In patients with persistent atrial fibrillation, two therapeutic alternatives exist, namely res toration and maintenance of sinus rhythm versus ventricular rate control combined with anticoagulation. Currently, the selection of the best therapeutic strategy in an individual patient relies for the most part on clinical judgement and personal experience. At present, there are no prospective scientific data to support the superiority of one treatment over the other with respect to overall survival or quality of life. This review summarizes the present knowledge on this important clinical problem with particular emphasis on issues such as efficacy of antiarrhythmic drugs to prevent recurrent atrial fibrillation, proarrhythmic haz ards of these compounds, or efficacy and safety of anticoagulation in nonrheumatic atrial fibrillation. These data serve as the basis of ongoing clinical trials prospectively comparing the merits and demerits of the two therapeutic strategies in the most common arrhythmia encountered in clinical practice.
Kannel WB, Abbott RD, Savage DD, McNamara PMEpidcmiologic features of chronic atrial fibrillation. The Framingham study . N Engl J Mcd306:1018-1022. 1982
2.
Lake FR, Cullen KJ, de Klerk NH, et al. Atrial fibrillation and mortality in an elderly population. Aust N Z J Med19:321-326, 1989
3.
Flegel KM, Shipley MJ, Rose G.Risk of stroke in nonrheumatic atrial fibrillation. Lancet1:526-529, 1987
4.
Onundarson PT , Thorgeirsson G., Jonmundsson E., et al. Chronic atrial fibrillation—Epidemiologic features and 14 years follow-up. A case-control study. Eur Heart J3:521-527, 1987
5.
Krahn AD, Manfreda J., Tate RB, Mathewson Fal, Cuddy TEThe natural history of atrial fibrillation: Incidence, risk factors, and prognosis in the Manitoba follow-up study. Am J Med98:476-484, 1995
6.
Psaty BM, Manolio TA, Kuller LH, et al. Incidence of and risk factors for atrial fibrillation in older adults. Circulation96:2455-2461, 1997
7.
Wolf PA, Kannel WB, Baker CS, et al. Increased mortality, stroke and medical costs imposed by atrial fibrillation. J Am Coll Cardiol27:312A, 1996
8.
Sopher SM, Camm AJAtrial fibrillation: Maintenance of sinus rhythm versus rate control. Am J Cardiol77:24A-37A, 1996
9.
Wijffels Mcef , Kirchhof Cjhj, Dorland R., Allessie MAAtrial fibrillation begets atrial fibrillation: A study in awake chronically instrumented goats . Circulation92: 1954-1968,1995
10.
Daoud EG, Knight BP, Weiss R., et al. Effect of verapamil and procainamide on atrial fibrillation-induced electrical remodeling in humans. Circulation96:1542-1550,1997
11.
Nattel S., Hadjis T., Talajic M.The treatment of atrial fibrillation—An evaluation of drug therapy, electrical modalities and therapeutic considerations. Drugs48:345-371,1994
12.
Prystowsky EN, Benson DW, Fuster V.Hart RG, Kay N., Myerburg RJ, Naccarelli GV, Wyse DGManagement of patients with atrial fibrillation . Circulation93:1262-1277, 1996
13.
Nattel S.Newer developments in the management of atrial fibrillation. Am Heart J130:1094-1106, 1995
14.
Golzari H., Cebul RD, Bahler RCAtrial fibrillation: Restoration and maintenance of sinus rhythm and indications for anticoagulation therapy. Ann Int Med125:311-323, 1996
15.
Hohnloser SH , van de Loo A., Baedeker F.Efficacy and proarrhythmic hazards of pharmacologic cardioversion of atrial fibrillation: Prospective comparison of sotalol versus quinidine. J Am Coll Cardiol26:852-858, 1995
16.
Van Gelder IC , Crijns HJ, Van Gilst WH, Verwer R., Lie KIPrediction of uneventful cardioversion and maintenance of sinus rhythm from direct-current electrical cardioversion of chronic atrial fibrillation. Am J Cardiol68: 41-46, 1991
17.
Metcalfe MJ , Smith F., Jennings K., Patterson N.Does cardioversion of atrial fibrillation result in myocardial damage?BMJ290:1364, 1988
18.
Levy S., Lauribe P. Dolla E, Kou W., Kadish A., Calkins H., Paganelli F. Moyal C, Bremondy M., Schork A.A randomized comparison of external and internal cardioversion of chronic atrial fibrillation. Circulation86:1415-1420, 1992
19.
Alt E., Schmitt C., Ammer R. Coenen M, Fotuhi P., Karch M. Blasini R.Initial experience with intracardiac atrial defibrillation in patients with chronic atrial fibrillation. Pacing Clin Electrophysiol17:1067-1078, 1994
20.
Coplen SE, Antman EM, Berlin JA, Hewitt P., Chalmers TCEfficacy and safety of quinidine therapy for the maintenance of sinus rhythm after cardioversion. A meta-analysis of randomized control trials. Circulation82:1106-1116, 1990
21.
Juul-Möller S., Edvardssion N., Rehnqvist-Ahlberg N.Sotalol versus quinidine for the maintenance of sinus rhythm after direct current conversion of atrial fibrillation. Circulation82:1932-1939, 1993
22.
CrijnsHJGM, Van Gelder IC, Van Gilst WH, Hillege H, Gosselink ATM, Lie KI. Serial antiarrhythmic drug treatment to maintain sinus rhythm after electrical cardioversion for chronic atrial fibrillation or atrial flutter. Am J Cardiol68:335-341, 1991
23.
Hall JI, Wood DRFactors affecting cardioversion of atrial arrhythmias with special reference to quinidine. Br Heart J30:84-90, 1968
24.
Byrne-Quinn E., Wing AJMaintenance of sinus rhythm after DC reversion of atrial fibrillation. A double-blind controlled trial of long-acting quinidine bisulfate. Br Heart J32:570-576, 1970
25.
Härtel G., Louhija A., Halonen PIValue of quinidine in maintenance of sinus rhythm after electric conversion of atrial fibrillation. Br Heart J32:57-60, 1970
26.
Gunning JF, Kristinsson A., Miller G., Saunders K.Long-term follow-up of direct current cardioversion after cardiac surgery with special reference to quinidine. Br Heart J32:462-466,1970
27.
Hillestad L. , Bjerkelund C., Dale J., Maltau J., Storstein O.Quinidine in maintenance of sinus rhythm after electroconversion of chronic atrial fibrillation. A controlled clinical study . Br Heart J33:518-521, 1971
28.
Härtel G., Louhija A., Konttinen A.Disopyramide in the prevention of recurrence of atrial fibrillation after electroconversion. Clin Pharmacol Ther15:551-555, 1974
29.
Södermark T. , Edhag O., Sjögren A., Jonsson B., Olsson A., Orö L., et al. Effect of quinidine on maintaining sinus rhythm after conversion of atrial fibrillation or flutter. A multicentre study from Stockholm. Br Heart J37:486-492, 1975
30.
Boissel JP, Wolf E., Gillet J., Soubrane A., Cavallaro A., Mazoyer G., et al. Controlled trial of a long-acting quinidine for maintenance of sinus rhythm after conversion of sustained atrial fibrillation. Eur Heart J2:49-55,1981
31.
Lloyd EA, Gersh BJ, Formann R.The efficacy of quinidine and disopyramide in the maintenance of sinus rhythm after electroconversion from atrial fibrillation. A double-blinded study comparing quinidine, disopyramide and placebo. S Afr Med J65:367-369,1984
32.
Karlson BW, Torstensson I., Abjorn C., Jansson SO, Peterson LEDisopyramide in the maintenance of sinus rhythm after electroconversion of atrial fibrillation. A placebo-controlled one-year follow-up study. Eur Heart J9:284-290, 1988
33.
Van Gelder IC, Crijns HJ, Van Gilst WH, Van Wijk LM, Hamer HP, Lie KIEfficacy and safety of flecainide acetate in the maintenance of sinus rhythm after electrical cardioversion of chronic atrial fibrillation or atrial flutter. Am J Cardiol64:1317-1321,1989
34.
Edhag O., Erhardt LR, Lundmann T., Södermark T., Sjögren A.Verapamil and quinidine in maintaining sinus rhythm after electroconversion of atrial fibrillation. Opuscula Medica27:22-24, 1982
35.
O'Keeffe DB , Nicholls DP, Morton P., Murtagh GJ, Scott MEMaintenance of sinus rhythm after elective cardioversion from chronic stable atrial fibrillation: Amiodarone compared with quinidine. Br Heart J51:103, 1984
36.
Touboul P., Aliot E., Brembilla-Perrot B.Flecainide in the prevention of atrial fibrillation after DC conversion: Comparison with quinidine (Abstract). Circulation84 (Suppl II):127,1991
37.
Woo KS, Kong SMDisopyramide and quinidine in maintenance of sinus rhythm after electroconversion (Abstract). Circulation62(Suppl III):181, 1980
38.
Rasmussen K. , Andersen A., Abrahamsen AM, Overskeid K., Bathen J.Flecainide versus disopyramide in maintaining sinus rhythm following conversion of chronic atrial fibrillation (Abstract) . Eur Heart J9(Suppl I):52, 1988
39.
Reimold SC, Cantillon CO, Friedman PL, Antman EMPropafenone versus sotalol for suppression of recurrent symptomatic atrial fibrillation. Am J Cardiol71:558-563, 1993
40.
Hohnloser SHIndications and limitations of class II and III antiarrhythmic drugs in atrial fibrillation. Pacing Clin Electrophysiol17:1019-1025, 1994
41.
Horowitz LN , Spielman SR, Greenspan AM, Mintz GS, Morganroth J., Brown R., Brady PM, Kay HRUse of amiodarone in the treatment of persistent and paroxysmal atrial fibrillation resistant to quinidine therapy. J Am Coll Cardiol6:1402-1407, 1985
42.
Gold RL, Haffajee CI, Charos G., Sloan K., Baker S., Alpert JSAmiodarone for refractory atrial fibrillation. Am J Cardiol57:124-127, 1986
43.
Brodsky MA, Allen BJ, Walker CJ, Casey TP, Luckett CR, Henry WLAmiodarone for maintenance of sinus rhythm after conversion of atrial fibrillation in the setting of a dilated left atrium. Am J Cardiol60:572-575,1987
44.
Blevins RD, Kerin NZ, Benaderet D., Frumin H., Faitel K., Jarandilla R., Rubinfire M.Amiodarone in the management of refractory atrial fibrillation. Arch Int Med147: 1401-1404,1987
45.
Gosselink Atm , Crijns Hjg, van Gelder IC, Hillige H., Wiesfeld Acp, Lie KILow-dose amiodarone for maintenance of sinus rhythm after cardioversion of atrial fibrillation or flutter. JAMA267:3289-3293,1992
46.
Skoularigis J., Röthlisberger C., Skudicky D., Essop MR, Wisenbaugh T., Sareli P.Effectiveness of amiodarone and electrical cardioversion for chronic rheumatic atrial fibrillation after mitral valve surgery. Am J Cardiol72:423-427, 1993
47.
Chun S., Sager PT, Stevenson WG, Nademanee K., Middlekauff HR, Singh BNLong-term efficacy of amiodarone for the maintenance of normal sinus rhythm in patients with refractory atrial fibrillation or flutter. Am J Cardiol76:47-50,1995
48.
Zarembski DG , Nolan PE, Slack MK, Caruso ACTreatment of resistant atrial fibrillation. A meta-analysis comparing amiodarone and flecainide. Arch Int Med155: 1885-1891,1995
49.
Deedwania PC , Singh BN, Ellenbogen K., Singh S., Fletcher R., Fisher S., for the CHF-STAT Investigators.Amiodarone is more effective than placebo for spontaneous restoration and maintenance of sinus rhythm in patients with chronic atrial fibrillation and congestive heart failure. J Am Coll Cardiol22:46A, 1996
50.
Levine JH, Morganroth J., Kadish AHMechanisms and risk factors for proarrhythmia with type Ia compared with Ic antiarrhythmic drug therapy. Circulation80:1063-1069, 1989
51.
Jackman WM, Friday KJ, Anderson JL, Aliot EM, Clark M., Lazarra R.The long QT syndromes: A critical review, new clinical observations and a unifying hypothesis. Prog Cardiovasc Dis31:115-172, 1988
52.
Hohnloser SH , Singh BNProarrhythmia with class III antiarrhythmic drugs: Definition, electrophysiologic mechanisms, incidence, predisposing factors, and clinical implications. J Cardiovasc Electrophysiol6:920-936,1996
53.
Hohnloser SH , Klingenheben T., Singh BNAmiodarone-associated proarrhythmic effects: A review with special reference to torsade de pointes tachycardia. Ann Int Med121:529-535, 1994
54.
Balser JR, Bennett PB, Hondeghem LM, Roden DMSuppression of time-dependent outward current in guinea pig ventricular myocytes . Circ Res69:519-529,1991
55.
Nattel S., Talajic M., Quantz M., DeRoode M.Frequency-dependent effects of amiodarone on atrioventricular nodal function and slow-channel action potentials: Evidence for calcium channel blocking activity. Circulation76:442-449, 1987
56.
Brachmann J. , Scherlag BJ, Rosenshtraukh LV, Lazzara R.Bradycardia-dependent triggered activity: Relevance to drug-induced multiform ventricular tachycardia . Circulation68:846-856,1983
57.
Vrobel TR, Miller PE, Mostow ND, Rakita L.A general overview of amiodarone toxicity: Its prevention, detection, and management. Prog Cardiovasc Dis31:393-426, 1989
58.
Kerin NZ, Blevins RD, Goldman L., Faitel C., Rubinfire M.The incidence, magnitude and time course of the amiodarone-warfarin interaction . Arch Int Med148:1779-1781, 1988
59.
Nademanee K. , Kannan R., Hendrickson J., Ookhtens M., Kay I.; Singh BNAmiodarone-digoxin interaction: Clinical significance, time course of development, potential pharmacokinetic mechanisms and therapeutic implications. J Am Coll Cardiol4:111-116, 1984
60.
Lip Gyh.Docs atrial fibrillation confer a hypercoagulablc state?Lancet346:1313-1314, 1995
61.
Ezekowitz MD , James KE, Nazarian SM, Davenport J., Brodcrick JP, Gupta SR, Thadani V., Meyer ML, Bridgcrs SL, for the Veterans Affairs Stroke Prevention in Nonrheumatic Atrial Fibrillation Investigators.Silent cerebral infarction in patients with nonrheumatic atrial fibrillation . Circulation92:2178-2182,1995
62.
Kinch JW, Davodoff R.Prevention of embolic events after cardioversion of atrial fibrillation . Arch Intern Med155:1353-1360, 1995
63.
Atrial Fibrillation Investigators. Risk factors for stroke and efficacy of antithrombotic therapy in atrial fibrillation. Arch Int Med154:1449-1457, 1994
64.
The EuropeanAtrial Fibrillation Trial Study Group. Optimal oral anticoagulant therapy in patients with nonrheumatic atrial fibrillation and recent cerebral ischemia. N Engl J Med333:5-10, 1995
65.
Hylek EM, Skates SJ, Sheehan MA, Singer DEAn analysis of the lowest effective intensity of prophylactic anticoagulation for patients with nonrheumatic atrial fibrillation. N Engl J Med335:540-546,1996
Stroke Prevention in Atrial Fibrillation Investigators. Stroke prevention in atrial fibrillation study: Final results. Circulation84:527-539,1991
68.
Peterson P. , Godtfredsen J., Andersen E., Andersen B.Placebo-controlled, randomized trial of warfarin and aspirin for prevention of thromboembolic complications in chronic atrial fibrillation: The Copenhagen AFASAK study . Lancet1:175-178,1989
69.
TheBoston Area Anticoagulation Trial for Atrial Fibrillation Investigators. The effect of low-dose warfarin on the risk of stroke in patients with nonrheumatic atrial fibrillation. N Engl J Med323:1505-1511, 1990
70.
Connolly SJ , Laupacis A., Gent M., Roberts RS, Cairns JA, Joyner C., for the CAFA Study Coinvestigators.Canadian atrial fibrillation anticoagulation (CAFA) study . J Am Coll Cardiol18:349-355,1991
71.
Ezekowitz MD , Bridgers SL, James KE, Carlinger NH, Colling CL, Gornick CC, Krause-Steinrauf H., Kurtzke JF, Nazarian SM, Radford MJ, Rickles FR, Shabetai R., Deykin D., for the Veterans Affairs Stroke Prevention in Nonrheumatic Atrial Fibrillation Investigators.Warfarin in the prevention of stroke associated with nonrheumatic atrial fibrillation. N Engl J Med327:1406-1412, 1992
72.
EAFT Study Group. Secondary prevention in non-rheumatic atrial fibrillation after transient ischaemic attack or minor stroke. Lancet342:1255-1262,1993
73.
Hohnloser SH , Kuck KHAtrial fibrillation: Maintaining stability of sinus rhythm or ventricular rate control? The need for prospective data: The PIAF trial. Pacing Clin Electrophysiol20:1989-1992,1997
74.
The Planning and Steering Committees of the AFFIRM Study for the NHLBI AFFIRM Investigators.Atrial fibrillation follow-up investigation of rhythm management— The AFFIRM study design. Am J Cardiol79:1198-1202, 1997
75.
The VA Cooperative Study Investigators.Antiarrhythmics for maintenance of sinus in atrial fibrillation: Study design . (in preparation), 1998
