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CLINICAL STATEMENTS AND GUIDELINES

January 2, 2024 Circulation. 2024;149:e1–e156. DOI: 10.1161/CIR.0000000000001193 e78

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

6 Randomized, controlled studies and a comprehen-

sive Cochrane database analysis5 have established the efficacy of sotalol6,7,10,17,18 for maintenance of sinus rhythm in patients with AF. In SAFE-T, the median time to AF recurrence was 74 days in the sotalol group, compared with 6 days for placebo (P<0.001).16 A Cochrane database meta-analysis of 5 randomized studies totaling 1882 patients with AF5 reported sotalol to be associated with an increase in all-cause mortality (RR, 2.23 [95% CI, 1.03-4.81]). However, this study included patients with advanced HF, and sotalol may still have a role in patients with preserved heart function. Patients undergoing initiation or reloading of oral sotalol should be admitted for at least 3 days to a health care facility that can provide calculations of CrCl, continuous electrocardiographic monitoring, and cardiac resuscitation. A recent FDA-approved intravenous sotalol formulation can be used to evaluate the drug safety and tolerability within 6 hours and thus may reduce cost and length of stay, although the data are limited to a small sample size and very selected population.32

7 In the randomized, double-blind, placebo-controlled

CAST (Cardiac Arrhythmia Suppression Trial),26,27 the Vaughan Williams class IC antiarrhythmic agents flecainide and encainide were associated with an increased mortality rate in patients with recent MI; most patients also had LVEF <50%.26 In the continuation of the study (CAST-II), the class IC agent moricizine also increased the mortality rate within the first 14 days of treatment.33 In CASH (Cardiac Arrest Study Hamburg),34 propafenone was associated with worse outcomes and increased mortality in a population of cardiac arrest survivors, most of whom had structural heart disease. Thus, IC agents are best avoided in patients with AF who have a previous MI or significant structural heart disease, including HFrEF, due to the risk of worsening HF and increased mortality. 8.	 ANDROMEDA (Antiarrhythmic Trial with Dronedarone in Moderate to Severe CHF Evaluating Morbidity Decrease)28 was a randomized, double-blind placebo-controlled study that tested the hypothesis that dronedarone would reduce the rate of hospitalization attributable to HF and possibly reduce mortality by reducing the incidence of arrhythmic death. The study enrolled patients who were hospitalized with new or worsening HF and who had at least 1 episode of NYHA

Figure 23. Treatment Algorithm for Drug Therapy for Maintenance of Sinus Rhythm. In each box, drugs are listed in alphabetical order. Significant structural heart disease with scar or fibrosis. Colors correspond to Table 2. HFrEF indicates heart failure with reduced ejection fraction; HF, heart failure; IV, intravenous; LV, left ventricular; LVEF, left ventricular ejection fraction; MI, myocardial infarction; and NYHA FC, New York Heart Association functional class.

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