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CLINICAL STATEMENTS AND GUIDELINES

January 2, 2024 Circulation. 2024;149:e1–e156. DOI: 10.1161/CIR.0000000000001193 e66

Joglar et al 2023 Guideline for the Diagnosis and Management of Atrial Fibrillation

AVNA has been shown to be feasible and associated with improvements in EF in patients with EF <40%, and NYHA class, albeit with elevated pacing thresholds.10,11 Left bundle area pacing may deliver the advantages of His bundle pacing with reduced risk of elevated pacing thresholds or lead dislodgement.12 Early studies have shown stable EF with conduction system pacing and AVNA in follow-up, and improvement in patients with EF <50%.12,24

8 RHYTHM CONTROL

8.1 Goals of Therapy With Rhythm Control

Recommendations for Goals of Therapy With Rhythm Control Referenced studies that support the recommendations are summarized in the Online Data Supplement. COR LOE Recommendations

1 B-R 1 In patients with reduced LV function and persistent

(or high burden) AF, a trial of rhythm control should be recommended to evaluate whether AF is contributing to the reduced LV function.1–6

2a B-R 2.	 In patients with symptomatic AF, rhythm control can

be useful to improve symptoms.7–11

2a B-R 3.	 In patients with a recent diagnosis of AF (<1 year),

rhythm control can be useful to reduce hospitalizations, stroke, and mortality.12–14

2a B-R 4 In patients with AF and HF, rhythm control can be

useful for improving symptoms and improving outcomes, such as mortality and hospitalizations for HF and ischemia.15–19

2a B-NR 5.	 In patients with AF, rhythm-control strategies can be

useful to reduce the likelihood of AF progression.20–27

2b C-LD 6 In patients with AF where symptoms associated with

AF are uncertain, a trial of rhythm control (eg, cardioversion or pharmacological therapy) may be useful to determine what if any symptoms are attributable to AF.28–32

2b B-NR 7 In patients with AF, rhythm-control strategies may

be useful to reduce the likelihood of development of dementia or worsening cardiac structural abnormalities.33–45

Synopsis When caring for a patient with AF, deciding between rhythm and rate control is important but critical to acknowledge that the decision is nuanced, can evolve over time, and that the 2 strategies are necessarily not mutually exclusive depending on the definition used. For example, in EAST-AFNET 4 (Early Treatment of Atrial Fibrillation for Stroke Prevention Trial), which randomized patients with recently identified AF to rhythm- or rate-control strategies, in those patients randomized to the rhythm control arm, initially 87% were treated with antiarrhythmic drugs and 8% with AF ablation; but, at 2 years, 35% were not on antiarrhythmic drugs or had received AF ablation.12 Similarly, although the decision on whether to use rhythm control is often based on symptoms, in a post hoc analysis of the same trial, benefits in the composite outcome of death, stroke, or cardiac hospitalization was observed in all patients regardless of whether symptoms were present or not.30 Data from EAST-AFNET 4 and large registries have consistently demonstrated the importance of monitoring patients for increased AF burden once AF has been identified and that rhythm-control therapies are more likely to be successful when implemented early when AF burden begins to increase.13,14,30,46,47 Finally, for all patients with AF, continued long-term management of modifiable risk factors is essential.48

Recommendation-Specific Supportive Text 1.	 AF and reduced LV function are often recognized

in the same patient, with the combination being associated with worse prognosis when compared with patients with either HF or AF alone.1,49 Several studies have demonstrated improved LV function in patients with AF after restoration of sinus rhythm.2–6 The incidence of AF or other atrial arrhythmias as an important contributor to reduced LVEF is unknown and likely dependent on arrhythmia burden, ventricular rates, and other factors.4–6 However, in patients who present with both AF and reduced LV function or develop reduced LV function after an initial diagnosis of AF, where no identifiable cause for the reduced LV function is observed, AF should initially be assumed as a very possible cause until proven otherwise. Although AF as a cause for reduced LV function is usually considered in the setting of rapid ventricular rates, improved LV function with rhythm control has been reported in the setting of AF with relatively well controlled heart rates.2,3

2 Rhythm and rate control can improve symptoms

in AF.7,8,50,51 Multiple studies have shown improved QOL with rhythm control.7–9,50,51 Continued symptoms due to AF are common with rate control. In the RACE II study, lenient rate control had similar primary outcomes (a combination of cardiovascular death, hospitalization for HF, and several other endpoints) compared to strict rate control, but at the end of the follow-up period (>2 years), 46% of patients in both groups had continued symptoms associated with AF.10 Although a different population, symptoms due to recurrent AF were identified in 56 of 303 (18%) patients with newly identified AF undergoing rhythm control with either AADs or catheter ablation.11

3 EAST-AFNET 4 randomized 2733 patients with

early onset AF (<1 year) and other risk factors for stroke to rhythm control or rate-control strategies.12 Rhythm control was associated with a 25% reduction in the combined endpoint of mortality rate, stroke, and hospitalizations due to HF or ACS. In 2 observational studies, 1 from claims

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