[Remodeling by atrial fibrillation and clinical implications for cardioversion].

Atrial fibrillation (AF) most often occurs in pre-diseased hearts. On the other hand substantial alterations (particularly atrial) are induced by the arrhythmia itself. Such remodeling occurs in a time-dependent manner. Remodeling of electrical, contractile, endothelial and structural properties / components has been reported. Medical treatment of AF importantly comprises anticoagulation according to risk stratification scores (CHADS2 or CHA2DS2VASc) besides rate control measures. In patients who remain syptomatic despite rate control a rhythm control strategy is indicated. In order to re-establish sinus rhythm patients may undergo electrical or pharmacological cardioversion. Electrical cardioversion is highly efficient but requires conscious sedation, pharmacological cardioversion should only be performed in hemodynamically stable patients with recent (< 48 h) onset AF. Several anti-arrhythmic options exist for pharmacological cardioversion (amiodarone, flecainide, propafenone and the recently approved atrial-specific agent vernakalant). While amiodarone has low efficacy for rapid restoration of sinus rhythm, it can be given to patients with heart failure or significant structural heart disease. Class-I substances can only be applied to patients without significant structural heart disease but onset of action is more rapid. Vernakalant can be applied to hemodynamically stable patients with structural heart disease and represents a novel alternative option for rapid pharmacological cardioversion.