An additional RCT in a population of patients with persistent AF, HFrEF, and an implanted cardioverter-defibrillator or cardiac resynchroniza- tion therapy defibrillator device demonstrated that AF catheter ablation was superior to amiodarone for maintenance of sinus rhythm, with second- ary endpoint analyses suggesting a lower rate of unplanned hospitalization and death.S6.3.4-2 Both studies have limitations, including relatively small and highly selected patient populations. Further, larger studies are needed to validate these findings. Other small studies conducted in patients with AF and HFrEF have shown the superiority of AF ablation over antiarrhythmic drugs in the mainte- nance of sinus rhythm and in outcomes such as improved LV ejection fraction, performance in a 6-minute walk test, and quality of life.S6.3.4-3,S6.3.4-4 However, the recent CABANA (Catheter Ablation verses Anti-arrhythmic Drug Therapy for Atrial Fi- brillation) trial (n=2204 patients randomized to either catheter ablation or drug therapy) showed that AF ablation was not superior to drug therapy for the primary cardiovascular outcomes of death, disabling stroke, serious bleeding, or cardiac arrest at 5 years among patients with new-onset or un- treated AF that required therapy.S6.3.4-5,S6.3.4-6 7. SPECIFIC PATIENT GROUPS AND AF 7.4. AF Complicating ACS Recommendations for AF Complicating ACS Referenced studies that support new or modified recommendations are summarized in Online Data Supplement 8. COR LOE Recommendations I B-R For patients with ACS and AF at increased risk of systemic thromboembolism (based -VASc risk score of 2 or greater), anticoagulation is recommended unless the bleeding risk exceeds the expected MODIFIED: New published data are available. LOE was updated from C in the 2014 AF Guideline to B-R. Anticoagulation options are described in supportive text. I C Urgent direct-current cardioversion of new-onset AF in the setting of ACS is recommended for patients with hemodynamic compromise, ongoing ischemia, or inadequate rate control. 