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World J Cardiol. Dec 31, 2009; 1(1): 11-22
Published online Dec 31, 2009. doi: 10.4330/wjc.v1.i1.11
Present concepts in management of atrial fibrillation: From drug therapy to ablation
Giovanni B Forleo, Luca Santini, Francesco Romeo
Giovanni B Forleo, Luca Santini, Francesco Romeo, Division of Cardiology, Department of Internal Medicine, University of Rome “Tor Vergata”, Viale Oxford, 81, 00133 Rome, Italy
Author contributions: Forleo GB and Santini L wrote the paper; Romeo F revised the paper critically for important intellectual contents.
Correspondence to: Francesco Romeo, Professor, MD, Director, Division of Cardiology, Department of Internal Medicine, University of Rome “Tor Vergata”, Viale Oxford, 81, 00133 Rome, Italy. romeocerabino@tin.it
Telephone: +39-6-20904009 Fax: +39-6-20904043
Received: December 1, 2009
Revised: December 26, 2009
Accepted: December 28, 2009
Published online: December 31, 2009

Atrial fibrillation (AF) management requires knowledge of its pattern of presentation, underlying conditions, and decisions about restoration and maintenance of sinus rhythm, control of the ventricular rate, and anti-thrombotic therapy. Maintenance of sinus rhythm is a desirable goal in AF patients because the prevention of recurrence may improve cardiac function, relieve symptoms and reduce the likelihood of adverse events. Anti-arrhythmic drug therapy is the first-line treatment for patients with paroxysmal and persistent AF based on current guidelines. However, currently used drugs have limited efficacy and cause cardiac and extracardiac toxicity. Thus, there is a continued need to develop new drugs, device and ablative approaches to rhythm management. Additionally, simpler and safer stroke prevention regimens are needed for AF patients on life-long anticoagulation, including occlusion of the left atrial appendage. The results of the Randomized Evaluation of Long-Term Anticoagulant Therapy study are encouraging in these settings. Knowledge on the pathophysiology of AF is rapidly expanding and identification of focally localized triggers has led to the development of new treatment options for this arrhythmia. Conversely, the clinical decision whether to restore and maintain sinus rhythm or simply control the ventricular rate has remained a matter of intense debate. In the minority of patients in whom AF cannot be adequately managed by pharmacological therapy, the most appropriate type of non-pharmacological therapy must be selected on an individualized basis. Curative treatment of AF with catheter ablation is now a legitimate option for a large number of patients. The evolution of hybrid therapy, in which two or more different strategies are employed in the same patient, may be an effective approach to management of AF. In any case, planning a treatment regimen for AF should include evaluation of the risks inherent in the use of various drugs as well as more invasive strategies.

Keywords: Antiarrhythmic medications, Atrial fibrillation, Catheter ablation