IIa B For patients with AF or atrial flutter of 48 hours duration or longer or of unknown duration who have not been anticoagulated for the preceding 3 weeks, it is reasonable to perform transesophageal echocardiography before cardioversion and proceed with cardioversion if no left atrial thrombus is identified, including in the LAA, provided that anticoagulation is achieved before transesophageal echocardiography and maintained after cardioversion for at least 4 IIb B-NR For patients with AF or atrial flutter of less than 48 hours duration with a CHA2 - VASc score of 0 in men or 1 in women, administration of heparin, a factor Xa inhibitor, or a direct thrombin inhibitor, versus no anticoagulant therapy, may be considered before cardioversion, without the need for postcardioversion oral MODIFIED: Recommendation LOE was changed from C in the 2014 AF Guideline to B-NR to reflect evidence from 2 registry studies and to include specific CHA2 -VASc scores derived from study results. Recommendation-Specific Supportive Text (New or Modified) 1. Three prospective RCTs have evaluated the safety and efficacy of newly initiated factor Xa inhibi- tors (rivaroxaban and apixaban) for cardioversion as an alternative to warfarin.S6.1.1-7,S6.1.1-8,S6.1.1-17 In addition, retrospective analyses have been per- formed on the subset of patients undergoing cardioversion within the context of the larger randomized trials that compared each of the FDA-approved NOACs with warfarin for throm- boembolism prevention with AF. The results were consistent and support the assertion that NOACs are an effective and safe alternative to warfarin for patients undergoing cardioversion. An alter- native to waiting 3 weeks before cardioversion is to perform transesophageal echocardiography to exclude thrombus (see separate recommen- dation in this section). The decision about long- term anticoagulant therapy (beyond 4 weeks) is based on the thromboembolic risk profile (Section 4) and bleeding risk profile. The 48-hour rule has also been questioned, because delay to car- dioversion of 12 hours or longer from symp- tom onset was associated with a greater risk of thromboembolic complications compared to cardioversion of less than 12 hours (1.1% versus and the risk of thromboembolic com- plications with cardioversion of 12 hour or longer increases substantially in patients >75 years of age and in women.S6.1.1-19 4. The data supporting the safety of current prac- tices of cardioversion of AF without oral anticoag- ulation in patients with AF duration <48 hours are limited. Two recent retrospective studies demon- strate that the risk of thromboembolic complica- tion after a cardioversion for AF lasting <48 hours is in the range of 0.7% to 1.1%, with higher risk in patients with risk factors that include female sex, HF, and diabetes mellitus, whereas patients <60 years of age without thromboembolic risk factors and those with postoperative AF appear to have a lower risk.S6.1.1-13,S6.1.1-14 cardioversions in 484 patients), the risk of throm- boembolism was nearly 5 times higher in patients without therapeutic anticoagulation than in those on therapeutic anticoagulation with either warfa- rin or heparin. All events in that study occurred in patients with a CHA2 -VASc score of 2.S6.1.1-14 In the absence of randomized trials, the risk of thromboembolic events should be weighed against the risk of anticoagulant-related bleeding for the individual patient. 6. Two recent retrospective studies evaluated the risk of thromboembolism in patients after cardio- version for AF lasting <48 hours. In 1 study (567 cardioversions in 484 patients), the risk of throm- boembolism was nearly 5 times higher in patients without therapeutic anticoagulation than in those on therapeutic anticoagulation with either warfa- rin or heparin, with no events in patients with a -VASc score of <2.S6.1.1-14 In the second study, for patients with AF lasting <48 hours and -VASc score 1, the overall event rate was low (0.4%), but this group accounted for 10 of the 38 thromboembolic events (26%) that occurred in the study.S6.1.1-13 These studies agree with prior studies of cardioversion in short-term In the absence of randomized trials, the risk of thromboembolic events should be weighed Recommendations for Prevention of Thromboembolism (Continued) COR LOE Recommendations CLINICAL STATEMENTS AND GUIDELINES against the risk of anticoagulant-related bleeding for the individual patient. 6.3. AF Catheter Ablation to Maintain Sinus Rhythm 6.3.4. Catheter Ablation in HF Recommendation for Catheter Ablation in HF Referenced studies that support the new recommendation are summarized in Online Data Supplement 7. COR LOE Recommendation IIb B-R AF catheter ablation may be reasonable in selected patients with symptomatic AF and HF with reduced left ventricular (LV) ejection fraction (HFrEF) to potentially lower mortality rate and reduce hospitalization for HF.S6.3.4-1,S6.3.4-2 NEW: New evidence, including data on improved mortality rate, has been published for AF catheter ablation compared with medical therapy in patients with HF. Recommendation-Specific Supportive Text (New) 1. In an RCT (CASTLE-AF [Catheter Ablation vs. Standard Conventional Treatment in Patients With LV Dysfunction and AF]), selected patients with HFrEF with paroxysmal or persistent AF and an implanted cardioverter-defibrillator or cardiac resynchronization therapy defibrillator device who did not respond to or could not take antiarrhyth- mic drugs were randomized to receive AF catheter ablation versus medical therapy (rate or rhythm control) in addition to guideline-directed manage- ment and therapy for HFrEF.S6.3.4-1 Patients in the AF catheter ablation group had significantly reduced overall mortality rate, reduced rate of hospitaliza- tion for worsening HF, and improved LV ejection fraction as compared with the medical therapy group, and according to device interrogation, more patients in the AF catheter ablation group were in sinus rhythm. An additional RCT in a population of patients with persistent AF, HFrEF, and an implanted cardioverter-defibrillator or cardiac resynchroniza- tion therapy defibrillator device demonstrated that AF catheter ablation was superior to amiodarone for maintenance of sinus rhythm, with second- ary endpoint analyses suggesting a lower rate of unplanned hospitalization and death.S6.3.4-2 Both studies have limitations, including relatively small and highly selected patient populations. Further, larger studies are needed to validate these findings. Other small studies conducted in patients with AF and HFrEF have shown the superiority of AF ablation over antiarrhythmic drugs in the mainte- nance of sinus rhythm and in outcomes such as improved LV ejection fraction, performance in a 6-minute walk test, and quality of life.S6.3.4-3,S6.3.4-4 However, the recent CABANA (Catheter Ablation verses Anti-arrhythmic Drug Therapy for Atrial Fi- brillation) trial (n=2204 patients randomized to either catheter ablation or drug therapy) showed that AF ablation was not superior to drug therapy for the primary cardiovascular outcomes of death, disabling stroke, serious bleeding, or cardiac arrest at 5 years among patients with new-onset or un- treated AF that required therapy.S6.3.4-5,S6.3.4-6 7. SPECIFIC PATIENT GROUPS AND AF 7.4. AF Complicating ACS Recommendations for AF Complicating ACS Referenced studies that support new or modified recommendations are summarized in Online Data Supplement 8. COR LOE Recommendations I B-R For patients with ACS and AF at increased risk of systemic thromboembolism (based -VASc risk score of 2 or greater), anticoagulation is recommended unless the bleeding risk exceeds the expected MODIFIED: New published data are available. LOE was updated from C in the 2014 AF Guideline to B-R. Anticoagulation options are described in supportive text. I C Urgent direct-current cardioversion of new-onset AF in the setting of ACS is recommended for patients with hemodynamic compromise, ongoing ischemia, or inadequate rate control. I C Intravenous beta blockers are recommended to slow a rapid ventricular response to AF in patients with ACS who do not display HF, hemodynamic instability, or bronchospasm. IIa B-NR If triple therapy (oral anticoagulant, aspirin, inhibitor) is prescribed for patients with AF at increased risk of stroke (based -VASc risk score of 2 or greater) who have undergone percutaneous coronary intervention (PCI) with stenting for ACS, it is reasonable to choose clopidogrel in preference to prasugrel.S7.4-4,S7.4-5 NEW: New published data are available. IIa B-R In patients with AF at increased risk of stroke (based on CHA2 -VASc risk score of 2 or greater) who have undergone PCI with stenting for ACS, double therapy with inhibitor (clopidogrel or ticagrelor) and dose-adjusted vitamin K antagonist is reasonable to reduce the risk of bleeding as compared with triple therapy.S7.4-3,S7.4-6 S7.4-8 NEW: New RCT data and data from 2 registries and a retrospective cohort study are available. IIa B-R In patients with AF at increased risk of stroke (based on CHA2 -VASc risk score of 2 or greater) who have undergone PCI with stenting for ACS, double therapy with inhibitors (clopidogrel) and low-dose rivaroxaban 15 mg daily is reasonable to reduce the risk of bleeding as compared with triple therapy.S7.4-2 NEW: New published data are available. CLINICAL STATEMENTS AND GUIDELINES IIa B-R In patients with AF at increased risk of stroke (based on CHA2 -VASc risk score of 2 or greater) who have undergone PCI with stenting for ACS, double therapy with a inhibitor (clopidogrel) and dabigatran 150 mg twice daily is reasonable to reduce the risk of bleeding as compared with triple NEW: New published data are available. IIb B-R If triple therapy (oral anticoagulant, aspirin, inhibitor) is prescribed for patients with AF who are at increased risk of stroke (based on CHA2 -VASc risk score of 2 or greater) and who have undergone PCI with stenting (drug eluting or bare metal) for ACS, a transition to double therapy (oral anticoagulant and P2Y12 inhibitor) at 4 to 6 weeks may be considered.S7.4-9,S7.4-10 NEW: New published data are available. IIb C Administration of amiodarone or digoxin may be considered to slow a rapid ventricular response in patients with ACS and AF associated with severe LV dysfunction and HF or hemodynamic instability. IIb C Administration of nondihydropyridine calcium antagonists may be considered to slow a rapid ventricular response in patients with ACS and AF only in the absence of significant HF or hemodynamic instability. Synopsis The incidence of AF in patients with ACS ranges from 10% to 21% and increases with patient age and se- verity of myocardial infarction (MI).S7.4-11,S7.4-12 In the Medicare population, AF is associated with increased in-hospital mortality rate (25.3% with AF versus versus 19.1%), and 1-year mortality rate (48.3% ver- With multivariate adjustment, AF re- mains an independent predictor of death: in hospital (odds ratio: 1.21), at 30 days (odds ratio: 1.20), and at 1 year (odds ratio: 1.34).S7.4-12 Patients who devel- op AF during hospitalization have a worse prognosis than those with AF on admission.S7.4-12 Stroke rates are higher in patients with MI and AF than in those without AF (3.1% for those with AF versus 1.3% for those in sinus rhythm).S7.4-11 Thus, AF is an indepen- dent predictor of poor long-term outcome in patients Patients treated for ACS normally require dual- antiplatelet therapy (DAPT) with aspirin plus a plate- receptor inhibitor and may require the ad- dition of warfarin or a NOAC ( triple therapy ) for primary prevention for patients with AF at increased risk of strokeS7.4-3 (Section 4.3.). An option is to con- sider double therapy the use of an oral antico- agulant plus a P2Y12 inhibitor without aspirin.S7.4-3 If triple therapy is used, efforts may be directed to minimize duration of triple therapy to a period of 4 to 6 weeks, as this is the period of greatest risk of stent thrombosis, especially in patients with ACS, such as ST-segment elevation MI. Use of DAPT alone may be considered for patients with ACS who have AF and a CHA2 -VASc score of 0 to 1, with recon- sideration of the indications for anticoagulation over Whereas Section 4.1.1. provides spe- cific guidance on the presence/absence of stroke risk associated with female sex in the CHA2 -VASc score, the randomized data set referenced in this section on double versus triple therapy in patients undergoing PCI (subset with ACS) does not present the data analysis stratified by sex; therefore, the rec- ommendation is provided in the context of overall -VASc score. The HAS-BLED score can be used to assess bleeding risk in patients for whom an- ticoagulation is being considered.S7.4-17 Urgent direct-current cardioversion is appropriate in patients with ACS presenting with new-onset AF and intractable ischemia, hemodynamic instability, or inade- quate rate control. Intravenous administration of a beta blocker is indicated for rate control in patients with ACS to reduce myocardial oxygen demands. Intrave- nous amiodarone is an appropriate alternative for rate control and may facilitate conversion to sinus rhythm. Digoxin may be considered in those with severe LV dys- function and HF or hemodynamic instability. However, recent data from the ARISTOTLE AF NOAC trial study population show that digoxin was independently as- sociated with higher mortality rate in patients with AF regardless of HF, and in patients with AF taking digoxin, the risk of death increased with higher serum digoxin Other meta-analysis studies sup- port these conclusions.S7.4-19 Treatment with angioten- sin-converting enzyme inhibitors appears to reduce the incidence of AF in patients with LV dysfunction after Recommendation-Specific Supportive Text (New or Modified) 1. This recommendation is modified to incor- porate the data from WOEST (What is the Optimal Antiplatelet & Anticoagulant Therapy in Patients With Oral Anticoagulation and and the recent evidence from PIONEER AF-PCI (Open-Label, Randomized, Controlled, Multicenter Study Exploring two Treatment Strategies of Rivaroxaban and a Dose-Adjusted Oral Vitamin K Antagonist Treatment Strategy in Subjects With Atrial Fibrillation who Undergo Percutaneous Coronary and RE-DUAL PCI (Randomized Evaluation of Dual Antithrombotic Therapy With Dabigatran Versus Triple Therapy With Recommendations for AF Complicating ACS (Continued) COR LOE Recommendations CLINICAL STATEMENTS AND GUIDELINES Warfarin in Patients With Nonvalvular Atrial Fibrillation Undergoing Percutaneous Coronary (see supportive text for recom- mendations 6 and 8 below). These 3 clinical tri- als enrolled both patients with stable ischemic disease and patients with ACS treated with PCI. These trials did not include patients with ACS managed medically. On the basis of these clinical trials, options for anticoagulants in this patient population include warfarin, rivaroxa- ban, and dabigatran. Although the use of the -VASc score has been validated only in several small studies of patients with AF and ACS, we believe it is reasonable to use this methodology to estimate the risk of systemic 4. A single-center prospective cohort study found that, as compared with triple therapy with clopi- dogrel, triple therapy with prasugrel was associ- ated with a higher incidence of Thrombolysis in Myocardial Infarction (TIMI) major or minor bleed- This finding was corroborated by the TRANSLATE-ACS (Treatment with Adenosine Diphosphate Receptor Inhibitors: Longitudinal Assessment of Treatment Patterns and Events After Acute Coronary Syndrome) study,S7.4-5 a mul- ticenter prospective cohort study of patients who underwent PCI for an acute MI. That study found that, as compared with triple therapy with clopi- dogrel, triple therapy with prasugrel was associ- ated with a higher incidence of BARC (Bleeding Academic Research Consortium) defined bleed- ing events. These events, however, were patient- reported bleeding events that did not require hospitalization. 5. WOEST was an RCT that showed that, as com- pared with triple therapy (aspirin, clopidogrel, and warfarin), double therapy with warfarin and clopidogrel was associated with fewer bleeding complications. WOEST, however, was not pow- ered to assess stent thrombosis.S7.4-3 Two other registry-based studies similarly showed that dou- ble therapy with warfarin and clopidogrel was not associated with higher risk of coronary isch- emia than triple therapy.S7.4-6,S7.4-7 Furthermore, a hospital-based retrospective cohort study found that double therapy with warfarin and ticagrelor had thrombotic and bleeding rates that were similar to those observed with triple The aforementioned studies were not based exclusively on patients with AF and ACS; patients with AF undergoing elective PCI for stable coronary artery disease were also included. 6. PIONEER AF-PCI was an international, multi- center, randomized, open-label trial of 2124 patients with AF (without moderate to severe mitral stenosis or a mechanical heart valve) who had undergone PCI with stenting. Patients were randomized in a 1:1:1 ratio to low-dose rivar- oxaban (15 mg once daily) plus a P2Y12 inhibitor for 12 months (Group 1); very-low-dose rivar- oxaban (2.5 mg twice daily) plus DAPT for 1, 6, or 12 months (Group 2); or standard therapy with a dose-adjusted vitamin K antagonist (once daily) plus DAPT for 1, 6, or 12 months (Group 3). Clopidogrel was the most common P2Y12 inhibitor used (>90%). The rates of clinically significant bleeding were lower in Groups 1 and 2 than in Group 3.S7.4-2 The rates of death from cardiovascular causes, MI, or stroke were similar It is important to note that the dose of rivaroxaban used in that study was lower than the dose recommended for stroke prophylaxis in AF. The study was not powered to evaluate risk of stent thrombosis or systemic 7. RE-DUAL PCI was an international, multicenter, randomized open-label trial of 2725 patients with nonvalvular AF who had undergone PCI with stenting. Patients were randomized to receive 1 of 3 treatments: double therapy with dabigatran (110 mg twice daily) plus either clopidogrel or ticagrelor (110-mg dual-therapy group), double therapy with dabigatran (150 mg twice daily) plus either clopidogrel or ticagrelor (150-mg dual- therapy group), or triple therapy with warfarin plus aspirin ( 100 mg daily) and either clopido- grel or ticagrelor (triple-therapy group). The inci- dence of major or clinically relevant nonmajor bleeding was higher in the triple-therapy group than in the 110-mg dual-therapy group and the 150-mg dual-therapy group. In addition, the 2 dual-therapy groups combined were noninferior to the triple-therapy group with regard to the composite efficacy endpoint of thromboembolic events (MI, stroke, or systemic embolism), death, or unplanned revascularization. Clopidogrel was the most common P2Y12 inhibitor used (88%). Notably, the study was not powered to evaluate risk of stent thrombosis or systemic In aggregate, the data to date on compari- sons of double versus triple therapy demonstrate that double therapy significantly reduces the risk of bleeding without a signal of harm with re- gard to stent thrombosis in clinical trials that en- rolled both patients with stable ischemic disease and patients with ACS. With regard to the anti- thrombotic dosages studied, only the RE-DUAL PCI trial and WOEST trials studied antithrombotic dosages known to reduce the risk of systemic CLINICAL STATEMENTS AND GUIDELINES The ongoing AU- GUSTUS (A Study of Apixaban in Patients With Atrial Fibrillation, not Caused by a Heart Valve Problem, who are at Risk for Thrombosis due to Having had a Recent Coronary Event, Such as a Heart Attack or a Procedure to Open the Vessels of the Heart) trial is an open-label 2 2 factorial RCT to evaluate the safety of apixaban versus vi- tamin K antagonist and aspirin versus aspirin pla- cebo in patients with AF and ACS or PCI.S7.4-24 The ENTRUST-AF-PCI (Edoxaban Treatment Versus Vi- tamin K Antagonist in Patients With Atrial Fibril- lation Undergoing Percutaneous Coronary Inter- vention) is an ongoing trial evaluating edoxaban treatment versus vitamin K antagonist treatment in patients with AF undergoing PCI.S7.4-25 These trials will provide further evidence on treatment approaches designed to mitigate bleeding while reducing the risks of stent thrombosis and sys- temic thromboembolism. 8. The ISAR-TRIPLE (Triple Therapy in Patients on Oral Anticoagulation After Drug Eluting Stent was a randomized, open- label trial of patients receiving anticoagulation who underwent PCI with drug-eluting stents. Patients received concomitant anticoagulant and aspirin and were randomized to 6 weeks versus 6 months of clopidogrel. There was no difference between the 2 groups in terms of the primary composite endpoint of death, MI, definite stent thrombosis, stroke, or TIMI major bleeding or in terms of the secondary bleeding endpoint of TIMI major bleeding at 9 The Bern PCI RegistryS7.4-10 is a pro- spective registry of consecutive patients who have undergone PCI for stable coronary artery disease or ACS at Bern University Hospital since 2009. Among patients who were discharged on triple therapy, there was no difference between 1 month versus >1 month of triple therapy in the primary composite endpoint of cardiac death, MI, stroke, definite stent thrombosis, or TIMI major bleeding at 1 year.S7.4-10 Although both the ISAR-TRIPLE trial and the Bern PCI Registry have limitations, the consistent find- ing in both patients with ACS and patients with stable ischemic heart disease suggests that with current drug-eluting stents, selecting bare metal stents to shorten the duration of DAPT is no longer indicated. Of the patients treated with triple therapy for 1 month in the Bern PCI Registry, 60% were treated with a current-gen- eration drug-eluting stent. 7.12. Device Detection of AF and Atrial Flutter (New) Recommendations for Device Detection of AF and Atrial Flutter Referenced studies that support new recommendations are summarized in Online Data Supplement 9. COR LOE Recommendations I B-NR In patients with cardiac implantable electronic devices (pacemakers or implanted cardioverter-defibrillators), the presence of recorded atrial high-rate episodes (AHREs) should prompt further evaluation to document clinically relevant AF to guide IIa B-R In patients with cryptogenic stroke (ie, stroke of unknown cause) in whom external ambulatory monitoring is inconclusive, implantation of a cardiac monitor (loop recorder) is reasonable to optimize detection of silent AF.S7.12-6 Recommendation-Specific Supportive Text (New) 1. Patients with AHREs detected by implanted devices are at increased risk of stroke and abun- dant data now link device-detected atrial tachy- cardia or AF (or AHREs) with the development of thromboembolic events.S7.12-1 S7.12-5 Remote monitoring with AHRE alerts increases the likeli- hood of detecting silent AF. However, it is unclear whether patients with AHREs benefit from oral anticoagulation. Careful review of stored electro- grams may confirm the presence of AF and rule out false positive events. Occasionally, the addi- tion of extended external electrocardiographic monitoring may be needed if data from the implanted device are uncertain. Prospective clini- cal trials of prophylactic anticoagulation based on device-detected AF are under way but have not been completed. Although increased duration of AHREs is associated with increased stroke risk, the threshold duration of AHREs that warrants anticoagulation is unclear. Current approaches factor in the duration of device-detected AF and the patient s stroke risk profile, bleeding risk, and preferences to determine whether to initiate long-term anticoagulation. 2. The cause of ischemic stroke remains unknown in 20% to 40% of patients, leading to a diag- nosis of cryptogenic stroke. Prolonged electrocar- diogram monitoring with an implantable cardiac monitor in these patients (age >40 years) has the advantage of increasing the likelihood of detect- ing silent AF that would escape detection with short-term monitoring. A recent RCT established CLINICAL STATEMENTS AND GUIDELINES the superiority of an implantable cardiac monitor over conventional monitoring for detecting silent AF, a finding with major clinical ramifications for A role in screening for silent AF may also exist for remote electrocardiographic acquisition and transmission with a smart worn or handheld WiFi-enabled device with remote 7.13. Weight Loss (New) Recommendation for Weight Loss in Patients with AF Referenced studies that support the new recommendation are summarized in Online Data Supplement 10. COR LOE Recommendation I B-R For overweight and obese patients with AF, weight loss, combined with risk factor modification, is recommended.S7.13-1 S7.13-3 NEW: New data demonstrate the beneficial effects of weight loss and risk factor modification on controlling AF. Recommendation-Specific Supportive Text (New) 1. Obesity is associated with atrial electrostructural One RCT dem- onstrated that a structured weight management program for obese patients (body mass index >27) with symptomatic AF reduced symptom burden and severity and reduced the number of AF episodes and their cumulative duration when compared with attempts to optimally manage risk factors alone.S7.13-1 Risk factor modification included assessment and treatment of underly- ing sleep apnea, hypertension, hyperlipidemia, glucose intolerance, and alcohol and tobacco use. A second nonrandomized observational study reported improved outcomes of AF catheter abla- tion among obese patients who enrolled in a weight loss program.S7.13-2 Observational studies have revealed that the degree of improvement in the AF type and symptoms were related to the degree of weight loss.S7.13-3,S7.13-8 Taken together, these studies support a treatment approach that addresses the risk factors for AF. ACC/AHA TASK FORCE MEMBERS Glenn N. Levine, MD, FACC, FAHA, Chair; Patrick T. O Gara, MD, MACC, FAHA, Chair-Elect; Jonathan L. Halperin, MD, FACC, FAHA, Immediate Past Chair*; Sana M. Al-Khatib, MD, MHS, FACC, FAHA; Joshua A. Beckman, MD, MS, FAHA; Kim K. Birtcher, PharmD, MS, AACC; Biykem Bozkurt, MD, PhD, FACC, FAHA*; Ralph G. Brindis, MD, MPH, MACC*; Joaquin E. Cigarroa, MD, FACC; Lesley H. Curtis, PhD, FAHA*; Anita Deswal, MD, MPH, FACC, FAHA; Lee A. Fleisher, MD, FACC, FAHA; Federico Gentile, MD, FACC; Samuel Gidding, MD, FAHA*; Zachary D. Goldberger, MD, MS, FACC, FAHA; Mark A. Hlatky, MD, FACC, FAHA; John Ikonomidis, MD, PhD, FAHA*; Jos A. Joglar, MD, FACC, FAHA; Laura Mauri, MD, MSc, FAHA*; Mariann R. Piano, RN, PhD, FAAN, FAHA; Susan J. Pressler, PhD, RN, FAHA*; Barbara Riegel, PhD, RN, FAHA*; Duminda N. Wijeysundera, MD, PhD PRESIDENTS AND STAFF American College of Cardiology C. Michael Valentine, MD, FACC, President Timothy W. Attebery, DSc, MBA, FACHE, Chief Execu- tive Officer William J. Oetgen, MD, MBA, FACC, FACP, Executive Vice President, Science, Education, Quality, and Pub- lishing MaryAnne Elma, MPH, Senior Director, Science, Educa- tion, Quality, and Publishing Amelia Scholtz, PhD, Publications Manager, Science, Education, Quality, and Publishing American College of Cardiology/ American Heart Association Katherine A. Sheehan, PhD, Director, Guideline Strat- egy and Operations Abdul R. Abdullah, MD, Senior Manager, Guideline Science Thomas S. D. Getchius, Manager, Guideline Science Zainab Shipchandler, MPH, Associate Guideline Advisor American Heart Association Ivor J. Benjamin, MD, President Nancy Brown, Chief Executive Officer Rose Marie Robertson, MD, FAHA, Chief Science and Medicine Officer Gayle R. Whitman, PhD, RN, FAHA, FAAN, Senior Vice President, Office of Science Operations Anne Leonard, MPH, RN, CCRC, FAHA, Senior Science and Medicine Advisor, Office of Science Operations Jody Hundley, Production and Operations Manager, Sci- entific Publications, Office of Science Operations ARTICLE INFORMATION This document was approved by the American College of Cardiology Clinical Policy Approval Committee, the American Heart Association Science Advisory and Coordinating Committee, and the Heart Rhythm Society Board of Trustees *Former Task Force member; current member during the writing effort. CLINICAL STATEMENTS AND GUIDELINES in September 2018, and the American Heart Association Executive Committee in January 2019. Supplemental materials are available with this article at https://www. ahajournals.org/doi/suppl/10.1161/CIR.0000000000000665. This article has been copublished in the Journal of the American College of Cardiology and HeartRhythm. Copies: This document is available on the websites of the American College of Cardiology (www.acc.org), the American Heart Association (professional. heart.org), and the Heart Rhythm Society (www.hrsonline.org). A copy of the document is also available at https://professional.heart.org/statements by selecting the Guidelines & Statements button. To purchase additional reprints, call 843-216-2533 or e-mail kelle.ramsay@wolterskluwer.com. The expert peer review of AHA-commissioned documents (eg, scientific statements, clinical practice guidelines, systematic reviews) is conducted by the AHA Office of Science Operations. For more on AHA statements and guide- lines development, visit https://professional.heart.org/statements. Select the Guidelines & Statements drop-down menu near the top of the web page, then click Publication Development. Permissions: Multiple copies, modification, alteration, enhancement, and/ or distribution of this document are not permitted without the express permis- sion of the American Heart Association. Instructions for obtaining permission are located at https://www.heart.org/permissions. A link to the Copyright Per- missions Request Form appears in the second paragraph (https://www.heart. org/en/about-us/statements-and-policies/copyright-request-form). REFERENCES PREAMBLE P-1. Committee on Standards for Developing Trustworthy Clinical Practice Guidelines, Institute of Medicine (US). Clinical Practice Guidelines We Can Trust. Washington, DC: National Academies Press; 2011. P-2. Committee on Standards for Systematic Reviews of Comparative Effectiveness Research, Institute of Medicine (US). Finding What Works in Health Care: Standards for Systematic Reviews. 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