What role for antiarrhythmic drugs today in patients with recurrent atrial fibrillation without relevant heart disease?

The efficacy of antiarrhythmic drugs (AADs) in the prevention of recurrent (paroxysmal or persistent) atrial fibrillation (AF) is rather low, since 1-year symptomatic recurrences are observed in similar to 50% of patients. New treatments have been suggested: upstream therapy does not appear to be effective in the prevention of AF recurrences, whereas catheter ablation has shown good results. Consistent data dealing with this procedure are available only in young patients, without relevant heart disease and with recurrent AF, refractory to AADs. In the present paper, an analysis of both systematic reviews of trials/meta-analyses and registries, which better express the real world, was carried out. The 1-year success rate of AF ablation in patients with the above mentioned characteristics was 70-80%. However, the 1-year single-procedure success rate, free of AADs, was only 47-57% in the trials and even lower in the real world (30-40%). The final success was increased by one or more repeated ablations, in 15-40% of patients, and by the use of AADs, ineffective before ablation, in similar to 40-50% of patients at 1-year and in similar to 60% at 2-year follow-up. AADs increased the success rate by similar to 15% in the trials and by a much higher percentage in the real world, even if not clearly definable. Considering that similar to 10-12% of patients have the first symptomatic recurrences only 1-2 years after ablation and others in the next years, AADs have still an important role in the management of patients with recurrent AF without relevant heart disease, not only as first-line treatment, but also in patients who underwent catheter ablation. Therefore, AF ablation appears to be more a supplementing procedure than a procedure alternative to AADs; in other words, the association ablation-AADs is more effective than AADs alone.