The worldwide social burden of atrial fibrillation: what should be done and where do we go?

Atrial fibrillation represents the most common arrhythmia in clinical practice and is associated with poor clinical outcome. Due to the aging of the population, the number of patients with atrial fibrillation will increase approximately 2.5-fold by the year 2050. Comparison studies between rhythm control and rate control strategies in management of atrial fibrillation have been biased by the limited efficacy of antiarrhythmic drugs in keeping an actual rhythm control, while their adverse effects may offset their antiarrhythmic benefits. In patients who are candidates for anti-bradycardia pacing atrial and dual chamber pacing have been demonstrated to be superior to single chamber ventricular pacing in reducing atrial fibrillation recurrences and in preventing progression to permanent atrial fibrillation. Algorithms aimed either to prevent atrial fibrillation relapsing or to interrupt new onset tachycardias early have been demonstrated to be safe and effective, but clinical studies which investigated their impact on clinical end points showed inconsistent results. Multifunction devices capable of delivering atrial shock have been demonstrated useful in patients who were candidates for ICD implantation because of life-threatening ventricular arrhythemias. Preliminary studies suggested a potential role of these devices in selected patients with brady-tachy syndrome without prior ventricular arrhythmias. Radiofrequency catheter ablation techniques of atrial fibrillation have been increasingly used in the last years. Both pulmonary vein ablation and left atrial circumferential ablation showed encouraging clinical results with 70-80% of patients free from atrial fibrillation with or without prior ineffective antiarrhythmic drugs. In the future, strategies to deal with the huge worldwide burden of atrial fibrillation will include a wider application of non pharmacological therapies as well as a big investment in basic and clinical research. New and more effective antiarrhythmic drugs are needed. Genetic studies will deeply change understanding and therapy of atrial fibrillation.