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CLINICAL STATEMENTS AND GUIDELINES January 2, 2024 Circulation. 2024;149:e1–e156. DOI: 10.1161/CIR.0000000000001193 e84 Joglar et al 2023 Guideline for the Diagnosis and Management of Atrial Fibrillation ARBs, aldosterone antagonists, statins, omega-3 polyunsaturated fatty acids, antioxidants, and sodium-glucose cotransporter 2 inhibitors (see Section 5, “Lifestyle and Risk Factor Modification for AF Management”). Targeting inflammation, a randomized study of glucocorticoids reduced recurrent AF after first occurrence of persistent AF, but adverse effects inhibit long-term steroid use.1–9 Statins reduced postoperative AF in small RCTs.10–14 However, an adequately powered placebo-controlled trial of rosuvastatin did not reduce postoperative AF.15 Statins do not prevent AF in other cardiovascular settings.16 RCTs and a meta-analysis provide limited though consistent support for the antioxidant ascorbic acid for postoperative AF.17 Targeting fibrosis, small or secondary studies of RCTs reported lower new AF with ACE inhibitors or ARBs.2–9 However, larger RCTs targeting AF failed to reduce recurrent AF.18–20 RCTs showed that MRAs reduced new-onset atrial arrhythmias in patients with HFrEF along with improvement of other cardiovascular outcomes.21,22 In patients with type 2 diabetes, HF, or CKD, sodium-glucose cotransporter 2 inhibitors appear to prevent new AF.23–25 In contrast, omega-3 fatty acids do not appear to reduce AF and, in 1 large study, was associated with higher occurrence of AF.26–31 With only limited or inconsistent data, no recommendations are made for use of these upstream therapies for prevention of AF. 8.4 AF Catheter Ablation Recommendations for AF Catheter Ablation Referenced studies that support the recommendations are summarized in the Online Data Supplement. COR LOE Recommendations 1 A 1 In patients with symptomatic AF in whom anti- arrhythmic drugs have been ineffective, contraindicated, not tolerated or not preferred, and continued rhythm control is desired, catheter ablation is useful to improve symptoms.1–10 1 A 2 In selected patients (generally younger with few comorbidities) with symptomatic paroxysmal AF in whom rhythm control is desired, catheter ablation is useful as first-line therapy to improve symptoms and reduce progression to persistent AF.11–16 1 A 3 In patients with symptomatic or clinically significant AFL, catheter ablation is useful for improving symptoms.17–19 2a B-NR 4 In patients who are undergoing ablation for AF, ablation of additional clinically significant supraventricular arrhythmias can be useful to reduce the likelihood of future arrhythmia.17,18,20–27 2a B-R 5 In patients (other than younger with few comorbidities) with symptomatic paroxysmal or persistent AF who are being managed with a rhythm-control strategy, catheter ablation as first-line therapy can be useful to improve symptoms.11–13,28 Cost Value Statement: Intermediate B-R 6 Catheter ablation for symptomatic AF provides intermediate economic value compared with antiarrhythmic drug therapy.29,30 2b B-NR 7 In selected* patients with asymptomatic or minimally symptomatic AF, catheter ablation may be useful for reducing progression of AF and its associated complications.31–39 *Younger patients with few comorbidities and a moderate to high burden of AF or persistent AF and AFL. Synopsis Catheter ablation has become an established therapy for AF because of multiple RCTs and evidence from large registries and continues to evolve as new technologies are developed. Previous professional society documents have provided different recommendations for catheter ablation dependent on whether AF was persistent or paroxysmal.25,40 More recent information has shown that ablation for AF is more effective than antiarrhythmic drugs for both persistent and paroxysmal AF and that earlier implementation of rhythm control strategies is an important factor for improving AF ablation success rat es.4,35,41–44 As with all strategies for rhythm control of AF, impact on a patient’s goals of care and QOL should be the focus. For example, significantly reducing the frequency and duration of AF episodes but not eliminating all future episodes of AF may represent a clinically important improvement. Although RCTs have mainly used younger patients (<70 years of age) who also experience the largest benefits, observational studies have reported improvement in QOL with catheter ablation in older patients.3–6,8,45–47 Recommendation-Specific Supportive Text 1. In patients who have not responded to an antiar- rhythmic drug due to a high burden of recurrent AF or adverse effects from the medication, RCTs have consistently demonstrated lower risk for recurrent symptomatic AF after ablation when compared with using another antiarrhythmic medication.1–10 As an example, in STOP-AF, patients who had failed ≥1 antiarrhythmic drug (approximately 70% and 30% for 1 or 2 failed drugs, respectively) were randomized to either another antiarrhythmic drug or catheter ablation. At 1 year follow-up, catheter ablation was associated with a treatment success rate of 70% compared with 7% in the drug arm.10 Similarly, in the Thermo-cool (NAVISTAR THERMOCOOL Catheter for the Radiofrequency Ablation of Symptomatic Paroxysmal Atrial Fibrillation) trial, patients with paroxysmal AF who had failed 1 antiarrhythmic medication were randomized to catheter ablation or another antiarrhythmic drug. After 9 months, 66% of patients in the catheter ablation Recommendations for AF Catheter Ablation (Continued ) COR LOE Recommendations Downloaded from http://ahajournals.org by on October 7, 2026