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CLINICAL STATEMENTS AND GUIDELINES

January 2, 2024 Circulation. 2024;149:e1–e156. DOI: 10.1161/CIR.0000000000001193 e68

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

with the ablation-based CASTLE-AF (Catheter Ablation versus Standard Conventional Therapy in Patients with Left Ventricular Dysfunction and Atrial Fibrillation) trial (sinus rhythm at study completion: AF-CHF: 75% versus CASTLE-AF: 66%), and additionally the benefit of rhythm control in patients with HF is likely greatest in those patients with recently identified AF.15–18,49

5 AF commonly, but not always, progresses over

time to higher burdens and becomes more sustained.20,59 Large registry studies have reported that AF progression is more commonly observed with a rate-control strategy compared to a rhythm-control strategy over a 1- to 2-year period, although the absolute magnitude and difference has varied. For example, in 2 registry studies, progression to a more sustained form of AF burden was observed in 26% to 28% of patients undergoing a rate-control strategy compared with 6% to 11% of patients treated with a rhythm-control strategy while, in an analysis of the ORBIT AF trial, although rhythm control was associated with a lower likelihood of progression, AF progression was much more common regardless of strategy (66% for rate control and 56% for rhythm control) likely due to older patients in this cohort.21–23 AF progression is a complex process, and although the choice between rhythm-control and rate-control strategy has an impact, many other factors such as age, presence or absence of HF or other comorbidities, LA size, heart rate, and modifiable risk factors are also important.21–27

6 The reported prevalence of asymptomatic AF var-

ies from 10% to 40% depending on study cohort.28 Asymptomatic and symptomatic patients with AF have similar risks for death and stroke.28,29 In a post hoc analysis of EAST-AFNET 4, similar magnitudes of benefit were observed in symptomatic and asymptomatic patients for reducing the combined endpoint of cardiovascular death, stroke, and hospitalization for HF.30 Nevertheless, the evidence base for the benefits of a rhythm-control trial in asymptomatic patients with sinus rhythm is limited. Improved energy with return to sinus rhythm was noted in 1 observational study of 13 asymptomatic patients with persistent AF.31 In another study that included 18 asymptomatic patients, at 1-month follow-up, no patients had improvement in symptoms, although sinus rhythm was maintained in only 35% of patients.32 In 2 small studies that focused on the impact of catheter ablation in asymptomatic patients, maintenance of sinus rhythm was associated with

Figure 20. Flowchart for Treatment Choices When Required to Decrease AF Burden. *Younger with few comorbidities. Colors correspond to Table 2. AF indicates atrial fibrillation.

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