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CLINICAL STATEMENTS AND GUIDELINES January 2, 2024 Circulation. 2024;149:e1–e156. DOI: 10.1161/CIR.0000000000001193 e90 Joglar et al 2023 Guideline for the Diagnosis and Management of Atrial Fibrillation 2b C-LD 3 In patients with AF who require significant ventricular pacing, conduction system pacing may be useful to reduce progression of AF.14,15 3: No benefit B-R 4 In patients with AF, specialized atrial pacing algorithms designed to suppress AF are not useful for reducing the incidence or slowing the progression of AF.12,16–18 Synopsis In patients with pacemakers, programming strategies to reduce RV pacing reduce the incidence of AF.1–6 Because AF is observed in patients with symptomatic sinus node dysfunction who require permanent pacemakersfor rate support, pacing algorithms were designed 20 to 30 years ago to suppress atrial ectopy but, unfortunately, no algorithm was able to successfully reduce AF in RCTs.12,16–19 More recently, antitachycardia pacing algorithms have been designed to identify and terminate atrial arrhythmias and have been moderately effective in patients with arrhythmias associated with more organized atrial activation due to reentry.7–13 Recommendation-Specific Supportive Text 1. Several randomized and nonrandomized stud- ies have shown that in patients who require cardiac-implanted electronic devices for sinus node dysfunction who have intact atrioventricular conduction, devices that maintain atrioventricular synchrony reduce the incidence and progression of AF.1–6 Although maintenance of atrioventricular synchrony is important, post hoc analysis of MOST and a meta-analysis have demonstrated that the amount of ventricular pacing is an important contributor to the development of AF.6,20 Algorithms designed specifically to reduce ventricular pacing reduced the incidence of AF in individual studies, but meta-analyses of RCTs suggests that the benefit may extend only to those patients with very infrequent pacing (<10%).19,21–23 In the only randomized study that solely evaluated patients with atrioventricular block (and >70 years of age) who required permanent pacing, dual-chamber pacing did not reduce the incidence of AF when compared with single-chamber ventricular pacing.24 2 Several studies have reported that specialized antitachycardia pacing algorithms can terminate atrial tachyarrhythmias but have not reduced AF burden.7–9 However, in a post hoc analysis of a subset of patients who had high success rate of antitachycardia pacing (≥60%), antitachycardia pacing algorithms reduced the overall AF/AT burden from 2.5 hours/day to 0.68 hours/day (P<0.01).10 A more recent study (MINERVA [Minimize Right Ventricular Pacing to Prevent Atrial Fibrillation and Heart Failure]) found a modestly effective pacing algorithm that monitors for periods of regularization of atrial activity to initiate pacing algorithms reduced progression to persistent AF.11,12 This algorithm may be more effective in patients who have undergone previous AF ablation.13 3 Early nonrandomized evidence suggests that His bundle and left bundle pacing may reduce AF incidence and progression when compared with RV pacing in patients with high burden ventricular pacing.14,15 In 1 study, left bundle branch area pacing reduced the incidence of new AF when compared with RV pacing, but this benefit was only evident in those patients with ventricular pacing >20%.14 However, a meta-analysis that has evaluated all published evidence has only demonstrated a trend toward reduced AF. In 1 study, His bundle pacing reduced the likelihood of development of persistent AF in patients with sinus node dysfunction and a PR interval >180 ms.25 There is indirect evidence for the potential benefit of the ventricular depolarization pattern for reducing AF because an algorithm that automatically adjusts pacing parameters based on intrinsic conduction has been associated with a decrease in longer AF episodes (>48 hours) when compared with conventional programming in a retrospective analysis.26–28 4 Several studies have evaluated atrial pacing algo- rithms to reduce AF.12,16–19 Pacing algorithms to minimize ventricular pacing in ATTEST (Atrial Therapy Efficacy and Safety Trial), a combination of algorithms designed to suppress AF and also provide antitachycardia pacing did not suppress atrial arrhythmias in patients with paroxysmal AF (AF frequency 1.3 episodes/month when “on” compared with 1.2 episodes/month when “off”).8 Despite optimistic results in some studies,12 a meta-analysis found no benefit with atrial pacing algorithms for reducing the incidence of AF.19 8.6 Surgical Ablation Recommendations for Surgical Ablation Referenced studies that support the recommendations are summarized in the Online Data Supplement. COR LOE Recommendations 2a B-R 1 For patients with AF who are undergoing cardiac surgery, concomitant surgical ablation can be beneficial to reduce the risk of recurrent AF.1–3 2a B-NR 2. In patients undergoing surgical ablation, anticoagulation therapy is reasonable for at least 3 months after the procedure to reduce the risk of stroke or systemic embolism.2–4 2b B-R 3 For patients with symptomatic, persistent AF refractory to antiarrhythmic drug therapy, a hybrid epicardial and endocardial ablation might be reasonable to reduce the risk of recurrent atrial arrhythmia.5–7 Recommendations for the Role of Pacemakers and ICDs for the Prevention and Treatment of AF (Continued ) COR LOE Recommendations Downloaded from http://ahajournals.org by on October 7, 2026