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CLINICAL STATEMENTS AND GUIDELINES

January 2, 2024 Circulation. 2024;149:e1–e156. DOI: 10.1161/CIR.0000000000001193 e96

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

APAF-CRT (Ablate and Pace in Atrial Fibrillation plus Cardiac Resynchronization Therapy) mortality trial of 133 subjects with AF, HF, and narrow QRS was stopped early due to a HR of 0.26 for allcause mortality, also suggesting that when AVNA is performed in patients with HF, CRT is preferable to conventional RV pacing.23 Data are accumulating regarding similarly improved outcomes with conduction system pacing compared with conventional RV pacing in this population.32–35

7 Conduction of AF may hinder delivery of biventricu-

lar pacing therapy (CRT) and worsen outcomes.25 Initial clinical trials of CRT included low numbers of patients with AF,50 and observational analyses suggested a reduced benefit of CRT in patients with AF due to ineffective biventricular pacing.51,52 A systematic review to evaluate the impact of AVNA in patients with AF and CRT found AVNA was associated with significant reductions in all-cause mortality (RR, 0.42 [95% CI, 0.26-0.68]), cardiovascular mortality (RR, 0.44 [95% CI, 0.24-0.81]), and improvement in NYHA class (RR, –0.52 [95% CI, –0.87 to –0.17]).24 Confirmatory evidence of the importance of adequate biventricular pacing percentage is provided by an analysis of remote monitoring data showing a strong association between increasing percentages of biventricular pacing and reduced mortality, with the greatest magnitude reduction at >98% pacing.53 In a systematic review and meta-analysis of 31 studies in 83 571 individuals, CRT alone did not improve the mortality rate in patients with AF, but the all-cause mortality rate was lower in the AVNA group.25 Many patients with CRT devices also have combined defibrillator therapy. In a pooled analysis of 664 patients with AF and CRT in whom 282 underwent AVNA, a significant reduction in appropriate and inappropriate ICD shocks and a decrease in all-cause hospitalizations was associated with AVNA.26

8 In an observational study of 24 patients with

AF-induced cardiomyopathy and NYHA class III/ IV HF, the median time from onset of arrhythmia to cardiomyopathy and HF was 4.2 years. Aggressive rate/rhythm control resulted in significant LVEF recovery in all patients within 6 months. Five of 24 patients had recurrent AF, and all had a rapid decline in LVEF within 6 months after arrhythmia recurrence.27 In an observational cohort of 69 patients with AF and LVEF <40% who underwent catheter ablation, patients who maintained sinus rhythm (65%) had complete LV function recovery and maintained normal LVEF over 28±11 months of follow-up, compared with those who had recurrent AF/AT.28 Long-term surveillance to detect recurrent AF can be beneficial and can be accomplished by various modalities, including wearable devices, smart watches, random monitoring (Holter, event, mobile telemetry), and implantable loop recorders. 9.	 In patients with arrhythmia-induced cardiomyopa-

thy and HFrEF, the ideal target heart rate for rate control remains uncertain. However, because of the potential negative impact of rapid ventricular rates on HF and cardiomyopathy, a stricter rate-control strategy may be reasonable. In the AF-CHF trial, which compared rate control versus rhythm control using antiarrhythmic therapy in AF and HFrEF, the target rate control was defined as ventricular rate <80 bpm during resting 12-lead electrocardiography and <110 bpm during a 6-minute walk test.29 In the RACE II trial, 614 patients with permanent AF were randomized to a heart rate <80 bpm at rest and <110 bpm during moderate exercise or lenient control (resting heart rate, <110 bpm), with results showing similar outcomes in each arm. However, RACE II trial patients were rate controlled at enrollment (baseline heart rate, 96 bpm), and only 15% of the study cohort had an LVEF <40%, plus very few patients had heart rates >100 bpm, even in the lenient rate control gorup.54 In a crossover study of 20 patients with persistent AF and LVEF <40%, patients were given escalating doses of metoprolol (average dose, 121 mg) to get target heart rate <70 bpm. After 3 months, average resting heart rate decreased from 94±14 bpm to 85±12 bpm, but no significant differences in QOL on functional status were noted.31 Strict rate control is also advisable in patients with ICDs and CRT (See Table 20 in Section 7.1, “Broad Considerations for Rate Control”).55,56

10 In small observational series of patients undergo-

ing AVNA and His bundle pacing, postprocedural increase in EF and improved functional class has been demonstrated, at the expense of increased pacing thresholds in some patients.32,35 A singlecenter study comparing outcomes after AVNA with His bundle pacing and left bundle area pacing in 105 patients showed a higher rate of recurrent AVN conduction in the His bundle pacing group and longer fluoroscopy time.33 Acute threshold rise, exit block, and elevated long-term thresholds were also seen in the His bundle pacing group but not in left bundle area pacingin follow-up limited to 10.5 months. Both strategies were associated with a significantly improved EF in patients with EF <50% at baseline (N=16; 37%±7.6% versus 46%±13%; P=0.02).33 An observational comparative study of patients undergoing AVNA, of whom 113 had RV (56) or BiV (57) pacing and 110 had conduction system pacing (84 His bundle pacing and 46 left bundle area pacing) showed increased

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