Antiarrhythmic therapy of atrial fibrillation: are we treating too late?

Atrial fibrillation (AF) is associated with increased risk for stroke, heart failure and mortality. The causality between worse prognosis and AF is not clear at this time and AF may just be expression of underlying heart disease that by itself is associated with increased morbidity and mortality. AF is characterized by progression from rare paroxysmal episodes to permanent AF. It has been well recognized that maintenance of sinus rhythm with either antiarrhythmic drugs or catheter ablation is easier to achieve if treatment is established early on. In addition to the established indication of symptomatic improvement, the focus of AF management is shifting to earlier intervention to prevent cardiovascular complications. This concept is currently under investigation in the ongoing EAST trial. Early treatment initiation is desirable from a pathophysiologic perspective. This includes consequent prevention and treatment of AF risk factors, efforts for early diagnosis, and stroke prevention according to the CHA2DS2-VASc score. As long as no data support prognostic advantages with "aggressive" rhythm control therapy it remains reserved for symptomatic patients, since both, medication and catheter ablation, convey a significant risk for complications.