Management of chronic atrial fibrillation: Current therapeutic strategies

Two major treatment strategies have emerged for the management of chronic atrial fibrillation (AF). The first is to allow the patient to remain in AF and to pharmacologically control the ventricular rate to minimize symptoms while administering antithrombotic therapy to prevent stroke. The second strategy, which is more appropriate for patients who are highly symptomatic or are not candidates for chronic anticoagulation, is to maintain sinus rhythm with antiarrhythmic drugs. The class III antiarrhythmic agents sotalol, amiodarone, and dofetilide have become the mainstay in managing chronic AF Each of the two treatment strategies carries significant benefits and risks, and the optimal approach has not yet been determined. Until it is, symptomatology and the likelihood of maintaining sinus rhythm are the chief guides for selecting which strategy is best for individual patients, along with duration of AF, left atrial size, contraindications to anticoagulation, and proarrhythmic risk with class III agents.