Antiarrhythmic Drug Therapy for Atrial Fibrillation Muhammad Rizwan Sardar, MD a,b,c, *, Wajeeha Saeed, MD d , Peter R. Kowey, MD c,e Atrial fibrillation (AF) is the most common arrhythmia, and its incidence increases with advanced age. About 1% of patients with AF are younger than 60 years, 12% are between 75 and 85 years, and one-third of patients with AF are older than 80 years. 1–3 It is estimated that there are 3 million AF cases, and prevalence is expected to reach 7 million by 2050. 4,5 Incidence rates of AF vary among different races. Individuals of Euro- pean descent have lifetime risk of 20% to 25% of developing AF after the 40 years of age. 6 Although risk factors for developing AF are more prevalent in African Americans, their incidence seems to be lower than whites. 7 AF is associated with a 3-fold to 5-fold increased risk of stroke, and stroke caused by AF has significantly higher mortality and morbidity than without AF. There is a 3-fold increase in the risk of heart failure (HF), 8 2-fold increased risk of dementia, and higher mortality associated with AF. There are more than 470,000 hospitalizations in the United States with the primary diagnosis of AF, and it is esti- mated to cause 100,000 deaths per year. AF, be- sides being one of the leading causes of mortality and morbidity, adds $26 billion to costs in the US health system annually. 9 Treatment of AF is multifold but revolves around 1 essential consideration: whether or not to attempt to restore sinus rhythm or to treat AF by controlling ventricular rate only. This decision de- pends on symptom severity, age of the patient, un- derlying heart disease, and other comorbidities, which may limit therapeutic options. Disclosures: Fee for Atrial Fibrillation Education Program, North American Center for Continuing Medical Ed- ucation (M.R. Sardar); no relevant disclosure (W. Saeed); and fee-for-service consultation for Sanofi, Gilead, Otsuka, Servier, ChanRx, Forest, Merck, Cardiome, Xention (P.R. Kowey). a Department of Cardiology, Cooper University Hospital, 3rd Floor Dorrance, One Cooper Plaza, Camden, NJ 08103, USA; b Lankenau Institute for Medical Research (LIMR), Wynnewood, PA 19096, USA; c Jefferson Med- ical College, Thomas Jefferson University, Philadelphia, PA 19107, USA; d Albert Einstein College of Medicine, Bronx Lebanon Hospital Center, Bronx, NY 10457, USA; e Lankenau Institute for Medical Research (LIMR), Lan- kenau Medical Center, Wynnewood, PA 19096, USA * Corresponding author. Department of Cardiology, Cooper University Hospital, 3rd Floor Dorrance, One Cooper Plaza, Camden, NJ 08103. E-mail address: rizwansardar@hotmail.com KEYWORDS  Atrial fibrillation  Cardioversion  Antiarrhythmic  Pharmacologic therapy  Rhythm control  Rate control  Upstream therapy  Prevention KEY POINTS  Atrial fibrillation (AF) is a complex disease, requiring better understanding in a multifaceted approach.  Better research is needed to develop, subclassify, and identify new therapeutic targets, which hold the promise that precise therapies aimed at preventing or reversing AF will be developed.  Antiarrhythmic therapeutic strategies for AF should be focused on controlling pathophysiologic re- modeling, with better prevention and disease-modifying strategies. Cardiol Clin - (2014) -–- http://dx.doi.org/10.1016/j.ccl.2014.07.012 0733-8651/14/$ – see front matter Ó 2014 Elsevier Inc. All rights reserved. cardiology.theclinics.com