-
Rate-control approach desired (d/t pt preference, etc)
Control rest/exercise heart rate1 w/ 1st-line agent,2 no antithrombotic tx (unless HCM)3 - BB or non-DHP-CCB (diltiazem/verapamil)2 [I/B]. If COPD, CCB [I/C]; if hyperthyroid, BB preferred [I/C], if cannot be used, then CCB [I/C]
- Resting goal HR ≤80 [IIa/B]; if asymptomatic w/ preserved LV systolic fxn, consider lenient ≤110 [IIb/B]. Adjust to control rate during exertion [I/C]
If BB/CCB failure/intolerance, use non-1st-line rate control - Digoxin/combos:2 Combine BB w/ other drugs, including digoxin; titrate to avoid bradycardia. Digoxin may be combined w/ BB or CCB [IIa/B]
- If drug rate control inadequate/sx persist, use rhythm control4
- If drug tx inadequate and rhythm control not achievable: AV-node ablation4 + pacing [IIa/B]
Footnotes 1 RCTs show no superiority of rhythm vs rate control. Initial rate-control strategy reasonable for many; consider rhythm control if persistent AF sx, rate control difficulties, younger pt age, tach-mediated CM, 1st AF episode, acute illness-precipitated AF, chronic HF w/ sx despite rate control [IIa/C], or pt preference; rhythm-control preferred for HCM. Recommendations are regardless of AF/aflutter type. Correct underlying causes.
2 Drugs alpha-listed. Non-DHP-CCB (diltiazem, verapamil): do not use CCB if LV dysfnx/↓EF/pre-excitation [III/B] or if decompensated HF [III/C]. BB choice (cardioselective, etc.) depends on pt condition; consider CCB if COPD. If decompensated HF, start BB after stabilization. Digoxin: avoid in HCM or pre-excitation. Amiodarone may be used for rate control when other measures fail/contraindicated [IIb/C]; do not use in pre-excitation [III/B]. If HCM, rhythm-control preferred; if rate control used, BB/CCB or combine both; amiodarone or disopyramide reasonable w/ BB/CCB [IIa/C]; avoid digoxin.
3 Reasonable to omit antithrombotic tx if CHA2DS2-VASc 0 [IIa/B]; except HCM requires anticoagulation regardless of score [I/B]. CHA2DS2-VASc (stroke risk): 0 (0%), 1 (1.3%), 2 (2.2%), 3 (3.2%), 4 (4%), 5 (6.7%), 6 (9.8%), 7 (9.6%), 8 (6.7%), 9 (15.2%).
4 Do not AV-node ablate before drug rate control trial [III/C]. If RVR causing/suspected cause of tach-induced CM, AV-nodal blockade or rhythm control reasonable [IIa/B]. If tach-mediated CM suspected w/ rate not controllable: consider AV-node ablation [IIb/C].
Rate control5 +/- antithrombotic tx6,7 Consider antithrombotic options6,7 [IIb/C] based on stroke/bleed risks, renal fxn, pt preference [I/C] - No antithrombotic tx (unless HCM)6
- Anticoagulant (warfarin; apixaban, dabigatran, rivaroxaban)7
- Aspirin7
- Women w/ AF are at increased stroke risk vs men; a study concluded that women <65 yo w/o other risk factors (ie, CHA2DS2-VASc=1 solely d/t gender) are at low stroke risk and don’t require anticoagulation
Control heart rate;5 adjust to control rate during exertion [I/C] - BB/CCB (diltiazem/verapamil)8 is 1st line [I/B]. If COPD, CCB [I/C]; if hyperthyroid, BB [I/C], if can’t be used, CCB [I/C]; if systolic HF, BB. Resting goal HR ≤80 [IIa/B]; if no sx & preserved LV systolic fxn, consider lenient ≤110 [IIb/B]
- If BB/CCB failure/intolerance, use dig/combos:8 Dig controls resting HR in HFrEF [I/C]. Combine BB w/ other drugs, incl. dig; titrate to avoid bradycardia. Dig may be combined w/ BB or CCB [IIa/B] incl. for HF pts (avoid CCB if HFrEF) [IIa/B]
- If HF w/ rest/exercise HR not controlled w/ BB, CCB (in HFpEF) or dig (alone or combined): consider amiodarone8 [IIb/C]
- If drug rate control inadequate/sx persist, use rhythm control.9 If drug tx inadequate and rhythm control not achievable: AV-node ablation9 + pacing [IIa/B]
Footnotes 5 RCTs show no superiority of rhythm vs rate control. Initial rate-control strategy reasonable for many; consider rhythm control if persistent AF sx, rate control difficulties, younger pt age, tach-mediated CM, 1st AF episode, acute illness-precipitated AF, chronic HF w/ sx despite rate control [IIa/C], or pt preference; rhythm-control preferred for HCM. Recommendations are regardless of AF/aflutter type. Correct underlying causes.
6 HCM requires anticoagulation regardless of score [I/B]. If pt undergoing cardiac surgery, may consider LAA surgical excision [IIb/C]. CHA2DS2-VASc (stroke risk): 0 (0%), 1 (1.3%), 2 (2.2%), 3 (3.2%), 4 (4%), 5 (6.7%), 6 (9.8%), 7 (9.6%), 8 (6.7%), 9 (15.2%).
7 Antithrombotics: Re-eval needs/choices periodically [I/C]. Warfarin: INR goal 2-3; √ INR weekly during tx start, monthly when stable [I/A]; if levels not maintained, use dabigatran/rivaroxaban/apixaban [I/C]. Renal: DTI/FXa-I: √ renal fxn pre-tx, when clinically indicated, and at least annually [I/B]. If severe/end-stage CKD, warfarin is anticoagulant of choice [IIa/B]. If postcoronary revasc (PCI/surg): reasonable to add clopidogrel 75 mg/day (not aspirin) to anticoagulant.
8 Drugs alpha-listed. Non-DHP-CCB (diltiazem, verapamil): do not use CCB if LV dysfnx/↓EF/pre-excitation [III/B] or if decompensated HF [III/C], but may be used alone [I/B] or w/ digoxin [IIa/B] if HFpEF; BB choice (cardioselective, etc.) depends on pt condition; consider CCB if COPD; if decompensated HF, start BB after stabilization. Digoxin: avoid in HCM or pre-excitation. Amiodarone may be used for rate control when other measures failed/contraindicated [IIb/C]; do not use in pre-excitation [III/B]. If HCM, rhythm-control preferred; if rate control used, BB/CCB or combine both; amiodarone or disopyramide reasonable w/ BB/CCB [IIa/C]; avoid digoxin.
9 Do not AV-node ablate before drug rate control trial [III/C]. If RVR causing/suspected cause of tach-induced CM, AV-nodal blockade or rhythm control reasonable [IIa/B]. If tach-mediated CM suspected w/ rate not controllable: consider AV-node ablation [IIb/C].
CHA2DS2-VASc ≥2 (including hx stroke/TIA) Combine anticoagulation10 + rate control11 Anticoagulate10,12 based on stroke/bleed risks, renal fxn, pt preference [I/C] - Warfarin w/ INR 2-3 [I/A]12
- DTI/FXa-I: dabigatran, rivaroxaban, apixaban [I/B]12
- If postcoronary revasc (PCI/surg): reasonable to add clopidogrel 75 mg/day (not aspirin) to anticoagulant [IIb/B]
Control heart rate;11 adjust to control rate during exertion [I/C] - BB/CCB (diltiazem/verapamil)13 is 1st line [I/B]. If COPD, CCB [I/C]; if hyperthyroid, BB [I/C], if can’t be used, CCB [I/C]; if systolic HF, BB. Resting goal HR ≤80 [IIa/B]; if no sx & preserved LV systolic fxn, consider lenient ≤110 [IIb/B]
- If BB/CCB failure/intolerance, use dig/combos:13 Dig controls resting HR in HFrEF [I/C]. Combine BB w/ other drugs, incl. dig; titrate to avoid bradycardia. Dig may be combined w/ BB or CCB [IIa/B] incl. for HF pts (avoid CCB if HFrEF) [IIa/B]
- If HF w/ rest/exercise HR not controlled w/ BB, CCB (in HFpEF) or dig (alone or combined): consider amiodarone13 [IIb/C]
- If drug rate control inadequate/sx persist, use rhythm control.14 If drug tx inadequate and rhythm control not achievable: AV-node ablation14 + pacing [IIa/B]
Footnotes 10 HCM requires anticoagulation regardless of score [I/B]. If pt undergoing cardiac surgery, may consider LAA surgical excision [IIb/C]. CHA2DS2-VASc (stroke risk): 0 (0%), 1 (1.3%), 2 (2.2%), 3 (3.2%), 4 (4%), 5 (6.7%), 6 (9.8%), 7 (9.6%), 8 (6.7%), 9 (15.2%).
11 RCTs show no superiority of rhythm vs rate control. Initial rate-control strategy reasonable for many; consider rhythm control if persistent AF sx, rate control difficulties, younger pt age, tach-mediated CM, 1st AF episode, acute illness-precipitated AF, chronic HF w/ sx despite rate control [IIa/C], or pt preference; rhythm-control preferred for HCM. Recommendations are regardless of AF/aflutter type. Correct underlying causes.
12 Antithrombotics: Re-eval needs/choices periodically [I/C]. Warfarin: INR goal 2-3; √ INR weekly during tx start, monthly when stable [I/A]; if levels not maintained, use dabigatran/rivaroxaban/apixaban [I/C]. Renal: DTI/FXa-I: √ renal fxn pre-tx, when clinically indicated, and at least annually [I/B]. If mod to severe CKD w/ CHA2DS2-VASc ≥2, consider reduced DTI/FXa-I doses [IIb/C] (safety/efficacy not established). If severe/end-stage CKD, warfarin is anticoagulant of choice [IIa/B].
13 Drugs alpha-listed. Non-DHP-CCB (diltiazem, verapamil): do not use CCB if LV dysfnx/↓EF/pre-excitation [III/B] or if decompensated HF [III/C], but may be used alone [I/B] or w/ digoxin [IIa/B] if HFpEF; BB choice (cardioselective, etc.) depends on pt condition; consider CCB if COPD; if decompensated HF, start BB after stabilization. Digoxin: avoid in HCM or pre-excitation. Amiodarone may be used for rate control when other measures failed/contraindicated [IIb/C]; do not use in pre-excitation [III/B]. If HCM, rhythm-control preferred; if rate control used, BB/CCB or combine both; amiodarone or disopyramide reasonable w/ BB/CCB [IIa/C]; avoid digoxin.
14 Do not AV-node ablate before drug rate control trial [III/C]. If RVR causing/suspected cause of tach-induced CM, AV-nodal blockade or rhythm control reasonable [IIa/B]. If tach-mediated CM suspected w/ rate not controllable: consider AV-node ablation [IIb/C].
-
Rhythm-control approach desired (d/t pt preference, younger age, tach-mediated CM, 1st AF episode/acute-illness-precipitated, HCM, etc)
Restore sinus rhythm15 via DC cardioversion, antiarrhythmic drug, or RF cath ablation; +/- rate control. No long-term antithrombotic tx (unless HCM).16 Correct underlying causes [I/C]. - DC cardiovert [I/B] + peri-procedural anticoagulation.17 Repeat/serial attempts17 based on sinus rhythm duration, sx, pt preference17 +/- rate-control tx [IIa/C]
- Pharmacologic cardioversion18 + peri-procedural anticoagulation17 + rate-control tx: flecainide, dofetilide, propafenone, IV ibutilide [I/A] or amiodarone18 [IIa/A]
- Postconversion pill-in-pocket prn option: propafenone/flecainide + BB/non-DHP-CCB (diltiazem/verapamil), once proven safe in monitored setting, reasonable to terminate out-pt AF [IIa/B]
- Postconversion drug maintenance options19 based on CAD/LVH/HF, comorbidities, drug risks [I/A], +/- rate-control tx. OK to continue antiarrhythmic despite infrequent well-tolerated recurrences [IIb/C]; stop if AF becomes permanent [III/B]
Cath ablation19 + peri-ablation anticoagulation17 is an option; factor risk/benefit, pt preference. - Cath ablation19 for paroxysmal AF w/ sx: useful if refractory/intolerant to ≥1 class I/III drug [I/A]; reasonable as initial strategy before class I/III drug trial for recurrent paroxysmal AF w/ sx [IIa/B]
- Cath ablation19 for persistent AF w/ sx reasonable if refractory/intolerant to ≥1 class I/III drug [IIa/A], consider for long-standing (>12 mo) persistent AF w/ sx [IIb/B]; consider as initial strategy before class I/III drug trial [IIb/B]
- Cath ablation of accessory pathway recommended for pre-excited AF19 [I/C]
- If undergoing cardiac surgery for other reasons: maze procedure reasonable for select pts19 [IIa/C]
Footnotes 15 RCTs show no superiority of rhythm vs rate control. Initial rate-control strategy reasonable for many; consider rhythm control if persistent AF sx, rate control difficulties, younger pt age, tach-mediated CM, 1st AF episode, acute illness-precipitated AF, chronic HF w/ sx despite rate control [IIa/C], or pt preference; rhythm-control preferred for HCM. Recommendations are regardless of AF/aflutter type. Correct underlying causes.
16 Reasonable to omit antithrombotic tx if CHA2DS2-VASc 0 [IIa/B]; except HCM requires anticoagulation regardless of score [I/B]. CHA2DS2-VASc (stroke risk): 0 (0%), 1 (1.3%), 2 (2.2%), 3 (3.2%), 4 (4%), 5 (6.7%), 6 (9.8%), 7 (9.6%), 8 (6.7%), 9 (15.2%).
17 Anticoagulate w/ warfarin ≥3 wks pre/4 wks post [I/B]; dabigatran, rivaroxaban, or apixaban are reasonable [IIa/C]. If no anticoagulation for preceding 3 wks, reasonable to √ TEE pre-cardioversion for LA thrombus, cardiovert if anticoagulation achieved pre-TEE and maintained ≥4 wks post-cardioversion [IIaB]. DC cardioversion: on repeat attempts, consider location adjustment/pressure application on electrodes, or pre-tx w/ antiarrhythmic drug [I/B]. Pharmacologic conversion most likely effective when initiated w/in 7 days after AF episode onset.
18 Drugs alpha-listed. Class I: flecainide, propafenone. Class III: amiodarone, dofetilide, dronedarone, sotalol. Consider amiodarone only if other agents failed/contraindicated [I/C]. If HF: amiodarone or dofetilide. If HCM: dofetilide, dronedarone, sotalol [IIb/C]. In-pt vs out-pt initiation: data on out-pt best established for amiodarone, dronedarone; do not initiate dofetilide out-pt [III/B].
19 Cath ablation to restore sinus rhythm should not be done w/ sole intent of obviating anticoagulation [III/C]. Cath ablation may be reasonable in selected symptomatic pts w/ significant LV dysfnx w/ HF. Cath ablation of accessory pathway recommended in pre-excited AF w/ sx, esp. if short refractory period [I/C]. Maze may be used as stand-alone for highly select sx pts not well managed w/ other approaches [IIb/B].
Rhythm control20 +/- antithrombotic tx21,22 Consider antithrombotic options21,22 [IIb/C] based on stroke/bleed risks, renal fxn, pt preference [I/C] - No antithrombotic tx (unless HCM)21
- Anticoagulant (warfarin; apixaban, dabigatran, rivaroxaban)22
- Aspirin22
- Women w/ AF are at increased stroke risk vs men; a study concluded that women <65 yo w/o other risk factors (ie, CHA2DS2-VASc=1 solely d/t gender) are at low stroke risk and don’t require anticoagulation
Restore sinus rhythm20 via DC cardioversion, antiarrhythmic drug, or RF cath ablation; +/- rate control. Correct underlying causes [I/C]. - DC cardiovert [I/B] + peri-procedural anticoagulation.23 Repeat/serial attempts based on sinus rhythm duration, sx, pt preference23 +/- rate-control tx [IIa/C]
- Pharmacologic cardioversion24 + peri-procedural anticoagulation23 + rate-control tx: flecainide, dofetilide, propafenone, IV ibutilide [I/A] or amiodarone24 [IIa/A]
- Postconversion pill-in-pocket prn option: propafenone/flecainide + BB/non-DHP-CCB (diltiazem/verapamil), once proven safe in monitored setting, reasonable to terminate out-pt AF [IIa/B]
- Postconversion maintenance drug options24 based on CAD/LVH/HF, comorbidities, drug risks [I/A], +/- rate-control tx. OK to continue antiarrhythmic despite infrequent well-tolerated recurrences [IIb/C]; stop if AF becomes permanent [III/B]
Cath ablation25 + peri-ablation anticoagulation23 is an option; factor risk/benefit, pt preference. - Cath ablation25 for paroxysmal AF w/ sx: useful if refractory/intolerant to ≥1 class I/III drug [I/A]; reasonable as initial strategy before class I/III drug trial for recurrent paroxysmal AF w/ sx [IIa/B]
- Cath ablation25 for persistent AF w/ sx reasonable if refractory/intolerant to ≥1 class I/III drug [IIa/A], consider for long-standing (>12 mo) persistent AF w/ sx [IIb/B]; consider as initial strategy before class I/III drug trial [IIb/B]
- Cath ablation of accessory pathway recommended for pre-excited AF25 [I/C]
- If undergoing cardiac surgery for other reasons: maze procedure reasonable for select pts25 [IIa/C]
Footnotes 20 RCTs show no superiority of rhythm vs rate control. Initial rate-control strategy reasonable for many; consider rhythm control if persistent AF sx, rate control difficulties, younger pt age, tach-mediated CM, 1st AF episode, acute illness-precipitated AF, chronic HF w/ sx despite rate control [IIa/C], or pt preference; rhythm-control preferred for HCM. Recommendations are regardless of AF/aflutter type. Correct underlying causes.
21 HCM requires anticoagulation regardless of score [I/B]. CHA2DS2-VASc (stroke risk): 0 (0%), 1 (1.3%), 2 (2.2%), 3 (3.2%), 4 (4%), 5 (6.7%), 6 (9.8%), 7 (9.6%), 8 (6.7%), 9 (15.2%).
22 Antithrombotics: Re-eval needs/choices periodically [I/C]. Warfarin: INR goal 2-3; √ INR weekly during tx start, monthly when stable [I/A]; if levels not maintained, use dabigatran/rivaroxaban/apixaban [I/C]. Renal: DTI/FXa-I: √ renal fxn pre-tx, when clinically indicated, and at least annually [I/B]. If severe/end-stage CKD, warfarin is anticoagulant of choice [IIa/B]. If postcoronary revasc (PCI/surg): reasonable to add clopidogrel 75 mg/day (not aspirin) to anticoagulant.
23 Anticoagulate w/ warfarin ≥3 wks pre/4 wks post [I/B]; dabigatran, rivaroxaban, or apixaban are reasonable [IIa/C]. If no anticoagulation for preceding 3 wks, reasonable to √ TEE precardioversion for LA thrombus, cardiovert if anticoagulation achieved pre-TEE and maintained ≥4 wks postcardioversion [IIaB]. DC cardioversion: on repeat attempts, consider location adjustment/pressure application on electrodes, or pre-tx w/ antiarrhythmic drug [I/B]. Pharmacologic conversion most likely effective when initiated w/in 7 days after AF episode onset.
24 Drugs alpha-listed. Class I: flecainide, propafenone. Class III: amiodarone, dofetilide, dronedarone, sotalol. Consider amidarone only if other agents failed/contraindicated [I/C]. If HF: amiodarone or dofetilide. If HCM: dofetilide, dronedarone, sotalol [IIb/C]. In-pt vs out-pt initiation: data on out-pt best established for amiodarone, dronedarone; do not initiate dofetilide out-pt [III/B].
25 Cath ablation to restore sinus rhythm should not be done w/ sole intent of obviating anticoagulation [III/C]. Cath ablation may be reasonable for in selected symptomatic pts w/ significant LV dysfnx w/ HF. Cath ablation of accessory pathway recommended in pre-excited AF w/ sx, esp. if short refractory period [I/C]. Maze may be used as stand-alone for highly select sx pts not well managed w/ other approaches [IIb/B].
CHA2DS2-VASc ≥2 (including hx stroke/TIA) Combine anticoagulation + rhythm control26 Anticoagulate27,28 based on stroke/bleed risks, renal fxn, pt preference [I/C] - Warfarin w/ INR 2-3 [I/A]29
- DTI/FXa-I: dabigatran, rivaroxaban, apixaban [I/B]29
- If postcoronary revasc (PCI/surg): reasonable to add clopidogrel 75 mg/day (not aspirin) to anticoagulant [IIb/B]
Restore sinus rhythm26 via DC cardioversion, antiarrhythmic drug, or RF cath ablation; +/- rate control. Correct underlying causes [I/C]. - DC cardiovert [I/B] + peri-procedural anticoagulation.29 Repeat/serial attempts based on sinus rhythm duration, sx, pt preference29 +/- rate-control tx [IIa/C]
- Pharmacologic cardioversion30 + peri-procedural anticoagulation29 + rate-control tx: flecainide, dofetilide, propafenone, IV ibutilide [I/A] or amiodarone31 [IIa/A]
- Postconversion pill-in-pocket prn option: propafenone/flecainide + BB/non-DHB-CCB (diltiazem/verapamil), once proven safe in monitored setting, reasonable to terminate out-pt AF [IIa/B]
- Postconversion maintenance drug options30 based on CAD/LVH/HF, comorbidities, drug risks [I/A], +/- rate-control tx. OK to continue antiarrhythmic despite infrequent, well-tolerated, recurrences [IIb/C]; stop if AF becomes permanent [III/B]
Cath ablation31 + peri-ablation anticoagulation29 is an option; factor risk/benefit, pt preference. - Cath ablation31 for paroxysmal AF w/ sx: useful if refractory/intolerant to ≥1 class I/III drug [I/A]; reasonable as initial strategy before class I/III drug trial for recurrent paroxysmal AF w/ sx [IIa/B]
- Cath ablation31 for persistent AF w/ sx reasonable if refractory/intolerant to ≥1 class I/III drug [IIa/A], consider for long-standing (>12 mo) persistent AF w/ sx [IIb/B]; consider as initial strategy before class I/III drug trial [IIb/B]
- Cath ablation of accessory pathway recommended for pre-excited AF31 [I/C]
- If undergoing cardiac surgery for other reasons: maze procedure reasonable for select pts31 [IIa/C]
Footnotes 26 RCTs show no superiority of rhythm vs rate control. Initial rate-control strategy reasonable for many; consider rhythm control if persistent AF sx, rate control difficulties, younger pt age, tach-mediated CM, 1st AF episode, acute illness-precipitated AF, chronic HF w/sx despite rate control [IIa/C], or pt preference; rhythm-control preferred for HCM. Recommendations are regardless of AF/aflutter type. Correct underlying causes.
27 HCM requires anticoagulation regardless of score [I/B]. If pt undergoing cardiac surgery, may consider LAA surgical excision [IIb/C]. CHA2DS2-VASc (stroke risk): 0 (0%), 1 (1.3%), 2 (2.2%), 3 (3.2%), 4 (4%), 5 (6.7%), 6 (9.8%), 7 (9.6%), 8 (6.7%), 9 (15.2%).
28 Antithrombotics: Re-eval needs/choices periodically [I/C]. Warfarin: INR goal 2-3; √ INR weekly during tx start, monthly when stable [I/A]; if levels not maintained, use dabigatran/rivaroxaban/apixaban [I/C]. Renal: DTI/FXa-I: √ renal fxn pre-tx, when clinically indicated, and at least annually [I/B]. If mod to severe CKD w/ CHA2DS2-VASc ≥2, consider reduced DTI/FXa-I doses [IIb/C] (safety/efficacy not established). If severe/end-stage CKD, warfarin is anticoagulant of choice [IIa/B].
29 Anticoagulate w/ warfarin ≥3 wks pre/4 wks post [I/B]; dabigatran, rivaroxaban, or apixaban are reasonable [IIa/C]. If no anticoagulation for preceding 3 wks, reasonable to √ TEE precardioversion for LA thrombus, cardiovert if anticoagulation achieved pre-TEE and maintained ≥4 wks postcardioversion [IIaB]. DC cardioversion: on repeat attempts, consider location adjustment/pressure application on electrodes, or pre-tx w/ antiarrhythmic drug [I/B]. Pharmacologic conversion most likely effective when initiated w/in 7 days after AF episode onset.
30 Drugs alpha-listed. Class I: flecainide, propafenone. Class III: amiodarone, dofetilide, dronedarone, sotalol. Consider amidarone only if other agents failed/contraindicated [I/C]. If HF: amiodarone or dofetilide. If HCM: dofetilide, dronedarone, sotalol [IIb/C]. In-pt vs out-pt initiation: data on out-pt best established for amiodarone, dronedarone; do not initiate dofetilide out-pt [III/B].
31 Cath ablation to restore sinus rhythm should not be done w/ sole intent of obviating anticoagulation [III/C]. Cath ablation may be reasonable in selected symptomatic pts w/ significant LV dysfnx w/ HF. Cath ablation of accessory pathway recommended in pre-excited AF w/ sx, esp. if short refractory period [I/C]. Maze may be used as stand-alone for highly select sx pts not well managed w/ other approaches [IIb/B].
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