Medical management of atrial fibrillation: state of the art.
Predominantly a disease of advancing age, atrial fibrillation (AF) is the most common sustained arrhythmia. Its prevalence is rising as the proportion of elderly people in the population continues its inexorable rise. Without more effective therapeutic interventions, AF-related cardiovascular and cerebrovascular morbidity and mortality will also continue to rise. Antiarrhythmic drugs are an essential tool in the management of AF and may be used as premedication before cardioversion; together with cardioversion to help or assist cardioversion; or given afterward to prevent recurrence. If AF recurs after one or two cardioversions, then it is usual to adopt a rate control strategy; highly symptomatic patients who fail cardioversion may benefit from ablation therapy. We are already on the threshold of a large expansion in the use of ablation therapy, a strategy that has potential to deliver dramatic improvements in outcome. Not only can AF be cured by ablative therapy, but there is also evidence that it confers functional improvement as well. It will not, however, be appropriate for all AF patients and pharmacological therapies will continue to have an important place in the management of AF. The plethora of antiarrhythmic drugs currently available for the treatment of AF is a reflection that none is wholly satisfactory, each having limited efficacy combined with poor safety and tolerability. Improved class III antiarrhythmic agents, such as dronedarone; new classes of antiarrhythmic agents, such as atrial repolarization delaying agents; and upstream therapies dealing with substrate represent potential sources of new pharmacological therapies for AF.