Pharmacological Therapy of Atrial Fibrillation. An update

Atrial fibrillation (AF) is a common arrhythmia associated with significant morbidity and mortality. The aim of therapies is to reduce the frequency, duration and severity of AF, improve quality of life, prevent of a tachycardia-induced cardiomyopathy, reduce risk of emboli, and if possible, prolong life. Life-threatening and hemodinamically intolerable AF requires immediate electrical cardioversion (CV). For the better-tolerated episodes, if duration of episode is less than 48 hours, pharmacological conversion or electrical CV may be performed without anticoagulation, otherwise for episodes longer than 48 hours, anticoagulant therapy with warfarin to a target INR of 2-3 for 3 to 4 weeks before elective CV is advised. Earlier CV may be taken into account if transesophageal echocardiography does not reveal evidence of embolic risk. When selecting an antiarrhythmic drug, underlying structural heart disease and concomitant other diseases should be carefully evaluated. Beta blocker is preferred in ischaemic heart disease, digoxin in left ventricular (LV) dysfunction, beta blocker or verapamil in hypertrophic cardiomyopathy, verapamil or diltiazem in patients (pts) with hypertension and in pts without organic heart disease for ventricular rate control. Sotalol, dofetilide or amiodarone should be preferred in coronary heart disease, sotalol, dofetilide or amiodarone in dilated cardiomyopathy, amiodarone or dofetilide in congestive heart failure, propafenone or flecainide in pts with hypertension/mild LV hypertrophy or in pts without structural heart disease for suppression of AF. Frequent or intolerable paroxysmal and persistent AF episodes should prove a strategy directed at sinus rhythm maintenance. In contrast, infrequent or well-tolerated paroxysmal AF can be observed without antiarrhythmic intervention, some of them may need only rate control. In pts with infrequent and brief episodes of AF, the long-term warfarin may not be necessary, but in high-risk pts with paroxysmal/persistent/chronic AF dose-adjusted warfarin is even better than low dose warfarin plus aspirin for prevention of emboli. The methods of non-pharmacological treatment for rate control or restore sinus rhythm may be necessary in pts refractory to drug therapy.