The Place of Antiarrhythmic Drugs and Rhythm Control in the Treatment of Atrial Fibrillation

Atrial fibrillation (AF) is the most common arrhythmia, with incidence increasing with age and a ranging severity of symptoms. The arrhythmia, perpetuated from electrical, functional and structural remodelling by AF itself, can ultimately lead to increased morbidity and mortality. Emerging evidence appears to support the initiation of rhythm control, particularly early on in the disease course. Antiarrhythmic drugs have proved useful in inducing and maintaining cardioversion, but treatment varies depending on the degree of structural heart disease. Drug trials and selection of therapy have historically focused largely on cardiac safety. Class Ic drugs have demonstrated safety and efficacy in patients with little to no structural heart disease, yet their use continues to be superseded by the use of other drugs, especially amiodarone, which carries significant risks of extracardiac effects and end-organ toxicities. This article discusses the role of sinus rhythm control and antiarrhythmic drugs in AF, with an emphasis on patients exhibiting no or minimal structural heart disease and the importance of selecting an appropriate antiarrhythmic drug, taking into account arrhythmia burden, presence of concurrent cardiovascular disease and severity and, most importantly, the safety of the drug therapy.