[Can atrial fibrillation be managed without anti-arrhythmia drugs?]

Antiarrhythmic drugs are widely used in atrial fibrillation. The demonstration of severe pro-arrhythmic effects in recent years has led to the reappraisal of their indications in this pathology. Antiarrhythmic agents have three roles: reduction of the fibrillation, maintenance of sinus rhythm and, in case of failure, control of the ventricular response. In the first indication, although intravenous injection of Class Ic antiarrhythmics is effective in 70% of cases, there is an alternative: electrical cardioversion, which is effective in 90% of cases with the transthoracic method when a certain number of technical conditions are respected. The success rate is even better with endocavitary defibrillation. Sinus rhythm is sustained in only 25% of patients at one year with placebo and in 50% of patients with antiarrhythmic therapy. The alternatives in this indication are few at present and consist in right atrial pacing in cases of vagal fibrillation and biatrial pacing for resynchronizing the activation of the two atriae when there is a major interatrial conduction defect. The control of the ventricular response, in cases of permanent atrial fibrillation, is usually reserved to digitalis, betablockers, amiodarone and some calcium antagonists. They are often inadequate and an alternative is radiofrequency catheter ablation of the atrioventricular node, which requires permanent ventricular pacing. In conclusion, there are a few alternatives to antiarrhythmic drug therapy in atrial fibrillation, but they are relatively ineffective in maintaining sinus rhythm.