Perspective:

The following are 10 points to remember from this review of atrial fibrillation (AF):

1. The muscle sleeves that surround the pulmonary veins often are the source of ectopy that trigger episodes of AF.

2. Electrical and structural remodeling in the atria facilitate the persistence of AF.

3. Restoration of sinus rhythm is associated with reversal of atrial remodeling, improved left ventricular function, and improved exercise tolerance and quality of life.

4. Most randomized studies have not demonstrated any advantage of a rhythm-control strategy over a rate-control strategy, but this may be because many patients randomized to rhythm-control experienced side effects or adverse events from antiarrhythmic drug therapy that had only limited efficacy in preventing AF.

5. Warfarin is superior to aspirin or the combination of aspirin plus clopidogrel for stroke prevention, and the combination of aspirin plus clopidogrel is superior to aspirin.

6. Dabigatran, a direct thrombin inhibitor, is at least as safe and effective as warfarin for stroke prevention and does not require dose adjustment.

7. Risk factors for proarrhythmia from rhythm-control medications include baseline QT prolongation, depressed left ventricular function, hypokalemia, female gender, renal insufficiency, bradycardia, and concomitant therapy with drugs that prolong the QT interval.

8. Dronedarone, the most recently approved rhythm-control agent, is contraindicated in patients with class IV heart failure and in patients with class II-III heart failure with recent decompensation.

9. The pill-in-pocket approach is ideal for patients with relatively infrequent episodes of symptomatic AF and minimal or no structural heart disease.

10. Catheter ablation of AF is a second-line therapeutic option in patients with symptomatic AF who have not responded adequately to first-line antiarrhythmic drugs.