The heterogeneous nature of atrial fibrillation presents unique challenges, especially in terms of management options. Physicians are now offered a plethora of therapeutic options and targets. These options include the various classes of the established antiarrhythmic drugs (AADs), as well as newer options, rate-controlling drugs and ablation procedures. Beyond the various management options, the heterogeneity of the patient population also presents several challenges. Distinct questions continue to be raised regarding the role of new AADs in atrial fibrillation, the management of inappropriate/ multiple shocks in patients with implantable cardioverter-defibrillators (ICDs) and the very specific challenge of managing patients with heart failure and concomitant atrial fibrillation.
The Development of New Antiarrhythmic Drugs
The use of ablation procedures continues to rise in popularity; however, this option still lacks support from data from large-scale clinical trials. While the treatment of atrial fibrillation is expected to benefit from ablation procedures as the technique evolves, AADs remain an important therapeutic strategy. Many of the AAD options in the current pharmacological armamentarium are limited in their efficacy and have potential for both cardiac and extra-cardiac adverse effects. Thus, there is still a clinical need for effective new AADs that have much improved safety profiles for the treatment of atrial fibrillation. Several novel AADs have been investigated, including the multichannel blocker dronedarone and more atrialselective agents, such as vernakalant.
Managing Inappropriate Shocks in Implantable Cardioverter├óÔé¼ÔÇ£Defibrillator Therapy
ICDs have made a significant contribution to the treatment of patients with life-threatening ventricular arrhythmias. Nevertheless, inappropriate shocks from ICDs remain a common complication of this form of therapy. Inappropriate shocks can occur because of problems with the defibrillator lead or from supraventricular tachyarrhythmias, most commonly atrial fibrillation. Frequent appropriate shocks can also occur due to ventricular arrhythmias. Frequent shocks can be painful and emotionally traumatic for the patient. In clinical practice there is a strong rationale for using adjunctive AADs in the context of patients with an ICD, particularly as alternative options to control frequent shocks from ICDs, such as antitachycardia pacing and radiofrequency catheter ablation, may not always be appropriate. However, the selection of the most appropriate agent as adjunctive therapy is a challenge.
Considerations for Managing Patients with Heart Failure and Atrial Fibrillation
There is considerable evidence that, in patients with heart failure, concomitant atrial fibrillation is associated with increased morbidity and mortality. The complex interplay between the two conditions creates specific challenges for the management of this patient population, and many of the current AADs for treating atrial fibrillation in patients with congestive heart failure remain unsatisfactory. Future therapy may require a combination of several strategies that focus on the management of underlying and concomitant conditions for which both pharmacological and invasive options may be needed.
In this supplement, these important considerations are expanded on by a panel of distinguished authors, reflecting the debates on these important topics in the field of heart rhythm disorders at the third Cardiac Rhythm/Electrophysiology And Targeted Education (CREATE) Annual Advisory Meeting held in December 2008.