What is the goal of antiarrhythmic drug therapy in atrial fibrillation (Afib) (AF) and which drugs are used?

Updated: Nov 18, 2019
  • Author: Lawrence Rosenthal, MD, PhD, FACC, FHRS; Chief Editor: Jeffrey N Rottman, MD  more...
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The goal of antiarrhythmic drug therapy is to reduce the duration and frequency of atrial fibrillation episodes, thus improving patient quality of life and symptoms. If successful, rhythm control can eliminate or delay the need for long-term anticoagulation with warfarin in some patients.

Several antiarrhythmic drugs are commonly used to prevent atrial fibrillation recurrence, such as quinidine, flecainide, propafenone, sotalol, and dofetilide. Other antiarrhythmic agents, such as amiodarone, are used in an off-label fashion with great clinical efficacy. Use of antiarrhythmic drugs requires caution because they are proarrhythmic. These agents can exacerbate preexisting arrhythmias and generate arrhythmia de novo. Tachyarrhythmias and bradyarrhythmias generated by these agents can be of ventricular or atrial origin. Drug-drug interactions and extracardiac side effects are common. Consultation with a cardiac electrophysiologist or knowledgeable clinician is recommended prior to antiarrhythmic drug initiation.

If maintenance of sinus rhythm is the goal, the American College of Cardiology (ACC)/American Heart Association (AHA)/Heart Rhythm Society (HRS) have jointly developed guidelines for the long-term antiarrhythmic treatment in the maintenance of sinus rhythm. [1] These guidelines are intended to help clinicians tailor antiarrhythmic therapy on an individual basis for their patients.

The following algorithm incorporates clinical trial data on the safety and efficacy of antiarrhythmic agents:

Antiarrhythmic drug algorithm for the medical mana Antiarrhythmic drug algorithm for the medical management of sinus rhythm in patients with atrial fibrillation.

For patients with no evidence of structural heart disease, flecainide, propafenone and sotalol should be considered first-line agents, and amiodarone and dofetilide can be considered as alternative agents. Amiodarone is considered a reasonable first-line agent for patients with substantial left ventricular hypertrophy (LVH). Dofetilide and sotalol are first-line therapy for patients with coronary artery disease (CAD), and amiodarone is considered a second-line agent in this population. For patients with heart failure, amiodarone and dofetilide are first-line agents.

The Atrial arrhythmia Conversion Trial (ACT) I and the open-label ACT IV trials suggest that intravenous vernakalant hydrochloride can quickly convert recent-onset AF to sinus rhythm. This is potentially an important therapeutic option for the treatment of patients with AF seen in the emergency department, as the treatment was well tolerated. [161]

Current practice constraints mandate that clinicians carefully consider patient populations at low and acceptable risks for outpatient antiarrhythmic drug initiation. Proarrhythmia is the most common adverse effect of antiarrhythmics during the loading phase. Although the proarrhythmic effect of these drugs extends into the maintenance phase, a monitored inpatient setting is generally recommended for drug initiation, especially for those patients with structural heart disease or substantial comorbidities. Nevertheless, certain antiarrhythmic drugs have established and acceptable safety profiles when used in outpatients without structural heart disease or other risk factors.

Schmidt et al found that the use of non-aspirin nonsteroidal anti-inflammatory agents (NSAIDs) is associated with an increased risk of AF or flutter, suggesting a need to add this caution when prescribing this course of medication. [162]

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