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Due to its broad extracardiac adverse effect profile, amiodarone is reserved as a last option when heart rate cannot be controlled even with maximal tolerated combination therapy, or in patients who do not qualify for atrioventricular node ablation and pacing. Many of the adverse effects from amiodarone have a direct relationship with cumulative dose, restricting the long-term value of amiodarone for rate control.487

7.1.4 Atrioventricular node ablation and pacemaker

implantation Ablation of the atrioventricular node and pacemaker implantation (‘ablate and pace’) can lower and regularize heart rate in patients with AF (see Supplementary data online, Additional Evidence Table S16). The procedure has a low complication rate and a low long-term mortality risk.468,488 The pacemaker should be implanted a few weeks before the atrioventricular node ablation, with the initial pacing rate after ablation set at 70– 90 b.p.m.489,490 This strategy does not worsen LV function,491 and may even improve LVEF in selected patients.492,493 The evidence base has typically included older patients. For younger patients, ablate and pace should only be considered if heart rate remains uncontrolled despite consideration of other pharmacological and non-pharmacological treatment options. The choice of pacing therapy (right ventricular or biventricular pacing) depends on patient characteristics, presence of heart failure, and LVEF.187,494 In severely symptomatic patients with permanent AF and at least one hospitalization for heart failure, atrioventricular node ablation combined with CRT should be considered. In the APAF-CRT (Ablate and Pace for Atrial Fibrillation-cardiac resynchronization therapy) trial in a population with narrow QRS complexes, atrioventricular node ablation combined with CRT was superior to rate control drugs for the primary outcomes (allcause mortality, and death or hospitalization for heart failure), and secondary outcomes (symptom burden and physical limitation).470,471 Conduction system pacing may become a potentially useful alternate pacing mode when implementing a pace and ablate strategy, once safety and efficacy have been confirmed in larger RCTs.495,496 In CRT recipients, the presence (or occurrence) of AF is one of the main reasons for suboptimal biventricular pacing.187 Improvement of biventricular pacing is indicated and can be reached by intensification of rate control drug regimens, atrioventricular node ablation, or rhythm control, depending on patient and AF characteristics.187 7.2 Rhythm control strategies in patients

with AF 7.2.1. General principles and anticoagulation Rhythm control refers to therapies dedicated to restoring and maintaining sinus rhythm. These treatments include cardioversion, AADs, percutaneous catheter ablation, endoscopic and hybrid ablation, and open surgical approaches (see Supplementary data online, Additional Evidence Table S17). Rhythm control is never a strategy on its own; instead, it should always be part of the AF-CARE approach. In patients with acute or worsening haemodynamic instability thought to be caused by AF, rapid electrical cardioversion is recommended. For other patients, a wait-and-see approach should be considered as an alternative to immediate cardioversion (Figure 12). The Rate Control versus Electrical Cardioversion Trial 7–Acute Cardioversion versus Wait and See (RACE 7 ACWAS) trial in patients with recent-onset symptomatic AF without haemodynamic compromise showed a wait-and-see approach for spontaneous conversion until 48 h after the onset of AF symptoms was noninferior as compared with immediate cardioversion at 4 weeks follow-up.10 Since the publication of landmark trials more than 20 years ago, the main reason to consider longer-term rhythm control therapy has been the reduction in symptoms from AF.497–500 Older studies have shown that the institution of a rhythm control strategy using AADs does not reduce mortality and morbidity when compared with a rate control-only strategy,497–500 and may increase hospitalization.457 In contrast, multiple studies have shown that rhythm control strategies have a positive effect on quality of life once sinus rhythm is maintained.501,502 Therefore, in the case of uncertainty of the presence of symptoms associated with AF, an attempt to restore sinus rhythm is a rational first step. In patients with symptoms, patient factors that favour an attempt at rhythm control should be considered, including suspected tachycardiomyopathy, a brief AF history, non-dilated left atrium, or patient preference. Rhythm control strategies have significantly evolved due to an increasing experience in the safe use of antiarrhythmic drugs,17 consistent use of OAC, improvements in ablation technology,503–509 and identification and management of risk factors and comorbidities.39,510,511 In the ATHENA trial (A Placebo-Controlled, Double-Blind, Parallel Arm Trial to Assess the Efficacy of Dronedarone 400 mg twice daily for the Prevention of

Non-dihydropyridine calcium channel antagonists Verapamil 2.5–10 mg i.v. bolus over 5 min 40 mg twice daily to 480 mg (extended release) once daily Contraindicated if LVEF ≤40%. Adapt doses in hepatic and renal impairment. Diltiazem 0.25 mg/kg i.v. bolus over 5 min, then 5–15 mg/h 60 mg three times daily to 360 mg (extended release) once daily Digitalis glycosides Digoxin 0.5 mg i.v. bolus (0.75–1.5 mg over 24 h in

divided doses) 0.0625–0.25 mg once daily High plasma levels associated with adverse

events. Check renal function before starting

digoxin and adapt dose in CKD patients. Digitoxin 0.4–0.6 mg 0.05–0.1 mg once daily Other Amiodaroned 300 mg i.v. diluted in 250 mL 5% dextrose over 30–60 min (preferably via central venous

cannula), followed by 900–1200 mg i.v. over 24 h diluted in 500–1000 mL via a central venous cannula 200 mg once daily after loading Loading: 200 mg three times daily for 4

weeks, then 200 mg daily or less as appropriate (reduce other rate control drugs according to heart rate) Contraindicated in iodine sensitivity. Serious potential adverse effects (including

pulmonary, ophthalmic, hepatic, and thyroid). Consider numerous drug interactions. © ESC 2024

AF, atrial fibrillation; CKD, chronic kidney disease; HF, heart failure; i.v., intravenous; min, minutes; N/A, not available or not widely available. Maximum doses have been defined based on the summary of product characteristic of each drug. aAll rate control drugs are contraindicated in Wolff–Parkinson–White syndrome; also intravenous amiodarone. bOther beta-blockers are available but not recommended as specific rate control therapy in AF and therefore not mentioned here (e.g. propranolol and labetalol). cNo data on atenolol; should not be used in heart failure with reduced ejection fraction or in pregnancy. dLoading regimen may vary; i.v. dosage should be considered when calculating total load.

ESC Guidelines                                                                                                                                                                                          3353

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