Recommendation 76: We recommend in patients with HF and AF that the ventricular rate be controlled at rest and during exercise (Strong Recommendation, Moderate Quality Evidence).

Recommendation 77: We recommend beta-blockers for rate control particularly in those with HFrEF (Strong Recommendation, Moderate Quality Evidence).

Recommendation 78: We recommend rate-limiting CCBs be considered for rate control in HFpEF (Weak Recommendation, Low Quality Evidence).

Recommendation 79: We recommend the use of antiarrhythmic therapy to achieve and maintain sinus rhythm, if rhythm control is indicated, be restricted to amiodarone (Strong Recommendation, Moderate Quality Evidence).

Recommendation 80: We recommend the addition of digoxin in patients with HFrEF and chronic AF and poor control of ventricular rate and/or persistent symptoms despite optimally tolerated beta-blocker therapy, or when beta-blockers cannot be used (Strong Recommendation, Low Quality Evidence).

Recommendation 81: We recommend that restoration and maintenance of sinus rhythm in chronic HF not be performed routinely, but individualized based on patient characteristics and clinical status (Strong Recommendation, High Quality Evidence).

Recommendation 82: We suggest catheter ablation of AF be considered as a therapeutic strategy to achieve and maintain sinus rhythm, if rhythm control is indicated and the patient has failed or is unable to tolerate antiarrhythmic therapy (Weak Recommendation, Low Quality Evidence).

Recommendation 83: We recommend oral anticoagulation for AF in patients with HF unless contraindicated, as per current CCS AF guidelines,16 and not to co-administer antiplatelet agents unless the latter are strongly indicated for other reasons (Strong Recommendation, High Quality Evidence).

Recommendation 84: We suggest that NOACs should be the agent of choice for stroke prophylaxis in patients with HF and non-valvular AF, and that the treatment dose be guided by patient specific characteristics including age, weight and renal function (Weak Recommendation, Moderate Quality Evidence).

Recommendation 85: We suggest the application of evidence-based therapies for HFrEF, per CCS HF Guidelines, for primary prevention of AF (Weak Recommendation, Moderate Quality Evidence).

Values and preferences:

• These recommendations are based on an understanding that the management of patients with HF with AF should be individualized with respect to the need to identify precipitating factors, to assess the risk of therapy such as the development of bradycardia and pro-arrhythmia with antiarrhythmic agents, and the bleeding risk of systemic anticoagulation.
• These recommendations place a high value on the understanding that the use of cardiac glycosides in patients with chronic HF and AF remains controversial with conflicting results from meta-analyses. Digoxin can cause atrial and ventricular arrhythmias particularly in the presence of hypokalemia. Not all glycosides and not all preparations have been studied in terms of efficacy and safety.
• These recommendations are consistent with the current CCS AF Guidelines.
• In patients with HF with AF, for whom a rate control strategy is employed, the heart rate treatment target remains unclear. Retrospective analyses of large RCTs suggest that rates greater than 110-115 bpm may be associated with worse outcomes.

Practical tips:

• In patients who are symptomatic from AF or whose symptoms of HF are believed to have substantial contribution from arrhythmia, consideration can be given for rhythm control.
• Non-dihydropyridine CCBs (e.g., verapamil and diltiazem) should not be used to control heart rate in patients with HFrEF because they can depress cardiac function and worsen HF.
• Dronedarone should not be used in patients with an EF < 35% and/or with recent decompensated HF because of in-creased risk of mortality. Agents such as sotalol, flecainide, and propafenone should also be avoided.
• Beta-blockers and non-dihydropyridine CCBs should not be routinely combined as part of a rate control strategy in patients with HF as this may be associated with high degree AV-block
• In acutely decompensated patients with AF and HFrEF, digoxin is the first choice for heart rate control and beta-blockers may be added when the patient has clinically stabilized
• Among patients with HF receiving digoxin for rate control, trough serum digoxin levels should not exceed 1.0ng/mL