STRATEGIES FOR MANAGING ATRIAL-FIBRILLATION

The limitations of current therapies for atrial fibrillation are forci ng a rethinking of how they should be used. Questions are being raised about the use of antiarrhythmic drugs, and new nonpharmacologic proce dures are promising alternatives. Most patients with atrial fibrillati on still require warfarin therapy, but some low-risk patients can fore go it. KEY POINTS Sinus rhythm spontaneously returns within the first 24 hours in almost half of cases of new atrial fibrillation. Patients with hemodynamic instability due to new-onset atrial fibrillation shou ld proceed directly to electrical cardioversion. Warfarin therapy to m aintain an International Normalized Ratio (INR) of 2.0 to 3.0 is curre ntly recommended for all patients with atrial fibrillation with no con traindications to it, except for patients younger than 60 years with l one atrial fibrillation, in whom the risk of stroke is low. Certain an tiarrhythmic drugs should be avoided in patients with congestive heart failure, in whom the risks may exceed the benefits. The maze procedur e is emerging as an option to restore and maintain sinus rhythm. Radio frequency atrioventricular node ablation and modification hold promise as options to control the ventricular rate without drugs.