Newer developments in the management of atrial fibrillation

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia encountered in clinical practice. Unlike reentrant supraventricular tachycardia and malignant ventricular tachyarrhythmias, for which highly effective and safe nonpharmacologic therapies are available, the treatment of AF remains controversial and often problematic. Whereas electrical cardioversion restores sinus rhythm in most patients with AF, the maintenance of sinus rhythm often requires membrane-active antiarrhythmic drugs that may increase mortality by inducing ventricular proarrhythmia. The control of ventricular response rate, often associated with oral anticoagulation to prevent thromboembolic complications, is an alternative strategy in AF management. The relative efficacy and risks of these strategies and their respective role in different patient subgroups remain to be established. This article focuses on newer developments in the management of AF, including prospects for improved methods to maintain sinus rhythm, newer approaches to rate control, controversies regarding the use of oral anticoagulation, and novel nonpharmacologic therapies. These newer developments may lead over the next 10 years to a revolution in the management of AF as profound as that produced over the last 10 years by nonpharmacologic therapy of other arrhythmias.