Treating arrhythmias: an expert opinion

Introduction: Significant progress has recently been made in the pharmacological treatment of arrhythmias. This concerns mainly atrial fibrillation, which affects millions of patients. Areas covered: This review covers recent, clinically relevant developments in arrhythmia treatment, especially with regard to novel agents for the management of atrial fibrillation: dronedarone for rhythm control, vernakalant for pharmacological conversion, and advances in antithrombotic treatment. The field of pharmacological treatment of ventricular arrhythmias is also briefly discussed. Relevant papers were identified by an extensive Pubmed search using appropriate keywords. Expert opinion: Dronedarone has been proposed as one of the first-choice antiarrhythmic drugs for almost all categories of patients with atrial fibrillation. However, its effectiveness in prevention of arrhythmia recurrences is less than that of amiodarone. Administration to patients with severe heart failure is associated with increased mortality and should be avoided. There are also very recent reports over rare but severe cases of hepatic injury in patients treated with dronedarone, including two cases of acute liver failure leading to liver transplant. Intravenous vernakalant is effective for the rapid pharmacological conversion of atrial fibrillation. Dabigatran, an oral direct thrombin inhibitor, has been shown to be effective in stroke reduction without increase in bleeding rates; additionally, no monitoring of antithrombotic effectiveness is needed. Rivaroxaban, an oral direct factor Xa inhibitor, has also shown promising results. These developments in the pharmacological treatment of arrhythmia will presumably affect clinical decision making.