[Drug therapy of atrial fibrillation]

The authors summarize the up-to-date knowledge relating to the pharmacological treatment of atrial fibrillation. They emphasize that drug treatment continues to be in the forefront of the therapy of the arrhythmia, which can now be considered to constitute a cardiovascular epidemic. In the era following the Atrial Fibrillation Follow-up Investigation of Rhythm Management (AF-FIRM) trial, the strategy of pharmacological treatment will certainly change: in place of "rhythm control", which in recent decades has been overforced in patients identical with the elderly, cardiac patients with an impaired left ventricular function who were enrolled into AFFIRM, there will be a more frequent use of ventricular "rate control". Naturally, this does not mean that, in certain patient groups, an effort should not be made to restore and maintain the sinus rhythm. In cases involving congestive heart failure and structural heart disease complicated by a depressed left ventricular systolic function, atrial fibrillation is currently treated with antiarrhythmic drugs possessing low proarrhythmic activity that prolong refractory period (Class 3), and with the even safer mortality-reducing beta-receptor blockers. The classical antiarrhythmic drugs (quinidine, procainamide, disopyramide) are being increasingly forced into the background, and the areas of indication of the novel Na(+)-channel blocker antiarrhythmics (propafenone, flecainide) have also narrowed: they are administered only in the event of atrial fibrillation in patients with a structurally intact heart or left ventricular hypertrophy. After a brief survey of the more important aspects of ventricular rate control, and of the drugs available, the research trends aimed at the progression of the pharmacological treatment of atrial fibrillation are outlined. The clinical introduction of procedures based on myocardial gene therapy is now a realistic therapeutic approach as concerns atrial fibrillation too.