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


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.