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CLINICAL STATEMENTS AND GUIDELINES January 2, 2024 Circulation. 2024;149:e1–e156. DOI: 10.1161/CIR.0000000000001193 e76 Joglar et al 2023 Guideline for the Diagnosis and Management of Atrial Fibrillation 4 Single oral doses of flecainide9–11 and propafe- none10–14 are effective for conversion of AF to sinus rhythm, with 3- to 4-hour conversion rates of 58% to 68% for flecainide (compared with 18%-29% for placebo) and 45% to 57% for propafenone (compared with 17%-29% for placebo) (Table 22). A beta blocker or nondihydropyridine calcium channel blocker is generally administered at least 30 minutes before a dose of flecainide or propafenone to prevent 1:1 atrioventricular conduction during AFL.15 The PITP strategy was studied in 268 patients with stable AF of recent onset who presented to the emergency department.16 Patients received single-dose oral flecainide or propafenone, and those who were successfully treated (n=210) were discharged with a plan for the PITP approach. In the 15±5month follow-up period, single-dose flecainide or propafenone was successful in 94% of episodes. However, the incidence of adverse effects is not insignificant (6%-17%).16–18 In view of this, and because in most studies, most patients received the first dose in the hospital before taking it as an outpatient, the PITP strategy should only be used for highly selected patients and after it first has been observed to be safe and effective in an inpatient setting.17,18,34 5 Intravenous procainamide was shown to be more effective than placebo for conversion of AF to sinus rhythm (conversion rates at 1 hour, 69% versus 38%; P=0.012) in a randomized, doubleblind study of 114 patients.19 However, intravenous procainamide is less effective than ibutilide for conversion of AF to sinus rhythm (conversion rates, 14% versus 76%; P=0.001).22 The efficacy of procainamide for conversion of AF to sinus rhythm was similarly inferior to that of ibutilide in an analysis of pooled data.23 In addition, intravenous procainamide is associated with a relatively high incidence of clinically significant hypotension (5%-12%)19,23 and can exacerbate HFrEF. 8.3 Antiarrhythmic Drugs for Maintenance of Sinus Rhythm 8.3.1 Specific Drug Therapy for Long-Term Maintenance of Sinus Rhythm Recommendations for Specific Drug Therapy for Long-Term Maintenance of Sinus Rhythm Referenced studies that support the recommendations are summarized in the Online Data Supplement. COR LOE Recommendations 2a A* 1. For patients with AF and HFrEF (≤40%), therapy with dofetilide*1 or amiodarone†2 is reasonable for long-term maintenance of sinus rhythm. B-NR† 2a A 2 For patients with AF and no previous MI, or known or suspected significant structural heart disease, or ventricular scar or fibrosis, use of flecainide3–5 or propafenone5–12 is reasonable for long-term maintenance of sinus rhythm. 2a A 3 For patients with AF without recent decompensated HF or severe LV dysfunction, use of dronedarone5,13–15 is reasonable for long-term maintenance of sinus rhythm. 2a A 4 For patients with AF without significant baseline QT interval prolongation or uncorrected hypokalemia or hypomagnesemia, use of dofetilide1,5,16 5–7,10,17,18 is reasonable for long-term maintenance of sinus rhythm, with proper dose selection based on kidney function and close monitoring of the QT interval, serum potassium and magnesium concentrations, and kidney function. 2a A 5 For patients with AF and normal LV function, use of low-dose amiodarone (100-200 mg/d) is reasonable for long-term maintenance of sinus rhy thm2,5,17–22 but, in view of its adverse effect profile,5,23,24 should be reserved for patients in whom other rhythm control strategies are ineffective, not preferred, or contraindicated. 2b A 6 For patients with AF without significant baseline QT interval prolongation, hypokalemia, hypomagnesemia, or bradycardia, use of sotalol5–7,10,17,18 may be considered for long-term maintenance of sinus rhythm, with proper dose selection based on kidney function and close monitoring of the QT interval, heart rate, serum potassium and magnesium concentrations, and kidney function. 3: Harm B-R 7 In patients with previous MI and/or significant struc- tural heart disease, including HFrEF (LVEF ≤40%), flecainide and propafenone25 should not be administered due to the risk of worsening HF, potential proarrhythmia, and increased mortality.26,27 3: Harm B-R 8 For patients with AF, dronedarone should not be administered for maintenance of sinus rhythm to those with NYHA class III and IV HF or patients who have had an episode of decompensated HF in the past 4 weeks, due to the risk of increased early mortality associated with worsening HF.28 *A LOE applies to data on dofetilide. †B-NR LOE applies to data on amiodarone. Synopsis Antiarrhythmic drugs are reasonable for long-term maintenance of sinus rhythm for patients with AF who are not candidates for, or decline, catheter ablation or who prefer antiarrhythmic therapy. Flecainide3–5 and propafenone5–11 are options for maintenance of sinus rhythm in patients with no previous history of MI or significant structural heart disease.26,27 Dronedarone is an option for maintenance of sinus rhythm in patients without recent decompensated HF or severe LV dysfunction.5,13–15 Dofetilide1,5,16 and sota lol5–7,10,17,18 are effective for maintenance of sinus rhythm but are associated with torsades de pointes and require QT interval monitoring. Sotalol is best avoided in patients with HFrEF, because most patients are already taking a beta blocker, and the addition of sotalol is unlikely to Recommendations for Specific Drug Therapy for Long-Term Maintenance of Sinus Rhythm (Continued ) COR LOE Recommendations Downloaded from http://ahajournals.org by on October 7, 2026