Digoxin may be considered in those with severe LV dys- function and HF or hemodynamic instability. However, recent data from the ARISTOTLE AF NOAC trial study population show that digoxin was independently as- sociated with higher mortality rate in patients with AF regardless of HF, and in patients with AF taking digoxin, the risk of death increased with higher serum digoxin Other meta-analysis studies sup- port these conclusions.S7.4-19 Treatment with angioten- sin-converting enzyme inhibitors appears to reduce the incidence of AF in patients with LV dysfunction after Recommendation-Specific Supportive Text (New or Modified) 1. This recommendation is modified to incor- porate the data from WOEST (What is the Optimal Antiplatelet & Anticoagulant Therapy in Patients With Oral Anticoagulation and and the recent evidence from PIONEER AF-PCI (Open-Label, Randomized, Controlled, Multicenter Study Exploring two Treatment Strategies of Rivaroxaban and a Dose-Adjusted Oral Vitamin K Antagonist Treatment Strategy in Subjects With Atrial Fibrillation who Undergo Percutaneous Coronary and RE-DUAL PCI (Randomized Evaluation of Dual Antithrombotic Therapy With Dabigatran Versus Triple Therapy With Recommendations for AF Complicating ACS (Continued) COR LOE Recommendations CLINICAL STATEMENTS AND GUIDELINES Warfarin in Patients With Nonvalvular Atrial Fibrillation Undergoing Percutaneous Coronary (see supportive text for recom- mendations 6 and 8 below). These 3 clinical tri- als enrolled both patients with stable ischemic disease and patients with ACS treated with PCI. These trials did not include patients with ACS managed medically. On the basis of these clinical trials, options for anticoagulants in this patient population include warfarin, rivaroxa- ban, and dabigatran. Although the use of the -VASc score has been validated only in several small studies of patients with AF and ACS, we believe it is reasonable to use this methodology to estimate the risk of systemic 4. 