Contemporary Treatment of Atrial Fibrillation

Abstract

Atrial fibrillation is the most common sustained cardiac arrhythmia and is associated with stroke, heart failure, impaired quality of life, hospitalization, and increased mortality. Contemporary treatment has shifted from a predominantly rate-control strategy toward earlier rhythm control in appropriately selected patients. Catheter ablation has become an established and increasingly first-line treatment for symptomatic paroxysmal atrial fibrillation and selected patients with persistent atrial fibrillation. Randomized evidence demonstrates lower arrhythmia recurrence and fewer hospitalizations with ablation compared with antiarrhythmic drug therapy in many symptomatic patients. Pulsed field ablation represents the most important recent procedural innovation because it uses nonthermal electroporation to produce myocardial lesions while potentially limiting collateral injury to the esophagus, phrenic nerve, and pulmonary veins. Cryoballoon and radiofrequency ablation remain established technologies, while hybrid epicardial–endocardial approaches and substrate-based strategies are being explored for persistent and long-standing persistent disease. Anticoagulation, stroke-risk assessment, left atrial appendage occlusion, and aggressive management of modifiable risk factors remain essential components of care regardless of rhythm-control strategy. Novel pharmacologic approaches targeting atrial ion channels, fibrosis, inflammation, microRNAs, and atrial-specific electrophysiology remain investigational. This review summarizes the contemporary management of atrial fibrillation, emphasizing early rhythm control, catheter ablation, pulsed field ablation, anticoagulation, risk-factor modification, and emerging therapies.