Prevention of atrial fibrillation complications with antiarrhythmic drugs: still an unmet need in clinical practice

Atrial fibrillation (AF) is the most common arrhythmia and is associated with substantial cardiovascular morbidity and mortality, with stroke being the most important complication. Present drugs used for the therapy of AF (antiarrhythmic drugs and anticoagulants) have major intrinsic limitations, including moderate efficacy and increased risks of life-threatening proarrhythmic effects and bleeding complications. There is great diversity in the pathophysiological substrate, clinical presentation and prognosis of AF. Therefore, assessing the risk of AF-associated stroke and choosing the most appropriate antithrombotic therapy, selecting in which patient to pursue a rhythm-versus a rate-control approach, and when to consider nonpharmacological therapies, such as catheter ablation, remain difficult decisions in most patients. Antiarrhythmic drugs like dronedarone have the potential to prevent AF-related complications like stroke and provides clinicians with a new option when choosing antiarrhythmic therapy. However, major concerns with dronedarone are its low efficacy for AF and lack of evidence for effectiveness in patients failing other antiarrhythmic agents. New oral anticoagulants like dabigatran have important safety advantages versus traditional vitamin-K antagonists in preventing stroke, but they do not arrest or prevent AF. Thus, there is still a clear unmet need for new and more effective antiarrhythmic drugs that prevent AF-related complications. Hopefully such new drugs will lead to improved patient management in the future.