, Spector P, et al. Treatment of atrial tachyarrhythmia and idiopathic heart failure. fibrillation with antiarrhythmic drugs or radiofrequency ablation: JACC Clin Electrophysiol 2024; 10: 870–81. two systematic literature reviews and meta-analyses. 82 Wang A, Green JB, Halperin JL, Piccini JP Sr. Atrial fibrillation and Circ Arrhythm Electrophysiol 2009; 2: 349–61. diabetes mellitus: JACC review topic of the week. J Am Coll Cardiol 62 Kuniss M, Pavlovic N, Velagic V, et al, and the Cryo-FIRST 2019; 74: 1107–15. Investigators. Cryoballoon ablation vs. antiarrhythmic drugs: first- 83 Bell DSH, Goncalves E. Atrial fibrillation and type 2 diabetes: line therapy for patients with paroxysmal atrial fibrillation. Europace Prevalence, etiology, pathophysiology and effect of anti-diabetic 2021; 23: 1033–41. therapies. Diabetes Obes Metab 2019; 21: 210–17. Seminar 84 Ostropolets A, Elias PA, Reyes MV, et al. Metformin is associated 104 Lee SR, Choi EK, Jung JH, Han KD, Oh S, Lip GYH. Smoking with a lower risk of atrial fibrillation and ventricular arrhythmias cessation after diagnosis of new-onset atrial fibrillation and the risk compared with sulfonylureas: an observational study. of stroke and death. J Clin Med 2021; 10: 2238. Circ Arrhythm Electrophysiol 2021; 14: e009115. 105 Teraoka JT, Tang JJ, Delling FN, Vittinghoff E, Marcus GM. 85 Marx N, Federici M, Schütt K, et al, and the ESC Scientific Document Smoking cessation and incident atrial fibrillation in a longitudinal Group. 2023 ESC Guidelines for the management of cardiovascular cohort. JACC Clin Electrophysiol 2024; 10: 2198–206. disease in patients with diabetes. Eur Heart J 2023; 44: 4043–140. 106 Voskoboinik A, Prabhu S, Ling LH, Kalman JM, Kistler PM. 86 Patti G, Di Gioia G, Cavallari I, Nenna A. Safety and efficacy of Alcohol and atrial fibrillation: a sobering review. J Am Coll Cardiol nonvitamin K antagonist oral anticoagulants versus warfarin in 2016; 68: 2567–76. diabetic patients with atrial fibrillation: a study-level meta-analysis of 107 Larsson SC, Drca N, Wolk A. Alcohol consumption and risk of atrial phase III randomized trials. Diabetes Metab Res Rev 2017; 33: e2876. fibrillation: a prospective study and dose-response meta-analysis. 87 Lip GYH, Jensen M, Melgaard L, Skjøth F, Nielsen PB, Larsen TB. J Am Coll Cardiol 2014; 64: 281–89. Stroke and bleeding risk scores in patients with atrial fibrillation 108 Kodama S, Saito K, Tanaka S, et al. Alcohol consumption and risk of and valvular heart disease: evaluating ‘valvular heart disease’ in a atrial fibrillation: a meta-analysis. J Am Coll Cardiol 2011; 57: 427–36. nationwide cohort study. Europace 2019; 21: 33–40. 109 Voskoboinik A, Wong G, Lee G, et al. Moderate alcohol 88 Otto CM, Nishimura RA, Bonow RO, et al. 2020 ACC/AHA consumption is associated with atrial electrical and structural Guideline for the management of patients with valvular heart changes: insights from high-density left atrial electroanatomic disease: executive summary: a report of the American College of mapping. Heart Rhythm 2019; 16: 251–59. Cardiology/American Heart Association Joint Committee on 110 Lee SR, Choi EK, Jung JH, Han KD, Oh S, Lip GYH. Lower risk of Clinical Practice Guidelines. Circulation 2021; 143: e35–71. stroke after alcohol abstinence in patients with incident atrial 89 Carnicelli AP, Hong H, Connolly SJ, et al, and the COMBINE AF fibrillation: a nationwide population-based cohort study. Eur Heart J (A Collaboration Between Multiple Institutions to Better Investigate 2021; 42: 4759–68. Non-Vitamin K Antagonist Oral Anticoagulant Use in Atrial 111 Voskoboinik A, Kalman JM, De Silva A, et al. Alcohol abstinence in Fibrillation) Investigators. Direct oral anticoagulants versus drinkers with atrial fibrillation. N Engl J Med 2020; 382: 20–28. warfarin in patients with atrial fibrillation: patient-level network 112 Larsson SC, Drca N, Jensen-Urstad M, Wolk A. Coffee consumption meta-analyses of randomized clinical trials with interaction testing is not associated with increased risk of atrial fibrillation: results from by age and sex. Circulation 2022; 145: 242–55. two prospective cohorts and a meta-analysis. BMC Med 2015; 13: 207. 90 Vahanian A, Beyersdorf F, Praz F, et al, and the ESC/EACTS 113 Mostofsky E, Johansen MB, Lundbye-Christensen S, Tjønneland A, Scientific Document Group. 2021 ESC/EACTS Guidelines for the Mittleman MA, Overvad K. Risk of atrial fibrillation associated with management of valvular heart disease. Eur Heart J 2022; 43: 561–632. coffee intake: findings from the Danish Diet, Cancer, and Health 91 Rashedi S, Keykhaei M, Sato A, et al. Anticoagulation and antiplatelet study. Eur J Prev Cardiol 2016; 23: 922–30. therapy for atrial fibrillation and stable coronary disease: meta- 114 Wong CX, Cheung CC, Montenegro G, et al. Caffeinated coffee analysis of randomized trials. J Am Coll Cardiol 2025; 85: 1189–203. consumption or abstinence to reduce atrial fibrillation: the DECAF 92 Vrints C, Andreotti F, Koskinas KC, et al, and the ESC Scientific randomized clinical trial. JAMA 2026; 335: 317–25. Document Group. 2024 ESC Guidelines for the management of 115 Lin AL, Nah G, Tang JJ, Vittinghoff E, Dewland TA, Marcus GM. chronic coronary syndromes. Eur Heart J 2024; 45: 3415–537. Cannabis, cocaine, methamphetamine, and opiates increase the 93 Kadhim K, Middeldorp ME, Elliott AD, et al. Prevalence and risk of incident atrial fibrillation. Eur Heart J 2022; 43: 4933–42. assessment of sleep-disordered breathing in patients with atrial 116 Romiti GF, Proietti M, Bonini N, et al, and the GLORIA-AF fibrillation: a systematic review and meta-analysis. Can J Cardiol Investigators. Clinical complexity domains, anticoagulation, and 2021; 37: 1846–56. outcomes in patients with atrial fibrillation: a report from the 94 Lee SR, Choi EK, Park SH, et al. Clustering of unhealthy lifestyle GLORIA-AF Registry phase II and III. Thromb Haemost 2022; and the risk of adverse events in patients with atrial fibrillation. 122: 2030–41. Front Cardiovasc Med 2022; 9: 885016. 117 Proietti M, Marzona I, Vannini T, et al. Long-term relationship 95 Pathak RK, Elliott A, Middeldorp ME, et al. Impact of between atrial fibrillation, multimorbidity and oral anticoagulant cardiorespiratory fitness on arrhythmia recurrence in obese drug use. Mayo Clin Proc 2019; 94: 2427–36. individuals with atrial fibrillation: the CARDIO-FIT study. 118 Romiti GF, Corica B, Mei DA, et al, and the GLORIA-AF J Am Coll Cardiol 2015; 66: 985–96. Investigators. Patterns of comorbidities in patients with atrial 96 Middeldorp ME, Ariyaratnam J, Lau D, Sanders P. Lifestyle fibrillation and impact on management and long-term prognosis: modifications for treatment of atrial fibrillation. Heart 2020; an analysis from the Prospective Global GLORIA-AF Registry. 106: 325–32. BMC Med 2024; 22: 151. 97 Wang TJ, Parise H, Levy D, et al. Obesity and the risk of new-onset 119 Okumura K, Akao M, Yoshida T, et al, and the ELDERCARE-AF atrial fibrillation. JAMA 2004; 292: 2471–77. Committees and Investigators. Low-dose edoxaban in very elderly 98 Overvad TF, Rasmussen LH, Skjøth F, Overvad K, Lip GY, patients with atrial fibrillation. N Engl J Med 2020; 383: 1735–45. Larsen TB. Body mass index and adverse events in patients with 120 Joosten LPT, van Doorn S, van de Ven PM, et al. Safety of switching incident atrial fibrillation. Am J Med 2013; 126: 640.e9–17. from a vitamin K antagonist to a non-vitamin K antagonist oral 99 Middeldorp ME, Pathak RK, Meredith M, et al. Prevention and anticoagulant in frail older patients with atrial fibrillation: results of regressive effect of weight-loss and risk factor modification on the FRAIL-AF randomized controlled trial. Circulation 2024; atrial fibrillation: the REVERSE-AF study. Europace 2018; 149: 279–89. 20: 1929–35. 121 Lip GYH, Tran G, Genaidy A, Marroquin P, Estes C. Revisiting the 100 Lincoff AM, Brown-Frandsen K, Colhoun HM, et al, and the dynamic risk profile of cardiovascular/non-cardiovascular SELECT Trial Investigators. Semaglutide and cardiovascular multimorbidity in incident atrial fibrillation patients and outcomes in obesity without diabetes. N Engl J Med 2023; five cardiovascular/non-cardiovascular outcomes: a machine- 389: 2221–32. learning approach. J Arrhythm 2021; 37: 931–41. 101 Ahn HJ, Lee SR, Choi EK, et al. Association between exercise habits 122 Krittayaphong R, Winijkul A, Methavigul K, Chichareon P, and stroke, heart failure, and mortality in Korean patients with Lip GYH. Clinical outcomes of patients with atrial fibrillation in incident atrial fibrillation: a nationwide population-based cohort relation to multimorbidity status changes over time and the impact study. PLoS Med 2021; 18: e1003659. of ABC pathway compliance: a nationwide cohort study. 102 Newman W, Parry-Williams G, Wiles J, et al. Risk of atrial J Thromb Thrombolysis 2025; 58: 97–108. fibrillation in athletes: a systematic review and meta-analysis. 123 Yao Y, Guo Y, Lip GYH, et al, and the mAF-App II Trial Br J Sports Med 2021; 55: 1233–38. investigators. The effects of implementing a mobile health- 103 Bizhanov KA, Abzaliyev KB, Baimbetov AK, Sarsenbayeva AB, technology supported pathway on atrial fibrillation-related adverse Lyan E. Atrial fibrillation: epidemiology, pathophysiology, and events among patients with multimorbidity: the mAFA-II clinical complications (literature review). J Cardiovasc Electrophysiol randomized clinical trial. JAMA Netw Open 2021; 4: e2140071. 2023; 34: 153–65. 1012 Seminar 124 Johnsen SP, Proietti M, Maggioni AP, Lip GYH. A multinational 131 Palm P, Qvist I, Rasmussen TB, Christensen SW, Håkonsen SJ, European network to implement integrated care in elderly Risom SS. Educational interventions to improve outcomes in multimorbid atrial fibrillation patients: the AFFIRMO Consortium. patients with atrial fibrillation—a systematic review. Int J Clin Pract Eur Heart J 2022; 43: 2916–18. 2020; 74: e13629. 125 Heidbuchel H, Van Gelder IC, Desteghe L, and the EHRA-PATHS 132 Ski CF, Cartledge S, Foldager D, et al. Integrated care in Investigators. ESC and EHRA lead a path towards integrated care cardiovascular disease: a statement of the Association of for multimorbid atrial fibrillation patients: the Horizon 2020 Cardiovascular Nursing and Allied Professions of the European EHRA-PATHS project. Eur Heart J 2022; 43: 1450–52. Society of Cardiology. Eur J Cardiovasc Nurs 2023; 22: e39–46. 126 Patel D, Mc Conkey ND, Sohaney R, Mc Neil A, Jedrzejczyk A, 133 Gallagher C, Elliott AD, Wong CX, et al. Integrated care in atrial Armaganijan L. A systematic review of depression and anxiety in fibrillation: a systematic review and meta-analysis. Heart 2017; patients with atrial fibrillation: the mind-heart link. 103: 1947–53. Cardiovasc Psychiatry Neurol 2013; 2013: 159850. 134 Gallagher C, Hendriks JM, Nyfort-Hansen K, Sanders P, Lau DH. 127 Segan L, Prabhu S, Kalman JM, Kistler PM. Atrial fibrillation and Integrated care for atrial fibrillation: the heart of the matter. stress: a 2-way street? JACC Clin Electrophysiol 2022; 8: 1051–59. Eur J Prev Cardiol 2022; 29: 2058–63. 128 Sears SF, Anthony S, Harrell R, et al. Managing atrial fibrillation: 135 Hendriks JML, Tieleman RG, Vrijhoef HJM, et al. Integrated the intersection of cardiology, health psychology, and the patient specialized atrial fibrillation clinics reduce all-cause mortality: post experience. Health Psychol 2022; 41: 792–802. hoc analysis of a randomized clinical trial. Europace 2019; 21: 1785–92. 129 Seligman WH, Das-Gupta Z, Jobi-Odeneye AO, et al. Development 136 Wijtvliet EPJP, Tieleman RG, van Gelder IC, et al, and the RACE 4 of an international standard set of outcome measures for patients Investigators. Nurse-led vs. usual-care for atrial fibrillation. with atrial fibrillation: a report of the International Consortium for Eur Heart J 2020; 41: 634–41. Health Outcomes Measurement (ICHOM) atrial fibrillation 137 Hendriks J, Tomini F, van Asselt T, Crijns H, Vrijhoef H. Cost- working group. Eur Heart J 2020; 41: 1132–40. effectiveness of a specialized atrial fibrillation clinic vs. usual care in 130 Holmlund L, Hörnsten C, Valham F, Olsson K, Hörnsten Å, patients with atrial fibrillation. Europace 2013; 15: 1128–35. Ängerud KH. Illness perceptions and health-related quality of life in Copyright © 2026 Elsevier Ltd. All rights reserved, including those for women and men with atrial fibrillation. J Cardiovasc Nurs 2024; 39: 49–57. text and data mining, AI training, and similar technologies. --- [PDF原文](https://sci-net.xyz/storage/7441382/3628897f323fb75c2fa4ac5b3cac229e235f3235f718e08456d24b64cc4e441e/Atrial-fibrillation.pdf) DOI: 10.1016/S0140-6736(25)02166-X