It is an exciting time for the management of patients with atrial fibrillation, with new therapies now appearing for both the antithrombotic prevention of stroke and for antiarrhythmic treatment. This monograph in its second edition captures the new advances and lives up to the series title—“Hot Topics in Cardiology.” For the past decade, management of atrial fibrillation has been relatively fixed—we saw that warfarin was needed, despite the difficulties of adjusting the dosage of warfarin to achieve adequate anticoagulation. For rhythm control, we found that many agents had proarrhythmic potential, and those now are used with great caution, with amiodarone emerging as the leading option. However, amiodarone has various toxicities that require close monitoring and limit its use. Then, trials evaluating the strategy of rhythm control versus just rate control did not show the anticipated benefit of restoring sinus rhythm.
Now we have new anticoagulants in development, with remarkable emerging data on some of these oral agents—including dabigatran and rivaroxaban. As presented by my colleagues, Drs. Ruff and Giugliano, other factor Xa inhibitors are also looking promising in other indications, with the trials in atrial fibrillation nearing completion. The findings show that the new agents not only are simpler to use but also do not require constant monitoring of the level of anticoagulation via the international normalized ratio. In addition, safety was improved, with lower rates of bleeding and intracranial hemorrhage. Then, at one of the two doses tested, better efficacy in preventing stroke or embolism was seen.
For antiarrhythmic management, Professor Hohnloser gives a fascinating update on a new, safer agent that has just been approved for use—dronedarone, a derivative of amiodarone. This compound does not have the iodine side group and, as such, does not have many of the toxicities of amiodarone. Then, a large trial was conducted, which showed that relative to placebo, dronedarone improved clinical outcomes (in addition to reducing the risk of recurrence of atrial fibrillation). Thus, a new era is emerging with improved outcomes for patients with atrial fibrillation. I encourage readers to review both of these excellent articles.