New AF quality measures elevate prevention, DOAC use, and quality of care

Clinical takeaway: Clinicians should document stroke risk annually, prescribe DOACs when indicated, aggressively address lifestyle risk factors, and ensure equitable access to rhythm-control strategies and catheter ablation.

The new AHA/ACC clinical performance and quality measures for atrial fibrillation (AF) are designed to translate the 2023 AF guideline into measurable clinical practice, with a stronger emphasis on prevention, equity, and evidence-based treatment. The report identifies 5 performance measures suitable for public reporting or pay-for-performance programs and 16 quality measures intended to support local quality improvement.

Among the core performance measures are a standardized evaluation for newly diagnosed AF, including echocardiography and laboratory testing; comprehensive secondary prevention focused on weight loss, physical activity, smoking cessation, alcohol reduction, and blood pressure control; annual documentation of validated stroke-risk scores; and appropriate DOAC prescribing. For AF patients undergoing PCI, the report endorses DOAC-based therapy plus a P2Y12 inhibitor with early aspirin discontinuation to reduce bleeding risk.

Drug-related quality measures highlight several areas of inappropriate therapy. DOACs should generally be avoided in patients with mechanical valves or moderate-to-severe/rheumatic mitral stenosis, where warfarin remains preferred. In patients with end-stage CKD or dialysis dependence, the document cautions against use of dabigatran or edoxaban and notes evidence supporting warfarin or apixaban when anticoagulation is warranted. The measures also discourage use of flecainide or propafenone in patients with prior MI, structural heart disease, or HFrEF, and dronedarone in patients with advanced or recently decompensated HF or permanent AF.

The update also reflects growing evidence supporting rhythm control and catheter ablation, particularly in patients with HFrEF, and introduces a dedicated measure to track equitable delivery of anticoagulation, rhythm-control therapies, and lifestyle interventions across demographic groups.

“The performance and quality measures are intended to advance the quality and equity of AF care across all patient populations with AF,” the writing committee noted.

What's changed

• The 2026 update replaces prior AF performance measures with a new framework containing 5 performance measures and 16 quality measures aligned with the 2023 AF guideline.
• Three of five performance measures are new, including measures for basic evaluation of newly diagnosed AF, comprehensive lifestyle and risk-factor management, and preferred antithrombotic strategies after PCI.
• Stroke-risk assessment and anticoagulation measures now allow use of validated risk scores beyond CHA2DS2-VASc alone.
• New quality measures emphasize equitable AF management, shared decision-making regarding rhythm- versus rate-control strategies, early rhythm control in patients with HFrEF, catheter ablation access, and patient counseling after AF detected during acute illness or surgery.
• Several drug-safety measures were added, including avoidance of inappropriate DOAC use in patients with mechanical valves, significant mitral stenosis, or severe kidney disease, and avoidance of flecainide, propafenone, or dronedarone in high-risk populations.

Source: Benjamin EJ, et al. (2026 Aug 17) Circ Popul Health Outcomes. 2026 AHA/ACC Clinical Performance and Quality Measures for Patients With Atrial Fibrillation