Atrial fibrillation is a highly prevalent condition, and the number of cases is only expected to increase. This rise is primarily due to the survival of elderly patients with pre-existing conditions.

Atrial fibrillation is currently treated with a variety of anti-arrhythmic agents. No single drug is completely safe and effective for all patients with atrial fibrillation. Atrial fibrillation is grouped into four patterns: 1) detected arrhythmia; 2) paroxysmal atrial fibrillation; 3) persistent atrial fibrillation and, 4) permanent atrial fibrillation.

Each pattern requires a different therapy. Paroxysmal atrial fibrillation is treated by preventing the recurrence of atrial fibrillation. Persistent atrial fibrillation is treated either by preventing atrial fibrillation, terminating the arrhythmia, or controlling ventricular rate.

For prevention of recurrences of atrial fibrillation the favored drug is amiodarone. Atrial fibrillation can be terminated effectively with the single-dose drug, propafenone and the intravenous medications, flecainide and amiodarone. Flecainide is rapidly effective (within 30 min). Heart rate can be controlled by the therapies listed in order of their effectiveness: 1) monotherapy with a beta blocker or calcium antagonist; 2) digitalis in combination with calcium antagonist or beta blocker and 3) digoxin alone. Dr. Camm noted that heart rate can be controlled with digitalis monotherapy, however, it is only effective at rest. Digitalis is not effective during exercise.

For treatment of recurrent atrial fibrillation, flecainide and propafenone are recommended in patients with otherwise normal hearts. These episodes can be prevented by treatment with disopyramide, quinidine and procainamide for patients with little or no heart disease. For patients with heart failure amiodarone and difeltilide are recommended. For patients with hypertension alone flecainide and propafenone are recommended followed by more powerful anti-arrhythmic drugs. If left ventricular hypertrophy is present, amiodarone is the drug of choice. For treatment of recurrent atrial fibrillation, flecainide and propafenone are recommended in patients with otherwise normal hearts.

For acute atrial fibrillation (less than 7 days) the recommended drugs are flecainide, propafenone, difeltilide, and ibutilide. The treatment of choice for chronic atrial fibrillation (more than 7 days) is difeltilide; digitalis is contraindicated for this condition.