Atrial fibrillation (AF) remains a major risk factor for
stroke. Unfortunately, clinical trials have failed to demonstrate that a strategy of rhythm control--
therapy to maintain normal sinus rhythm (NSR)--reduces
stroke risk. The apparent lack of benefit of rhythm control likely reflects the difficulty in maintaining NSR using currently available
therapies. However, there are signals from several trials that the presence of NSR is indeed beneficial and associated with better outcomes related to
stroke and mortality. Most electrophysiologists feel that as rhythm control strategies continue to improve, the crucial link between rhythm control and
stroke reduction will finally be demonstrated. Therefore, AF specialists tend to be aggressive in their attempts to maintain NSR, especially in patients who have symptomatic AF. A step-wise approach from
antiarrhythmic drugs to
catheter ablation to cardiac surgery is generally used. In select patients,
catheter ablation or cardiac surgery may supersede
antiarrhythmic drugs. The choice depends on the type of AF, concurrent
heart disease,
drug toxicity profiles, procedural risks, and patient preferences. Regardless of strategy, given the limited effectiveness of currently available rhythm control
therapies, oral anticoagulation is still recommended for
stroke prophylaxis in AF patients with other
stroke risk factors. Major challenges in
atrial fibrillation management include selecting patients most likely to benefit from rhythm control, choosing specific
antiarrhythmic drugs or procedures to achieve rhythm control, long-term monitoring to gauge the efficacy of rhythm control, and determining which (if any) patients may safely discontinue anticoagulation if long-term NSR is achieved.