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because of risk of torsades de pointes) Sotalol (80 160 mg twice daily; should be initiated in hospital in patients with structural heart disease because of risk of torsades de pointes) is not very effective for converting atrial fibrillation but can be used to maintain sinus rhythm following cardioversion Unfortunately, sinus rhythm will persist in only 25% of patients who have had a sustained (lasting more than several days) or recurrent episode of atrial fibrillation However, if the patient is treated long-term with an antiarrhythmic agent, sinus rhythm will persist in approximately 50% The most commonly used medications are amiodarone, sotalol, propafenone, flecainide, and dofetilide, but the latter four agents are associated with a clear risk of proarrhythmia, and amiodarone frequently causes other adverse effects Therefore, it may be prudent to determine whether atrial fibrillation recurs during a period of 6 months without antiarrhythmic drugs during which anticoagulation is maintained If it does recur, the decision as to whether to restore sinus rhythm and initiate long-term antiarrhythmic therapy can be based on how well the patient tolerates atrial fibrillation In such a patient, longterm anticoagulation is probably indicated in any case, because of the high rate of recurrence and the likely occurrence of asymptomatic paroxysmal episodes

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exception to the need for anticoagulation is the patient with lone atrial fibrillation (eg, no evidence of associated heart disease, hypertension, atherosclerotic vascular disease, or diabetes) who is under age 60 years Such patients should be treated with aspirin 81 325 mg daily or no antithrombotic therapy b Rate control or elective cardioversion Two large randomized controlled trials (the 4060-patient Atrial Fibrillation Follow-up Investigation of Rhythm Management, or AFFIRM trial; and the Rate Control Versus Electrical Cardioversion for Persistent Atrial Fibrillation, or RACE trial) compared strategies of rate control and rhythm control In both, a strategy of rate control and long-term anticoagulation was associated with no higher rates of death or stroke both, if anything, favored rate control and only a modestly increased risk of hemorrhagic events than a strategy of restoring sinus rhythm and maintaining it with antiarrhythmic drug therapy Of note is that exercise tolerance and quality of life were not significantly better in the rhythm control group Nonetheless, the decision as to whether to attempt to restore sinus rhythm following the initial episode remains controversial Elective cardioversion following an appropriate period of anticoagulation is generally recommended for the initial episode in patients in whom atrial fibrillation is thought to be of recent onset and when there is an identifiable precipitating factor Similarly, cardioversion is appropriate in patients who remain symptomatic from the rhythm despite aggressive efforts to achieve rate control However, it should be noted that even in patients for whom this is the initial episode of atrial fibrillation, the recurrence rate is sufficiently high that longer-term anticoagulation is generally appropriate until persistence of sinus rhythm can be confirmed for at least 6 months In cases in which elective cardioversion is required, it may be accomplished electrically (as described above) or pharmacologically Intravenous ibutilide may also be used as described above in a setting in which the patient can undergo continuous ECG monitoring for at least 3 hours following administration In patients in whom a decision has been made to continue antiarrhythmic therapy to maintain sinus rhythm (see next paragraph), cardioversion can be attempted with an agent that is being considered for long-term use For instance, after therapeutic anticoagulation has been established, amiodarone can be initiated on an outpatient basis (300 400 mg twice daily for 2 weeks, followed by 200 mg twice daily for at least a 2 4 weeks and then a maintenance dose of 200 mg daily) Because amiodarone increases the prothrombin time in patients taking warfarin and digoxin levels, careful monitoring of anticoagulation and drug levels is required Other agents that may be used for both cardioversion and maintenance therapy include propafenone (150 300 mg twice daily; should be avoided in patients with structural heart disease), flecainide (50 150 mg twice daily; should be avoided in patients with structural heart disease and should be used in conjunction with an AV nodal blocking drug if there is a history of atrial flutter), and dofetilide (05 mg twice daily; downward dose adjustment is required with renal dysfunction and dosing must be initiated in hospital.

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