Table 5

Recommendations for Maintenance of Sinus Rhythm

2006 Recommendations2011 Focused Update RecommendationsComments
Class I
 Before initiating antiarrhythmic drug therapy, treatment of precipitating or reversible causes of AF is recommended. (Level of Evidence: C)
  • 1. Before initiating antiarrhythmic drug therapy, treatment of precipitating or reversible causes of AF is recommended. (Level of Evidence: C)

2006 recommendation remains current.
  • 2. Catheter ablation performed in experienced centers is useful in maintaining sinus rhythm in selected patients with significantly symptomatic, paroxysmal AF who have failed treatment with an antiarrhythmic drug and have normal or mildly dilated left atria, normal or mildly reduced LV function, and no severe pulmonary disease (38–51). (Level of Evidence: A)

Modified recommendation (class of recommendation changed from IIa to I, wording revised, and level of evidence changed from C to A).
Class IIa
 Pharmacological therapy can be useful in patients with AF to maintain sinus rhythm and prevent tachycardia-induced cardiomyopathy. (Level of Evidence: C)
  • 1. Pharmacological therapy can be useful in patients with AF to maintain sinus rhythm and prevent tachycardia-induced cardiomyopathy. (Level of Evidence: C)

2006 recommendation remains current.
 Infrequent, well-tolerated recurrence of AF is reasonable as a successful outcome of antiarrhythmic drug therapy. (Level of Evidence: C)
  • 2. Infrequent, well-tolerated recurrence of AF is reasonable as a successful outcome of antiarrhythmic drug therapy. (Level of Evidence: C)

2006 recommendation remains current.
 Outpatient initiation of antiarrhythmic drug therapy is reasonable in patients with AF who have no associated heart disease when the agent is well tolerated. (Level of Evidence: C)
  • 3. Outpatient initiation of antiarrhythmic drug therapy is reasonable in patients with AF who have no associated heart disease when the agent is well tolerated. (Level of Evidence: C)

2006 recommendation remains current.
 In patients with lone AF without structural heart disease, initiation of propafenone or flecainide can be beneficial on an outpatient basis in patients with paroxysmal AF who are in sinus rhythm at the time of drug initiation. (Level of Evidence: B)
  • 4. In patients with AF without structural or coronary heart disease, initiation of propafenone or flecainide can be beneficial on an outpatient basis in patients with paroxysmal AF who are in sinus rhythm at the time of drug initiation (52–54). (Level of Evidence: B)

Modified recommendation (wording clarified).
 Sotalol can be beneficial in outpatients in sinus rhythm with little or no heart disease, prone to paroxysmal AF, if the baseline uncorrected QT interval is less than 460 ms, serum electrolytes are normal, and risk factors associated with Class III drug–related proarrhythmia are not present. (Level of Evidence: C)
  • 5. Sotalol can be beneficial in outpatients in sinus rhythm with little or no heart disease, prone to paroxysmal AF, if the baseline uncorrected QT interval is less than 460 ms, serum electrolytes are normal, and risk factors associated with Class III drug–related proarrhythmia are not present. (Level of Evidence: C)

2006 recommendation remains current.
  • 6. Catheter ablation is reasonable to treat symptomatic persistent AF (38,48,55–64). (Level of Evidence: A)

New recommendation
 Catheter ablation is a reasonable alternative to pharmacological therapy to prevent recurrent AF in symptomatic patients with little or no left atrium enlargement. (Level of Evidence: C)Modified recommendation (class of recommendation changed from IIa to I, wording revised and level of evidence changed from C to A).
Class IIb
  • 1. Catheter ablation may be reasonable to treat symptomatic paroxysmal AF in patients with significant left atrial dilatation or with significant LV dysfunction (38,48,55–64). (Level of Evidence: A)

New recommendation
Class III–Harm
 Antiarrhythmic therapy with a particular drug is not recommended for maintenance of sinus rhythm in patients with AF who have well-defined risk factors for proarrhythmia with that agent. (Level of Evidence: A)
  • 1. Antiarrhythmic therapy with a particular drug is not recommended for maintenance of sinus rhythm in patients with AF who have well-defined risk factors for proarrhythmia with that agent (65,66). (Level of Evidence: A)

2006 recommendation remains current.
 Pharmacological therapy is not recommended for maintenance of sinus rhythm in patients with advanced sinus node disease or AV node dysfunction unless they have a functioning electronic cardiac pacemaker. (Level of Evidence: C)
  • 2. Pharmacological therapy is not recommended for maintenance of sinus rhythm in patients with advanced sinus node disease or AV node dysfunction unless they have a functioning electronic cardiac pacemaker. (Level of Evidence: C)

2006 recommendation remains current.
  • Refers to pulmonary vein isolation with catheter ablation. An experienced center is defined as one performing more than 50 AF catheter ablation cases per year (67). Evidence-based technical guidelines including operator training and experience necessary to maximize rates of successful catheter ablation are not available; each center should maintain a database detailing procedures; success and complications, engage strategies for continuous quality improvement, and participate in registries and other efforts pooling data in order to develop optimal care algorithms (68).