Therapeutic approach to atrial fibrillation: when drugs and when the ablation

Treatment of atrial fibrillation is still an ongoing issue, due to the continuous development of new therapeutic options. As regards pharmacological prophylaxis, dronedarone, a non-iodinated derivative of amiodarone, has recently been evaluated in patients affected by atrial fibrillation and demonstrated a good safety and efficacy profile; it could be particularly beneficial in patients with advanced age, hypertension, diabetes, previous stroke, or left atrial enlargement, due to its association with lower mortality and hospital admissions, while it is not indicated in patients with advanced heart failure. Much more has been developed in the field of ablation, leading to a huge variability in technical approach and patient characteristics. In general, ablation can be considered an effective procedure for appropriately selected patients and shows an acceptable safety profile when performed by trained operators. On the basis of the available evidence, ablation should be the first choice in young patients with lone atrial fibrillation, and a second choice (after failed pharmacological prevention) in older patients or when a mild structural heart disease coexists, particularly when the arrhythmic burden is high and the patient is symptomatic; in patients with a major heart disease, ablation can be considered on a case by case basis.