Antiarrhythmic drugs to maintain sinus rhythm in patients with atrial fibrillation: Recommendations
- Kapil Kumar, MD
Kapil Kumar, MD
- Clinical Instructor in Medicine
- Harvard Medical School
- Section Editors
- Peter J Zimetbaum, MD
Peter J Zimetbaum, MD
- Section Editor — Cardiac Arrhythmias
- Professor of Medicine
- Harvard Medical School
- Bradley P Knight, MD, FACC
Bradley P Knight, MD, FACC
- Section Editor — Cardiac Arrhythmias
- Professor of Medicine
- Feinberg School of Medicine, Northwestern University
For patients with atrial fibrillation (AF), there are two main strategies to manage the irregular rhythm and its impact on symptoms: rhythm control (restoration followed by maintenance of sinus rhythm with either antiarrhythmic drugs or catheter ablation); and rate control with atrioventricular (AV) nodal blockers. (See 'Rhythm versus rate control' below.)
For those patients in whom a rhythm control strategy is chosen, the main goal of therapy is to reduce symptoms by decreasing the frequency and duration of episodes as well as the symptoms during recurrences [1,2]. As antiarrhythmic drugs are associated with a potential for serious adverse side effects, particularly the induction of proarrhythmia, they should be prescribed only by practitioners familiar with their use. Patients should be fully informed of both the benefits and risks associated with the use of these drugs. (See 'Drug-related arrhythmias and mortality' below.)
Rhythm control can be achieved with either antiarrhythmic drug therapy or nonpharmacologic methods. This topic provides recommendations for the former. The clinical trials describing the efficacy and toxicity (including proarrhythmia) of the different antiarrhythmic drugs are presented separately. (See "Antiarrhythmic drugs to maintain sinus rhythm in patients with atrial fibrillation: Clinical trials".)
Nonpharmacologic methods to maintain sinus rhythm (including surgery and radiofrequency ablation or cryoballoon ablation) in selected patients who are refractory to conventional therapy are discussed elsewhere. (See "Catheter ablation to prevent recurrent atrial fibrillation: Clinical applications" and "Surgical ablation to prevent recurrent atrial fibrillation".)
There are three settings in which a rhythm control strategy for the maintenance of sinus rhythm should be considered :
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- INITIAL MANAGEMENT DECISIONS
- Rhythm versus rate control
- Addressing precipitating factors
- AV nodal blocker therapy
- Possible role of angiotensin inhibition
- Restoration of sinus rhythm
- SELECTING AN ANTIARRHYTHMIC DRUG
- AF without structural heart disease
- AF associated with structural heart disease
- - Coronary heart disease
- - Heart failure
- - Left ventricular hypertrophy
- Drug-resistant AF
- INPATIENT VERSUS OUTPATIENT INITIATION
- LONG-TERM ISSUES
- AF recurrence
- Drug-related arrhythmias and mortality
- - Proarrhythmia
- - Bradyarrhythmia
- - Ambulatory monitoring
- Short- versus long-term therapy
- Concerns about dronedarone
- RECOMMENDATIONS OF OTHERS
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS