Selection of antiarrhythmic treatment in patients with AF requiring long-term rhythm control to mitigate symptoms

Table 3.4-1. Selection of antiarrhythmic treatment in patients with AF requiring long-term rhythm control to mitigate symptoms
Concomitant cardiac disease	Treatment methoda
No significant structural heart disease	1) Pharmacotherapy: – Recommended agents: dronedarone, flecainide, propafenone – Agents that may be considered: sotalolb 2) Percutaneous ablationc
CAD, significant valvular heart disease, HFpEF	1) Pharmacotherapy: – Recommended agents: amiodarone, dronedarone – Agents that may be considered: sotalolb 2) Percutaneous ablationc
HFrEF	1) Pharmacotherapy: amiodarone 2) Percutaneous ablationc,d
a The choice between pharmacotherapy and percutaneous ablation depends on the type of treatment (first-line vs second-line), type of AF (paroxysmal vs persistent), and the patient’s decision. b Patients treated with sotalol should be monitored for proarrhythmia (assess for QT prolongation with periodical ECG; our pattern is baseline 1 week after starting treatment and every 6 months afterwards). c Pulmonary vein isolation with radiofrequency or cryoballoon ablation. d Ablation as first-line treatment is usually reserved for patients with HF secondary to tachycardia-induced cardiomyopathy.
Adapted from the 2020 European Society of Cardiology guidelines.
AF, atrial fibrillation; CAD, coronary artery disease; ECG, electrocardiography; HF, heart failure; HFpEF, heart failure with preserved ejection fraction; HFrEF, heart failure with reduced ejection fraction.