Table 2.

Antiarrhythmic drug therapy for atrial fibrillation in heart failure

Guidelines	Agent	Class	Safety	Efficacy
Recommended	Amiodarone	Mixed channel blockade	Risks of toxicity, including thyroid, hepatic, pulmonary, and neurological.78	Superior efficacy for maintenance of sinus rhythm vs. placebo: odds ratio 0.15 (95% CI 0.10–0.22).79
	Dofetilide	III	Requires inpatient stay for loading. Risk of torsades 0.8–3.3%. Not approved in EU.	Lower risk of all-cause rehospitalization in patients with AF at baseline vs. placebo: relative risk 0.70 (95% CI 0.56–0.89).80
Caution required	Dronedarone	Mixed channel blockade	Increased mortality in patients with HF and permanent AF.15,81	Decreased risk of CV hospitalization or death in patients with AF and no recent HF decompensation vs. placebo: 0.76 (95% CI 0.69–0.84).82
	Sotalol	III	Concern for excess proarrhythmia in patients with acute myocardial infarction or LVEF ≤40%: relative risk 1.65 (95% CI 1.15–2.36) for all-cause mortality.83a	Sotalol was inferior to amiodarone in patients with AF (28% had NYHA class I/II HF).84
Contraindicated	Flecainide and Propafenone	I	Flecainide, encainide and moracizine increased mortality in patients with myocardial infarction.85 Propafenone can precipitate decompensated HF, particularly in CYP 2D6 slow-metabolizers.

^aSWORD evaluated d-sotalol rather than d,l-sotalol.