Recommendations for Management of AF in Patients With HF^* Referenced studies that support the recommendations are summarized in the Online Data Supplement.

COR	LOE	Recommendations
1	B-NR	1. In patients who present with a new diagnosis of HFrEF and AF, arrhythmia-induced cardiomyopathy should be suspected, and an early and aggressive approach to AF rhythm control is recommended.1,2
1	A	2. In appropriate patients with AF and HFrEF who are on GDMT, and with reasonable expectation of procedural benefit (Figure 24), catheter ablation is beneficial to improve symptoms, QOL, ventricular function, and cardiovascular outcomes.3–13
2a	B-NR	3. In appropriate patients with symptomatic AF and HFpEF with reasonable expectation of benefit, catheter ablation can be useful to improve symptoms and improve QOL.14,15
2a	B-R	4. In patients with AF and HF, digoxin is reasonable for rate control, in combination with other rate-controlling agents or as monotherapy if other agents are not tolerated.16,17
2a	B-NR	5. In patients with AF and HF with rapid ventricular rates in whom beta blockers or calcium channel blockers are contraindicated or ineffective, intravenous amiodarone is reasonable for acute rate control.†18,19
2a	B-R	6. In patients with AF, HFrEF (LVEF <50%), and refractory rapid ventricular response who are not candidates for or in whom rhythm control has failed, AVNA and biventricular pacing therapy can be useful to improve symptoms, QOL, and EF.20–23
2a	B-NR	7 In patients with AF, HF, and implanted biventricular pacing therapy in whom an effective pacing percentage cannot be achieved with pharmacological therapy, AVNA can be beneficial to improve functional class,24,25 reduce the risk of ICD shock,26 and improve survival.24,25
2a	B-NR	8. In patients with AF-induced cardiomyopathy who have recovered LV function, long-term surveillance can be beneficial to detect recurrent AF in view of the high risk of recurrence of arrhythmia-induced cardiomyopathy.27,28
2b	B-NR	9. In patients with suspected AF-induced cardiomyopathy or refractory HF symptoms undergoing pharmacological rate-control therapy for AF, a stricter rate-control strategy (target heart rate <80 bpm at rest and <110 bpm during moderate exercise) may be reasonable.29–31
2b	C-LD	10. In patients with AF and HFrEF who undergo AVNA, conduction system pacing of the His bundle or left bundle branch area may be reasonable as an alternative to biventricular pacing to improve symptoms, QOL, and LV function.32–35
3: Harm	B-R	11. In patients with AF and known LVEF <40%, nondihydropyridine calcium channel-blocking drugs should not be administered because of their potential to exacerbate HF.36
3: Harm	B-R	12. For patients with AF, dronedarone should not be administered for maintenance of sinus rhythm to those with NYHA class III and IV HF or patients who have had an episode of decompensated HF in the past 4 weeks, due to the risk of increased early mortality associated with worsening HF.37

^*Please see other recommendations on anticoagulation in AF (Section 8.4.4, “Anticoagulation Therapy Before and After Catheter Ablation”), rate control in HF (Section 7, “Rate Control”), and agents for pharmacological cardioversion (Section 7.2, “Specific Pharmacological Agents for Rate Control”) and maintenance of sinus rhythm (Section 8.3.1, “Specific Drug Therapy for Long-Term Maintenance of Sinus Rhythm”).

^†Consider the risk of cardioversion and stroke when using amiodarone as a rate-control agent.