Antiarrhythmic drugs in patients with recurrent atrial fibrillation: where are we?

In patients with recurrent atrial fibrillation (AF), the hallmark of treatment has long been the use of antiarrhythmic drugs. The following strategies are available: a) any antiarrhythmic treatment; b) out-of-hospital episodic treatment ("pill-in-the-pocket" approach); c) prophylactic antiarrhythmic therapy; and d) hybrid therapy. The following patients with recurrent AF should not undergo any antiarrhythmic therapy: after the first AF episode; patients with rare, hemodynamically well-tolerated and short-lasting (a few hours) AF episodes; patients with perioperative AF, without history of recurrent AF; patients with AF during acute myocardial infarction or other acute diseases, without history of recurrent AF; and "holiday heart" syndrome. In patients with infrequent AF episodes (< 1 per month) and hemodynamically well-tolerated, but long enough to require emergency room intervention or hospitalization, a good treatment might be the "pill-in-the-pocket" approach, consisting of a single-dose oral ingestion of flecainide or propafenone at the time and place of palpitation onset. A recent Italian study has shown that this treatment is effective and safe. When AF episodes are frequent and/or hemodynamically badly tolerated, the treatment of choice is the prophylactic therapy with antiarrhythmic drugs. When these drugs fail (ineffective or not tolerated) a non-pharmacological treatment or a hybrid therapy may be indicated.