Atrial fibrillation (AF) is the most common arrhythmia and is associated with substantial morbidity, including heart failure and stroke.^w1 AF is often encountered in patients with underlying heart disease such as hypertension, and coronary artery and valvular heart disease.1 2 The prevalence of AF increases with age, from 0.5% at age 50–59 years to almost 9% at age 80–89 years.^w2 The economic burden of AF has also become increasingly important. A large UK based survey of the costs associated with AF showed an increase from 0.6–1.2% of the total National Health Service budget in 1995 to 0.9–2.4% by 2000.^w3

In recent years, the results of large clinical trials have had a major impact on the contemporary management of AF.1 2 In addition, novel AF ablation techniques have significantly expanded our treatment arsenal.3 4 Despite these developments, management of AF in the individual patient often remains troublesome. In this article we aim to provided an overview of the modern treatment strategies for AF.

THE FIRST TIME AF IS DETECTED: GENERAL CONSIDERATIONS

When confronted with a patient with AF it is important to characterise the temporal pattern of the arrhythmia according to the 3P classification proposed in the American College of Cardiology/American Heart Association/European Society of Cardiology (ACC/AHA/ESC) guidelines.5 AF is classified into three subgroups: paroxysmal, persistent, or permanent. Paroxysmal AF is defined as recurrent AF that terminates spontaneously within 7 days (usually within 24 h). Persistent AF is recurrent or sustained AF lasting longer than 7 days, and restoration of sinus rhythm—by pharmacological or electrical cardioversion—is still an option. In permanent AF, the duration is longstanding and termination of the arrhythmia is no longer feasible or desired. It is also important to consider whether AF is first detected, frequently recurring, or secondary to another event or condition—for example, cardiac surgery, decompensated heart failure, …