The vernakalant story: how did it come to approval in Europe and what is the delay in the U.S.A?

The sudden onset of atrial fibrillation (AF) is often associated with rapid irregular palpitations, chest pain, shortness of breath and considerable anxiety. If a patient presents shortly after the onset of the arrhythmia the physician may adopt initially an expectant "wait and see" policy, perhaps with the help of mild sedation and drug therapy to reduce the ventricular rate. If the arrhythmia does not terminate spontaneously and has been present for less than 24-48 hours restoration of sinus rhythm by cardioversion should be considered. This manuscript reviews the option of electrical cardioversion versus pharmacologic and the data for, the role of, and the status of vernakalant with respect to the latter.