The Journal of Tehran University Heart Center Review Article Drug Therapy in Atrial Fibrillation Management: Where Do We Stand in 2010? Gholamreza Davoodi, MD*, Mehdi Montazeri, MD Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran. Abstract Atrial fibrillation (AF) is a commonly encountered arrhythmia in our daily practice. Every year a huge bulk of data is published about different management strategies, new antiarrhythmic drugs, anticoagulation protocols and ablation procedures in these patients. In this review article, we discuss different management strategies and new antiarrhythmic drugs as well as those commonly used. We will also have a brief look at anticoagulation in AF. We try to introduce the most recent publications in this field and we think that this review article may not only give information about the current state of antiarrhythmic therapy of AF, it may also show some progresses that we may anticipate in the near future. New drugs are promising in the management of AF because of better safety profile and also acceptable efficacy. A comparison between the catheter ablation procedure and antiarrhythmic therapy is beyond the scope of this article. J Teh Univ Heart Ctr 4 (2010) 172-178 Keywords: Atrial fibrillation • Anti-arrhythmia agents • Thromboembolism Introduction Atrial fibrillation (AF) is the most prevalent sustained cardiac arrhythmia. The prevalence of AF increases with age1-3 and it tends to occur more frequently in men; the reason for the latter is not clear yet.4 In addition to the structural heart disease, hypertension and obesity also play very important roles in the AF development. Alcohol consumption, fatty acid intake, inflammation, and oxidative stresses may predispose the development of AF.5 Approximately one third of patients have no evidence of cardiac involvement.6 AF is classified into first onset, paroxysmal, persistent, and permanent based on its pattern of evolution and response to treatment.7 The direct cost of AF on the National Health Service was 244-531 million Euros (0.6-1.2% of overall health care expenditure) in the UK in 1995.8 There are several management options for patients with AF which are evolving rapidly. The aim of the present review article is to explain the current state of drug therapy as well as new drugs used in the AF management. Pathogenesis The development and maintenance of AF depend on several factors, amongst which atrial re-entry and sustained ectopic atrial activities are the most important.6 Cardiac diseases can initiate atrial remodeling and create an irreversible substrate, after which enhanced ectopy and re-entry are facilitated.9 Atrial fibrosis and structural remodeling are common findings in long-lasting AF;10 and when they happen, maintenance of sinus rhythm becomes more difficult.11 Elevated levels of matrix metalloproteinase and longer duration of AF may contribute to difficulty in the conversion *Corresponding Author: Gholamreza Davoodi, Assistant Professor of Cardiology, Tehran University of Medical Sciences, Tehran Heart Center, North Kargar Street, Tehran, Iran. 1411713138. Tel: +98 21 88029600. Fax: +98 21 88029731. Email: ghdavoodi@yahoo.com. 172