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Electrical cardioversion

Rate control target = resting heart rate <110 b.p.m. (lenient control),

with stricter control with continuing symptoms

(Class IIa)

Beta-blocker or digoxin (Class I) Patient with persistent AF

LVEF ≤40%

Combination rate control therapy

(Class IIa)

Combination rate control therapy

(Class IIa)

Amiodarone

(Class I) Dronedarone, flecainide

or propafenone

(Class I)

Amiodarone or dronedarone

(Class I)

Sotalol (Class IIb)

HFrEF (LVEF ≤40%) Stable HFmrEF (LVEF 41–49%), coronary heart disease,

valvular heart disease Absence or minimal heart

disease

Sotalol (Class IIb)

Recurrence of AF symptoms

Antiarrhythmic drug therapy Y N

Shared decision-making on rhythm control

(Class I)

If failed antiarrhythmic

drug therapy If failed catheter

ablation

Catheter ablationa

(Class IIb)

Shared decision-making, considering all rhythm control options

(Class I) Beta-blocker, digoxin, diltiazem or verapamil

(Class I)

Catheter ablation (Class I) Re-do catheter

ablation Endoscopic

hybrid or surgical ablation Antiarrhythmic

drug therapy (see above) Consider rate control

strategy

Follow AF-CARE for [C] comorbidity and risk factor management & [A] avoid stroke and thromboembolism

Haemodynamic instability (Class I) Part of rhythm control strategy (Class IIa) Clarify benefit from sinus rhythm (Class IIa)

Endoscopic/ hybrid ablation

(Class IIa)

Figure 6 [R] Pathway for patients with persistent AF. AF, atrial fibrillation; AF-CARE, Atrial fibrillation—[C] Comorbidity and risk factor management, [A] Avoid stroke and thromboembolism, [R] Reduce symptoms by rate and rhythm control, [E] Evaluation and dynamic reassessment; b.p.m., beats per minute; HFmrEF, heart failure with mildly reduced ejection fraction; HFrEF, heart failure with reduced ejection fraction; LVEF, left ventricular ejection fraction. aIn patients with HFrEF: Class I if high probability of tachycardia-induced cardiomyopathy; and Class IIa in selected patients to improve prognosis. Downloaded from academic.oup.com/eurheartj/article/45/36/3314/7738779 by guest on 07 October 2026