New and emerging antiarrhythmic and anticoagulant agents for atrial fibrillation

To compare and contrast the pharmacology, efficacy, and safety of new, emerging, and established antiarrhythmic and anticoagulant medications and describe nonpharmacologic interventions for the treatment of atrial fibrillation (AF).

Shortcomings of established antiarrhythmic agents include a risk for proarrhythmias and intolerable adverse effects. Dronedarone is a recently introduced amiodarone congener for maintenance of sinus rhythm after cardioversion in patients with AF that is better tolerated than amiodarone. Vernakalant is an emerging antiarrhythmic agent for conversion of AF to normal sinus rhythm with atrial-selective activity that appears to minimize the risk for proarrhythmia. An unpredictable dose-response relationship and the need for laboratory monitoring are among the many shortcomings of warfarin. Rivaroxaban, an emerging oral direct factor Xa inhibitor, and dabigatran, an emerging oral direct thrombin inhibitor, have predictable dose-response relationships and do not require laboratory monitoring. Additional data from comparative clinical trials will clarify the role of these emerging agents in the treatment of AF. Various nonpharmacologic interventions may be used for rhythm control, rate control, or cardioversion in patients whose AF cannot be managed with pharmacotherapy because of a lack of efficacy or intolerable adverse effects.

New and emerging antiarrhythmic and anticoagulant agents offer advantages over established agents and may improve outcomes in patients with AF.