Management of arrhythmias: NOACs, digoxin, alcohol, light, and devices

Atrial fibrillation has taken centre stage in cardiovascular medicine with the ageing population and the introduction of novel treatment options such as catheter-based ablation 1,2 and, more recently, nonvitamin K oral anticoagulants or NOACs. 3,4In a Special Article entitled 'Updated European Heart Rhythm Association practical guide on the use of non-vitamin-K antagonist anticoagulants in patients with non-valvular atrial fibrillation: executive summary', Hein Heidbuchel and colleagues present on behalf of the European Heart Rhythm Association their novel guide. 5ince 2013, when the last version was published, numerous new studies have appeared that are relevant for patient management, as also outlined in the 2016 ESC Guidelines. 6The current practical guide includes new information, in particular an updated discussion on the definition of 'non-valvular atrial fibrillation' and the eligibility for NOACs including novel agents such as edoxaban. 7Furthermore, the 2017 practical guide contains tailored dosing information, an expanded chapter on neurological scenarios such as ischaemic stroke or intracranial haemorrhage during NOAC therapy, an updated anticoagulation card, and more specifics on start-up and follow-up issues.Many antiarrythmic drugs have been abandoned or their indication markedly restricted, mainly due to proarrhythmic or other side effects.The oldest antiarrythmic is digoxin, initially described by William Withering in 1778 after he had learned of the use of the plant in treating 'dropsy' or oedema-we would call it congestive heart failure today-from mother Hutton, an old woman who practised as a folk herbalist in Shropshire. 8Although in use for more than two centuries, its efficacy and safety are still debated in spite of numerous trials with the drug. 9This issue is discussed by Udo Bavendiek and colleagues from the Hannover Medical School in Germany in a Current Opinion entitled 'Assumption vs. evidence: the case of digoxin in atrial fibrillation and heart failure'. 10The numerous publications on digitalis caused increasing uncertainty in the medical and patient community regarding the start or continuation of such a treatment in patients with atrial fibrillation and/or heart failure.Even though these publications all end in mandating the conduct of further randomized trials, they increase the difficulties in the conduct of With thanks to Amelia Meier-Batschelet for help with compilation of this article.