Have sanctioned algorithms replaced empiric judgment in the selection process of antiarrhythmic drugs for the therapy for atrial fibrillation?

Treatment of atrial fibrillation (AF) includes rate control, anticoagulation, rhythm control, and therapy of any underlying structural heart disease and/or AF precipitant. Rhythm control, restoration of and maintenance of sinus rhythm (NSR), is required in patients who remain significantly symptomatic despite rate control. Rhythm control generally employs antiarrhythmic drugs (AAD). When the selection of AADs was limited, and included only class IA agents, the choice of drug to use was empiric, guided by anticipated tolerance and compliance. Now, with multiple classes of AADs available and with a better understanding of organ toxic and proarrhythmic risks, algorithms to guide drug selection have become both popularized and sanctioned. Notably, although such algorithms are now the standard of care and the norms to which practitioners should be held regarding the selection of an AAD for AF management, they have not removed empiricism and clinical judgment from the AAD selection process. Clinical decision making is still required to select from among any group of drug options as listed in the published algorithms, and to select the dosing regimen to use. Prior history, dosing frequency, desirability of b-blocking effect, electrolyte status, renal function, concomitant therapies, site of initiation, and anticipated patient compliance are also all nonalgorithmic issues in the decision process.