Strategies for managing atrial fibrillation

The limitations of current therapies for atrial fibrillation are forcing a rethinking of how they should be used. Questions are being raised about the use of antiarrhythmic drugs, and new nonpharmacologic procedures are promising alternatives. Most patients with atrial fibrillation still require warfarin therapy, but some low-risk patients can forego it. Sinus rhythm spontaneously returns within the first 24 hours in almost half of cases of new atrial fibrillation. Patients with hemodynamic instability due to new-onset atrial fibrillation should proceed directly to electrical cardioversion. Warfarin therapy to maintain an International Normalized Ratio (INR) of 2.0 to 3.0 is currently recommended for all patients with atrial fibrillation with no contraindications to it, except for patients younger than 60 years with lone atrial fibrillation, in whom the risk of stroke is low. Certain antiarrhythmic drugs should be avoided in patients with congestive heart failure, in whom the risks may exceed the benefits. The maze procedure is emerging as an option to restore and maintain sinus rhythm. Radiofrequency atrioventricular node ablation and modification hold promise as options to control the ventricular rate without drugs.