Rhythm Control of Atrial Fibrillation – Antiarrhythmic Drugs

Rhythm control (maintenance of sinus rhythm) is a fundamental treatment strategy in atrial fibrillation (AF).

The rhythm control strategy aims at restoration and long-term maintenance of sinus rhythm.
The goal is to eliminate or significantly reduce AF episodes, improve patient symptoms, and enhance quality of life.

The rhythm control strategy in AF includes:

Elimination and management of risk factors and comorbidities.
Pharmacological antiarrhythmic therapy aimed at maintaining sinus rhythm.
Pulsed-field ablation of AF, indicated in case of failure or intolerance of antiarrhythmic therapy.

If a patient is diagnosed with AF, anticoagulation therapy is indicated according to the CHA₂DS₂-VA score

regardless of whether the patient is in sinus rhythm or AF during treatment.
Because the patient may have asymptomatic AF episodes that carry a risk of thromboembolism (stroke).

Rhythm control of atrial fibrillation – Long-term therapy	Class
Amiodarone is recommended for long-term maintenance of sinus rhythm in patients with EF <40 % or structural heart disease.	I
Amiodarone is among the most effective antiarrhythmic drugs; however, it has a high incidence of adverse effects and therefore should not be used long term (>12 months).	IIb
Dronedarone is recommended for long-term maintenance of sinus rhythm in patients with EF >40 %, including those with structural heart disease.	I
Flecainide or propafenone are recommended for long-term maintenance of sinus rhythm in patients without structural heart disease.	I
During treatment with flecainide or propafenone, concomitant administration of AV nodal–blocking drugs (beta-blockers, verapamil, or diltiazem) should be considered to prevent 1:1 atrial flutter conduction.	IIa