Atrial Fibrillation and the Expanding Role of Catheter Ablation: Do Antiarrhythmic Drugs Have a Future?

Abstract

The main therapeutic strategies for treating atrial fibrillation include rate control, maintenance of sinus rhythm, and antiembolic treatment. Current antiarrhythmic drugs are effective in about 50% of patients and are often associated with adverse effects. Multiple trials suggest that rate control with proper anticoagulation treatment is associated with a similar prognosis to a more aggressive rhythm control strategy. Catheter ablation of atrial fibrillation has success rates that exceed currently available antiarrhythmic drugs. However, catheter ablation is an evolving technique that can result in complications. In some patients, antiarrhythmic drugs are still required following ablation. New antiarrhythmic drug strategies include developing drugs that are more atrial selective, alteration of the multichannel blocking agent, amiodarone, or the development of drugs with novel mechanisms of action such as gap junction facilitation of conduction. Although catheter ablation procedures will continue to grow, the millions of atrial fibrillation patients who will require therapy will continue to make antiarrhythmic drug therapy an important part of our ongoing therapeutic armamentarium.

New developments in atrial antiarrhythmic drug therapy

“…Advancing age is a major risk factor for AF and the prevalence of this condition is rising at an alarming rate with ageing of the population 1. Of the two principal options for the management of AF, rhythm control—which aims to restore and maintain sinus rhythm—is believed to be preferable to rate control, in which ventricular rate is regulated while the atria continue to fibrillate 1-3. However, currently available approaches for rhythm control have important limitations, which are discussed below, making rate control preferable in some cases, particularly in older patients with relatively few symptoms of AF.…”

Managing atrial fibrillation in patients with heart failure

“…Recent small studies have suggested that atrial fi brillation ablation may result in improvements in ejection fraction, quality of life, and exercise capacity in patients with heart failure [7,8]. However, atrial fi brillation ablation has a fi rst-time effectiveness of about 65%, and patients often undergo multiple procedures, with as many as a third remaining on long-term antiarrhythmic drugs [9]. Signifi cant complications occur in up to 5% undergoing this procedure [10].…”

Rhythm Control of Atrial Fibrillation in Heart Failure

“…47 Moreover, because catheter ablation and surgical ablation modify the arrhythmogenic substrate, previously ineffective antiarrhythmic drugs may be reevaluated following ablation procedures. 48 Finally, the performance of antiarrhythmic, ablative, and combined rhythm-control strategies Fig. 2.…”