New approaches to atrial fibrillation management: treat the patient, not the ECG.

Atrial fibrillation causes a significant burden on patients and the health care system. The main goals of atrial fibrillation therapy are to improve symptoms and reduce morbidity. There have been significant recent developments in both stoke prophylaxis and rhythm/rate control. The results of the ACTIVE W study emphasize the importance of effective oral anticoagulant therapy in patients with moderate-to-high risk for stroke. The RE-LY study showed superiority of dabigatran, an oral direct thrombin inhibitor, over warfarin in the prevention of stroke, or systemic embolism. Dronedarone, a new antiarrhythmic drug with multiple class effects, has been recently approved by the US Food and Drug Administration for the treatment of atrial fibrillation. Dronedarone has moderate rhythm and rate control efficacy; however, dronedarone significantly reduced cardiovascular hospitalization, cardiovascular death, and stroke in the large ATHENA trial. There is also an important shift in the paradigm of the goals of atrial fibrillation therapy. Instead of focusing solely on the electrocardiographic outcomes of treatment and considering "rhythm versus rate control," one needs to consider "symptom control" as well as patient well-being. This review will suggest that patient based outcomes rather than ECG-based outcomes should be the primary goals of treatment. Original reports and reviews on specific topics were identified through Medline. Randomized controlled trials were selected as the primary source of information. Analysis included critical review of the evidence available to date.