Atrial fibrillation (AF) is a supraventricular tachyarrhythmia characterised by uncoordinated atria activation with consequent deterioration of atrial mechanical function. It is the most common arrhythmia encountered in the clinical practice of the developed countries,^1w1 and accounts for 1% of all National Health Service expenditure in the United Kingdom.^w2

The prevalence and incidence of AF increases with advancing age, affecting approximately 5% of individuals older than 65 years and nearly 10% of those aged older than 80 years.² So common is this problem that it is expected that more than five million Americans will be living with AF by the year 2050.^w1 AF also coexists with common cardiovascular conditions, such as hypertension, heart failure, coronary artery disease and diabetes mellitus, and with an increasingly older general population, AF (and its co-morbidities) will become an increasing health care burden.^{2w3 w4} Indeed, hospitalisation rates for AF have increased by 2–3 fold.^w4 In the Framingham Heart Study, AF was associated with a 1.5- to 1.9-fold mortality risk, even after adjustment for the pre-existing cardiovascular conditions.^w5 AF also confers a substantial morbidity from stroke, thromboembolism, heart failure and impaired quality of life; indeed, stroke survivors associated with AF have more severe strokes with greater disability, longer hospital stays and lower rates of discharge to their own home.²

The aim of this review is to provide a practical and clinically useful approach to the management of AF. The current 2001 American College of Cardiology/American Heart Association/European Society of Cardiology (ACC/AHA/ESC) consensus guidelines¹ for the management of patients with AF will be updated in late 2006, and the evidence-based UK National Institute for Health and Clinical Excellence (NICE) guidelines are available (www.nice.org.uk) in their final form from June 2006. The extensive literature on the electrophysiology and …