A comprehensive review reported that approximately 10.55 million U.S. adults had atrial fibrillation, which was associated with an increased risk of stroke, heart failure, and mortality.

In the review, published in JAMA, investigators described a new four-stage classification system for atrial fibrillation (AF) evolution. The stages progress from stage I (at risk) through stage II (pre-AF with atrial pathology), stage III (diagnosed AF), and stage IV (permanent AF).

The EAST-AFNET 4 trial, cited in the review, found a 21% reduction in cardiovascular outcomes with early rhythm control compared with rate control when initiated within 12 months of AF diagnosis.

For stroke prevention, the review noted that oral anticoagulation was recommended in patients with an estimated stroke risk of 2% or greater per year. Direct oral anticoagulants showed lower bleeding risks compared with warfarin, except in patients with mechanical heart valves or moderate to severe mitral stenosis.

The CASTLE-AF trial, referenced in the review, demonstrated that catheter ablation was associated with reduced mortality or hospitalization for heart failure compared with medical therapy in patients with heart failure with reduced ejection fraction.

The investigators reported disparities in AF care. According to the review, women, Black and Hispanic patients, and those with lower socioeconomic status received guideline-directed care less frequently and experienced poorer outcomes.

The Centers for Medicare & Medicaid Services and Joint Commission instituted social determinants of health reporting requirements to address these disparities.

The review included evidence from 107 articles: 48 randomized clinical trials, 19 meta-analyses, and 12 guidelines or consensus documents.

The investigators noted limitations in trial evidence, including limited representation of Black and Hispanic participants and insufficient examination of social determinants of health.

Conflict of interest disclosures can be found in the study.