Given recent trials for the management of atrial fibrillation with an early ablation strategy (for example, EAST-AFNET 4, EARLY-AF, PROGRESSIVE-AF, STOP-AF), what is your approach to determining the appropriate timing for ablation in patients with atrial fibrillation?

I agree with Dr. @Dr. First Last. I also usually start with an antiarrhythmic drug and then offer ablation if the drug is not tolerated or is ineffectual. This is a shared decision-making process - some patients want nothing to do with drugs and prefer ablation and others want to try multiple drugs before they would even consider an ablation. Given that ablation for atrial fibrillation is not a life-saving procedure, I allow the patient to guide their care.

In agreement with what has been said already, I will add that treatment of atrial fibrillation should be geared around symptoms, systolic function, and stroke risk with options of antiarrhythmic medications, anti-tachycardia pacing for those who meet indications for devices, and ablation for the first; rate or rhythm control for the second with Marrouche et al., PMID 29385358 data for this; and appropriate CHADS-VASc risk stratification and DOAC > warfarin anticoagulation for the last (ablation that is 70-80% successful isn't part of the strategy for addressing stroke, but successful ablation with monitoring can be part of an AC wean; especially in those with device monitoring (Merino & Tamargo, PMID 34491472 is a reasonable read).

I do thin...

I am a strong believer in the value of sinus rhythm. Whether it is restored and maintained with drugs or ablation is up to patient preference. Given the long wait times for ablation I almost always start with an anti-arrhythmic. If not effective or tolerated move on to ablation. If a patient has little to no AF on an anti arrhythmic med without med side effects I will continue this approach. It is important to recognize that ablation keeps getting safer and more effective over time. If a patient transitions to persistent AF I will push for ablation - especially if not controlled with meds. Hugh Calkins

What is often forgotten is that even in "perfect" patients of ablation is NOT perfect. The improved outcomes noted with ablation strategies vs. medical therapy is a group win-not necessarily all individual patients. I agree with Dr. @Dr. First Last that in general sinus rhythm is better than atrial fibrillation and similarly am a big fan of choosing an anti-arrhythmic that is appropriate for the patient who I have suggested would be better off with sinus rhythm while awaiting an EP consult and ultimate scheduling of ablation.

I very much agree with what everyone has said. These answers are very helpful.

I also believe that restoring sinus rhythm is the goal. I also engage in a shared decision-making process. If patients have modifiable risk factors (obesity, sedentary lifestyle, uncontrolled diabetes, sleep apnea, Hypertension, smoking, etc.), I do emphasize to patients the importance of improving on these. Once the rhythm control strategy is chosen in the shared decision-making process, I also make sure patients are well aware of the possibility of recurrence of atrial fibrillation and the need for a second ablation procedure in some cases. I also discuss with the patient that anti-arrhythmic medications or ablation will have a higher success rate if we togeth...