Table 15

Summary of Recommendations for Specific Patient Groups and AF

RecommendationsCORLOEReferences
Hypertrophic cardiomyopathy
 Anticoagulation is indicated in HCM with AF independent of the CHA2DS2-VASc scoreIB(50,457)
 Antiarrhythmic drugs can be useful to prevent recurrent AF in HCM. Amiodarone or disopyramide combined with a beta blocker or nondihydropyridine calcium channel antagonist are reasonableIIaCN/A
 AF catheter ablation can be beneficial for HCM to facilitate a rhythm-control strategy when antiarrhythmics fail or are not toleratedIIaB(458–461)
 Sotalol, dofetilide, and dronedarone may be considered for a rhythm-control strategy in HCMIIbC(11)
AF complicating ACS
 Urgent cardioversion of new-onset AF in the setting of ACS is recommended for patients with hemodynamic compromise, ongoing ischemia, or inadequate rate controlICN/A
 IV beta blockers are recommended to slow RVR with ACS and no HF, hemodynamic instability, bronchospasmICN/A
 With ACS and AF with CHA2DS2-VASc score ≥2, anticoagulation with warfarin is recommended unless contraindicatedICN/A
 Amiodarone or digoxin may be considered to slow RVR with ACS and AF and severe LV dysfunction and HF or hemodynamic instabilityIIbCN/A
 Nondihydropyridine calcium antagonists might be considered to slow RVR with ACS and AF only in the absence of significant HF or hemodynamic instabilityIIbCN/A
Hyperthyroidism
 Beta blockers are recommended to control ventricular rate with AF complicating thyrotoxicosis unless contraindicatedICN/A
 When beta blockers cannot be used, a nondihydropyridine calcium channel antagonist is recommended to control ventricular rateICN/A
Pulmonary diseases
 A nondihydropyridine calcium channel antagonist is recommended to control ventricular rate with AF and COPDICN/A
 Cardioversion should be attempted for patients with pulmonary disease who become hemodynamically unstable with new-onset AFICN/A
WPW and pre-excitation syndromes
 Cardioversion is recommended for patients with AF, WPW syndrome, and RVR who are hemodynamically compromisedIC(64)
 IV procainamide or ibutilide to restore sinus rhythm or slow ventricular rate is recommended for patients with pre-excited AF and RVR who are not hemodynamically compromisedIC(64)
 Catheter ablation of the accessory pathway is recommended in symptomatic patients with pre-excited AF, especially if the accessory pathway has a short refractory periodIC(64)
 IV amiodarone, adenosine, digoxin, or nondihydropyridine calcium channel antagonists in patients with WPW syndrome who have pre-excited AF is potentially harmfulIII: HarmB(493–495)
Heart failure
 A beta blocker or nondihydropyridine calcium channel antagonist is recommended for persistent or permanent AF in patients with HFpEFIB(269)
 In the absence of preexcitation, an IV beta blocker (or a nondihydropyridine calcium channel antagonist with HFpEF) is recommended to slow ventricular response to AF in the acute setting, with caution in patients with overt congestion, hypotension, or HFrEFIB(502–505)
 In the absence of pre-excitation, IV digoxin or amiodarone is recommended to control heart rate acutelyIB(277,503,506,507)
 Assess heart rate during exercise and adjust pharmacological treatment in symptomatic patients during activityICN/A
 Digoxin is effective to control resting heart rate with HFrEFICN/A
 A combination of digoxin and beta blocker (or a nondihydropyridine calcium channel antagonist with HFpEF) is reasonable to control resting and exercise heart rate with AFIIaB(267,503)
 It is reasonable to perform AV node ablation with ventricular pacing to control heart rate when pharmacological therapy is insufficient or not toleratedIIaB(269,508,509)
 IV amiodarone can be useful to control heart rate with AF when other measures are unsuccessful or contraindicatedIIaCN/A
 With AF and RVR causing or suspected of causing tachycardia-induced cardiomyopathy, it is reasonable to achieve rate control by AV nodal blockade or a rhythm-control strategyIIaB(51,307,510)
 In patients with chronic HF who remain symptomatic from AF despite a rate-control strategy, it is reasonable to use a rhythm-control strategyIIaCN/A
 Amiodarone may be considered when resting and exercise heart rate cannot be controlled with a beta blocker (or a nondihydropyridine calcium channel antagonist with HFpEF) or digoxin, alone or in combinationIIbCN/A
 AV node ablation may be considered when rate cannot be controlled and tachycardia-mediated cardiomyopathy is suspectedIIbCN/A
 AV node ablation should not be performed without a pharmacological trial to control ventricular rateIII: HarmCN/A
 For rate control, IV nondihydropyridine calcium channel antagonists, IV beta blockers, and dronedarone should not be given with decompensated HFIII: HarmCN/A
Familial (genetic) AF
 For patients with AF and multigenerational family members with AF, referral to a tertiary care center for genetic counseling and testing may be consideredIIbCN/A
Postoperative cardiac and thoracic surgery
 A beta blocker is recommended to treat postoperative AF unless contraindicatedIA(533–536)
 A nondihydropyridine calcium channel blocker is recommended when a beta blocker is inadequate to achieve rate control with postoperative AFIB(537)
 Preoperative amiodarone reduces AF with cardiac surgery and is reasonable as prophylactic therapy for patients at high risk of postoperative AFIIaA(538–540)
 It is reasonable to restore sinus rhythm pharmacologically with ibutilide or direct-current cardioversion with postoperative AFIIaB(541)
 It is reasonable to administer antiarrhythmic medications to maintain sinus rhythm with recurrent or refractory postoperative AFIIaB(537)
 It is reasonable to administer antithrombotic medications for postoperative AFIIaB(542)
 It is reasonable to manage new-onset postoperative AF with rate control and anticoagulation with cardioversion if AF does not revert spontaneously to sinus rhythm during follow-upIIaCN/A
 Prophylactic sotalol may be considered for patients with AF risk after cardiac surgeryIIbB(536,543)
 Colchicine may be considered postoperatively to reduce AF after cardiac surgeryIIbB(544)

ACS indicates acute coronary syndromes; AF, atrial fibrillation; AV, atrioventricular; CHA2DS2-VASc, Congestive heart failure, Hypertension, Age ≥75 years (doubled), Diabetes mellitus, Prior Stroke or TIA or thromboembolism (doubled), Vascular disease, Age 65 to 74 years, Sex category; COPD, chronic obstructive pulmonary disease; COR, Class of Recommendation; HCM, hypertrophic cardiomyopathy; HF, heart failure; HFpEF, heart failure with preserved ejection fraction; HFrEF, heart failure with reduced ejection fraction; IV, intravenous; LOE, Level of Evidence; LV, left ventricular; N/A, not applicable; RVR, rapid ventricular response; and WPW, Wolff-Parkinson-White.