2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation (AF)

Vocabulary flashcards covering key AF concepts, guideline terminology, risk scores, therapies, and perioperative considerations from the 2023 ACC/AHA/ACCP/HRS AF guideline.

Atrial fibrillation (AF)

A supraventricular tachyarrhythmia with uncoordinated atrial activation and ineffective atrial contraction; ECG shows irregular R-R intervals, absent distinct P waves, and fibrillatory atrial activity.

Atrial flutter (AFL)

A rapid atrial tachycardia due to a macroreentrant circuit, commonly CTI-dependent; characterized by a sawtooth flutter waveform on ECG.

Atrial high‑rate episodes (AHREs)

Device-detected atrial tachyarrhythmias exceeding a programmed rate; require visual confirmation to diagnose AF and assess stroke risk.

Subclinical AF

AF identified in individuals without symptoms and without prior ECG documentation; often detected by implantable devices or wearables.

Atrial cardiomyopathy (atrial myopathy)

Structural, architectural, contractile, or electrophysiological atrial changes that may predispose to AF or thromboembolism.

AF burden

The frequency and duration of AF episodes; used to describe the overall amount of AF over monitoring time.

CHA2DS2‑VASc score

Validated clinical tool to estimate yearly risk of stroke in AF; components include heart failure, hypertension, age, diabetes, prior stroke/TIA, vascular disease, sex, etc.

HAS‑BLED score

Bleeding risk score used to balance anticoagulation decisions; includes hypertension, renal/liver dysfunction, prior bleeding, INR stability, age, drugs/alcohol.

Oral anticoagulation (OAC)

Therapy to reduce stroke risk in AF; includes vitamin K antagonists (warfarin) and direct oral anticoagulants (DOACs).

Direct oral anticoagulants (DOACs)

NOACs: apixaban, dabigatran, edoxaban, rivaroxaban; often preferred over warfarin for nonvalvular AF due to better safety/efficacy profiles.

Vitamin K antagonists (VKAs)

Anticoagulants such as warfarin; require INR monitoring and diet interaction management.

Left atrial appendage occlusion (LAAO)

Percutaneous or surgical closure of the left atrial appendage to reduce embolic stroke risk in AF, particularly when anticoagulation is contraindicated.

LAAOS III trial

Randomized trial showing surgical left atrial appendage occlusion (LAAO) plus anticoagulation reduces stroke/thromboembolism by about 33% in AF patients undergoing cardiac surgery.

Pulmonary vein isolation (PVI)

Catheter ablation target to electrically disconnect triggers from the pulmonary veins, a cornerstone of AF ablation.

Catheter ablation

Procedure to destroy AF substrates/triggers; shown to improve rhythm control and reduce AF burden in selected patients.

Atrioventricular nodal ablation (AVNA)

Eliminates AV node conduction to control rapid ventricular rates; requires pacing support (often CRT or pacing).

Heart failure with reduced ejection fraction (HFrEF)

HF with low left ventricular ejection fraction (LVEF ≤ 40%).

Heart failure with preserved ejection fraction (HFpEF)

HF with normal or near-normal LV systolic function but impaired diastolic function.

Lifestyle risk factor modification (LRFM)

Structured changes (weight loss, physical activity, BP control, smoking/alcohol cessation, diabetes management) to reduce AF risk/burden.

Shared decision‑making (SDM)

Process of clinicians and patients making decisions together, incorporating evidence and patient values/preferences.

AF stages/classification

New AF classification recognizing AF as a disease continuum with stages (risk factors, screening, prevention, rhythm/rate therapy) rather than a duration‑only label.

AF burden after ablation

AF episode duration/frequency used to predict recurrence and guide management after ablation.

Upstream therapy

Interventions targeting nonarrhythmic AF drivers (e.g., RAAS inhibitors, MRAs, statins, SGLT2 inhibitors, anti‑inflammatory strategies) to modify substrate and reduce AF burden.

Autonomic nervous system (ANS) in AF

Sympathetic and parasympathetic inputs can trigger AF and influence substrate; autonomic imbalance contributes to AF initiation and maintenance.

Atrial fibrillation burden modifiers

Factors such as AF burden, AF duration, and symptoms that influence stroke risk and rhythm/rate management decisions.

Early rhythm control (EAST‑AFNET 4)

Evidence suggesting benefits of initiating rhythm control early after AF diagnosis to reduce adverse outcomes.

Sleep-disordered breathing (SDB)

Conditions like sleep apnea that raise AF risk and AF recurrence; treatment may reduce AF burden though evidence is variable.

Pregnancy considerations in AF

AF management during pregnancy; anticoagulation choices and antiarrhythmic use must balance maternal/fetal safety.

Cardio-oncology considerations

AF risk and anticoagulation considerations in cancer patients, accounting for drug interactions and bleeding risk.

Periprocedural anticoagulation management

Strategies for holding/bridging anticoagulation around procedures (ablation, cardioversion) to balance bleeding and thromboembolism risks.

WPW (Wolff‑Parkinson‑White) syndrome

Preexcitation syndrome with accessory pathway; AF in WPW requires special rhythm control strategies to avoid dangerous conduction.

Torsades de pointes

Apolarity ventricular tachycardia often proarrhythmia risk with QT‑prolonging antiarrhythmics (notably ibutilide, dofetilide) and some DOAC interactions.

SERIES/CLASS OF RECOMMENDATIONS (COR/LOE)

ACC/AHA system: Class of Recommendation (strength) and Level of Evidence (quality) guiding guidance statements.

Left atrial enlargement (LA size)

Structural change associated with AF and predictor of recurrence after ablation and AF progression.

Atrial fibrosis and rotors (FIRM/ET)

Substrates like focal sources or rotor circuits contributing to AF maintenance and recurrence after ablation.

RATE vs RHYTHM control

Two main AF management strategies: rate control (control ventricular rate) and rhythm control (restore/maintain sinus rhythm); both can be appropriate depending on patient factors.