Atrial fibrillation is one of the biggest issues in cardiology today and is becoming more prevalent each year. It is, of course, already the most common arrhythmia, but the number of patients diagnosed with this problem is increasing steadily as the population ages. As such, each of us in practice sees more and more new patients with this abnormal heart rhythm.
The long history of atrial fibrillation management covers many aspects—but the longest running debate concerns rate versus rhythm control. The latter is what first comes to mind—to restore the heart to a normal sinus rhythm and, thus, eliminate the arrhythmia. The standard approach was to use antiarryhthmic drugs, and it seemed reasonable. However, these agents can cause proarrhythmia and, because of this, caution needs to be exercised in applying antiarrhythmic therapy, especially in patients with evidence of left ventricular dysfunction.
Therefore, new agents are being developed that are “atrial” selective and as such would avoid proarrhythmia (i.e. of ventricular arrhythmias) Rothman and Kowey review the latest trial data on these new agents. Amiodarone, one of the new agents, is said to be antiarrhythmogenic. Thus, deriving new versions of this agent would appear to be a good strategy. There are indeed newer versions of this class of drug, including the approved agent dronedarone, as well as celivarone and budiodarone. The authors offer an excellent review of the emerging data from this “hot” field. Finally, newer mechanisms are also being targeted, including the late sodium channel where the agent ranolazine has inhibitory properties and may have antiarrhythmic effects.
Alternatively, one could simply control patients’ heart rates and prescribe anticoagulants to avoid strokes, and thus not have additional agents on board that have potential side effects. There were two trials [1,2] that addressed this subject, and, interestingly, going against conventional wisdom, they both failed to show a benefit of rhythm control. Thus, it seems to be a toss up as to what approach to take.
Amidst this controversy, a new approach has emerged—ablation. This allows a “mechanical”/procedural approach to eradicate the arrhythmia. Technical success is high, and recurrence rates are moderate—which makes this approach very promising. Is it now time to adopt this new approach, or do we need another large trial of outcomes of rate versus rhythm control? With this abundance of history and key clinical issues, it is fortunate that Camm, who has researched this field throughout all these various advances, and Savelieva address this topic.
It is, therefore, my pleasure to introduce this issue of Hot Topics in Cardiology. I am sure you will learn as much as I did from this outstanding article.