There are two general approaches to treatingatrial fibrillation:
There are different indications for both rhythm control and rate control, each with its own inherent risks and benefits. In some cases, both strategies are used together. In general, rhythm control is more effective at reducing symptoms, improving quality of life, and preventing progression of atrial fibrillation and development of related complications like heart failure and dementia.
However, the rhythm control strategy can be a problem becauseantiarrhythmic drugsare usually necessary for restoring and maintaining normal heart rhythm.These drugs tend to be relatively ineffective, relatively toxic, or both. (Note that in some patients, getting rid of the atrial fibrillation with anablation procedureis feasible.)
The thing that is especially concerning about antiarrhythmic drugs is their unique toxicity, which often makes them difficult and relatively risky to administer and to take.
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There are two general kinds of toxicity commonly seen with antiarrhythmic drugs:The usual kinds of side effects seen with many drugs, such as allergies, insomnia, gastrointestinal disturbances, etc.Proarrhythmia, which poses a major problem with antiarrhythmic drugs.
There are two general kinds of toxicity commonly seen with antiarrhythmic drugs:
Proarrhythmia
Worse, the types of arrhythmias produced with proarrhythmia (in contrast to the atrial fibrillation itself) can be fatal. Therefore, any time antiarrhythmic drugs are used, there is at least some risk of causing life-threatening arrhythmias which should make doctors and patients reluctant to use them unless they are truly necessary.
Some drugs are more likely to cause proarrhythmia than others and some patients are more likely to experience proarrhythmia than others. The likelihood of proarrhythmia with a particular drug in a particular patient must be taken into account before these drugs are prescribed.
Treating Atrial Fibrillation
Six antiarrhythmic drugs are often used to treat atrial fibrillation: propafenone, flecainide, sotalol (Betapace), dofetilide (Tikosyn), amiodarone, and dronedarone (Multaq).For anybody taking these drugs, the treatment must be carefully individualized to minimize the risk of toxicity, but the following generalizations can be made:
How Atrial Fibrillation (AFib) Is Treated
A Word From Verywell
Both rate and rhythm control strategies have been shown to improve symptoms of atrial fibrillation. However, neither has been conclusively shown to improve survival compared with the other (except for possibly high-cardiovascular-risk patients who may benefit from rhythm control).
Atrial Fibrillation: Deciding to Go to the Hospital
10 SourcesVerywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read oureditorial processto learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.Joglar JA, Chung MK, Armbruster AL, et al.2023 ACC/AHA/ACCP/HRS guideline for the diagnosis and management of atrial fibrillation: A report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines[published correction appears inCirculation. 2024 Jan 2;149(1):e167].Circulation. 2024;149(1):e1-e156. doi:10.1161/CIR.0000000000001193Bunch TJ, Gersh BJ.Rhythm control strategies and the role of antiarrhythmic drugs in the management of atrial fibrillation: focus on clinical outcomes.J Gen Intern Med. 2011;26(5):531-7. doi:10.1007/s11606-010-1574-8Coughtrie AL, Behr ER, Layton D, Marshall V, Camm AJ, Shakir SAW.Drugs and life-threatening ventricular arrhythmia risk: results from the DARE study cohort.BMJ Open. 2017;7(10):e016627. doi:10.1136/bmjopen-2017-016627El Hussein MT, Pamnani P.Pill-in-the-pocket for paroxysmal atrial fibrillation: a review and case study.J Nurse Pract. 2024;20(7):105080. doi:10.1016/j.nurpra.2024.105080Kovacs B, Yakupoglu HY, Eriksson U, Krasniqi N, Duru F.Medical therapy with flecainide and propafenone in atrial fibrillation: Long-term clinical experience in the tertiary care setting.Cardiol J. 2023;30(1):82-90. doi:10.5603/CJ.a2022.0116Somberg J, Molnar J.Sotalol versus amiodarone in treatment of atrial fibrillation.J Atr Fibrillation. 2016;8(5):1359. doi:10.4022/jafib.1359Shojaee M, Feizi B, Miri R, Etemadi J, Feizi AH.Intravenous amiodarone versus digoxin in atrial fibrillation rate control; a clinical trial.Emerg (Tehran). 2017;5(1):e29.Wang SR, Huang KC, Lin TT, et al.The effect of antiarrhythmic medications on the risk of cardiovascular outcomes in patients with atrial fibrillation and coronary artery disease [published correction appears in Int J Cardiol. 2024 Sep 15;411:132257. doi: 10.1016/j.ijcard.2024.132257].Int J Cardiol. 2024;409:132198Khachatryan A, Merino JL, de Abajo FJ, et al.International cohort study on the effectiveness of dronedarone and other antiarrhythmic drugs for atrial fibrillation in real-world practice (EFFECT-AF).Europace. 2022;24(6):899-909. doi:10.1093/europace/euab262U.S. Food and Drug Administration.FDA Drug Safety Communication: Review update of Multaq (dronedarone) and increased risk of death and serious cardiovascular adverse events.Additional ReadingAmerican College of Cardiology Foundation, American Heart Association, European Society of Cardiology, et al.Management of Patients With Atrial Fibrillation (Compilation of 2006 ACCF/AHA/ESC and 2011 ACCF/AHA/HRS Recommendations): A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.Circulation2013; 127:1916.
10 Sources
Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read oureditorial processto learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.Joglar JA, Chung MK, Armbruster AL, et al.2023 ACC/AHA/ACCP/HRS guideline for the diagnosis and management of atrial fibrillation: A report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines[published correction appears inCirculation. 2024 Jan 2;149(1):e167].Circulation. 2024;149(1):e1-e156. doi:10.1161/CIR.0000000000001193Bunch TJ, Gersh BJ.Rhythm control strategies and the role of antiarrhythmic drugs in the management of atrial fibrillation: focus on clinical outcomes.J Gen Intern Med. 2011;26(5):531-7. doi:10.1007/s11606-010-1574-8Coughtrie AL, Behr ER, Layton D, Marshall V, Camm AJ, Shakir SAW.Drugs and life-threatening ventricular arrhythmia risk: results from the DARE study cohort.BMJ Open. 2017;7(10):e016627. doi:10.1136/bmjopen-2017-016627El Hussein MT, Pamnani P.Pill-in-the-pocket for paroxysmal atrial fibrillation: a review and case study.J Nurse Pract. 2024;20(7):105080. doi:10.1016/j.nurpra.2024.105080Kovacs B, Yakupoglu HY, Eriksson U, Krasniqi N, Duru F.Medical therapy with flecainide and propafenone in atrial fibrillation: Long-term clinical experience in the tertiary care setting.Cardiol J. 2023;30(1):82-90. doi:10.5603/CJ.a2022.0116Somberg J, Molnar J.Sotalol versus amiodarone in treatment of atrial fibrillation.J Atr Fibrillation. 2016;8(5):1359. doi:10.4022/jafib.1359Shojaee M, Feizi B, Miri R, Etemadi J, Feizi AH.Intravenous amiodarone versus digoxin in atrial fibrillation rate control; a clinical trial.Emerg (Tehran). 2017;5(1):e29.Wang SR, Huang KC, Lin TT, et al.The effect of antiarrhythmic medications on the risk of cardiovascular outcomes in patients with atrial fibrillation and coronary artery disease [published correction appears in Int J Cardiol. 2024 Sep 15;411:132257. doi: 10.1016/j.ijcard.2024.132257].Int J Cardiol. 2024;409:132198Khachatryan A, Merino JL, de Abajo FJ, et al.International cohort study on the effectiveness of dronedarone and other antiarrhythmic drugs for atrial fibrillation in real-world practice (EFFECT-AF).Europace. 2022;24(6):899-909. doi:10.1093/europace/euab262U.S. Food and Drug Administration.FDA Drug Safety Communication: Review update of Multaq (dronedarone) and increased risk of death and serious cardiovascular adverse events.Additional ReadingAmerican College of Cardiology Foundation, American Heart Association, European Society of Cardiology, et al.Management of Patients With Atrial Fibrillation (Compilation of 2006 ACCF/AHA/ESC and 2011 ACCF/AHA/HRS Recommendations): A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.Circulation2013; 127:1916.
Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read oureditorial processto learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.
Joglar JA, Chung MK, Armbruster AL, et al.2023 ACC/AHA/ACCP/HRS guideline for the diagnosis and management of atrial fibrillation: A report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines[published correction appears inCirculation. 2024 Jan 2;149(1):e167].Circulation. 2024;149(1):e1-e156. doi:10.1161/CIR.0000000000001193Bunch TJ, Gersh BJ.Rhythm control strategies and the role of antiarrhythmic drugs in the management of atrial fibrillation: focus on clinical outcomes.J Gen Intern Med. 2011;26(5):531-7. doi:10.1007/s11606-010-1574-8Coughtrie AL, Behr ER, Layton D, Marshall V, Camm AJ, Shakir SAW.Drugs and life-threatening ventricular arrhythmia risk: results from the DARE study cohort.BMJ Open. 2017;7(10):e016627. doi:10.1136/bmjopen-2017-016627El Hussein MT, Pamnani P.Pill-in-the-pocket for paroxysmal atrial fibrillation: a review and case study.J Nurse Pract. 2024;20(7):105080. doi:10.1016/j.nurpra.2024.105080Kovacs B, Yakupoglu HY, Eriksson U, Krasniqi N, Duru F.Medical therapy with flecainide and propafenone in atrial fibrillation: Long-term clinical experience in the tertiary care setting.Cardiol J. 2023;30(1):82-90. doi:10.5603/CJ.a2022.0116Somberg J, Molnar J.Sotalol versus amiodarone in treatment of atrial fibrillation.J Atr Fibrillation. 2016;8(5):1359. doi:10.4022/jafib.1359Shojaee M, Feizi B, Miri R, Etemadi J, Feizi AH.Intravenous amiodarone versus digoxin in atrial fibrillation rate control; a clinical trial.Emerg (Tehran). 2017;5(1):e29.Wang SR, Huang KC, Lin TT, et al.The effect of antiarrhythmic medications on the risk of cardiovascular outcomes in patients with atrial fibrillation and coronary artery disease [published correction appears in Int J Cardiol. 2024 Sep 15;411:132257. doi: 10.1016/j.ijcard.2024.132257].Int J Cardiol. 2024;409:132198Khachatryan A, Merino JL, de Abajo FJ, et al.International cohort study on the effectiveness of dronedarone and other antiarrhythmic drugs for atrial fibrillation in real-world practice (EFFECT-AF).Europace. 2022;24(6):899-909. doi:10.1093/europace/euab262U.S. Food and Drug Administration.FDA Drug Safety Communication: Review update of Multaq (dronedarone) and increased risk of death and serious cardiovascular adverse events.
Joglar JA, Chung MK, Armbruster AL, et al.2023 ACC/AHA/ACCP/HRS guideline for the diagnosis and management of atrial fibrillation: A report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines[published correction appears inCirculation. 2024 Jan 2;149(1):e167].Circulation. 2024;149(1):e1-e156. doi:10.1161/CIR.0000000000001193
Bunch TJ, Gersh BJ.Rhythm control strategies and the role of antiarrhythmic drugs in the management of atrial fibrillation: focus on clinical outcomes.J Gen Intern Med. 2011;26(5):531-7. doi:10.1007/s11606-010-1574-8
Coughtrie AL, Behr ER, Layton D, Marshall V, Camm AJ, Shakir SAW.Drugs and life-threatening ventricular arrhythmia risk: results from the DARE study cohort.BMJ Open. 2017;7(10):e016627. doi:10.1136/bmjopen-2017-016627
El Hussein MT, Pamnani P.Pill-in-the-pocket for paroxysmal atrial fibrillation: a review and case study.J Nurse Pract. 2024;20(7):105080. doi:10.1016/j.nurpra.2024.105080
Kovacs B, Yakupoglu HY, Eriksson U, Krasniqi N, Duru F.Medical therapy with flecainide and propafenone in atrial fibrillation: Long-term clinical experience in the tertiary care setting.Cardiol J. 2023;30(1):82-90. doi:10.5603/CJ.a2022.0116
Somberg J, Molnar J.Sotalol versus amiodarone in treatment of atrial fibrillation.J Atr Fibrillation. 2016;8(5):1359. doi:10.4022/jafib.1359
Shojaee M, Feizi B, Miri R, Etemadi J, Feizi AH.Intravenous amiodarone versus digoxin in atrial fibrillation rate control; a clinical trial.Emerg (Tehran). 2017;5(1):e29.
Wang SR, Huang KC, Lin TT, et al.The effect of antiarrhythmic medications on the risk of cardiovascular outcomes in patients with atrial fibrillation and coronary artery disease [published correction appears in Int J Cardiol. 2024 Sep 15;411:132257. doi: 10.1016/j.ijcard.2024.132257].Int J Cardiol. 2024;409:132198
Khachatryan A, Merino JL, de Abajo FJ, et al.International cohort study on the effectiveness of dronedarone and other antiarrhythmic drugs for atrial fibrillation in real-world practice (EFFECT-AF).Europace. 2022;24(6):899-909. doi:10.1093/europace/euab262
U.S. Food and Drug Administration.FDA Drug Safety Communication: Review update of Multaq (dronedarone) and increased risk of death and serious cardiovascular adverse events.
American College of Cardiology Foundation, American Heart Association, European Society of Cardiology, et al.Management of Patients With Atrial Fibrillation (Compilation of 2006 ACCF/AHA/ESC and 2011 ACCF/AHA/HRS Recommendations): A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.Circulation2013; 127:1916.
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