Atrial fibrillation is the most common type of sustained arrhythmia, and studies have shown a strong association between atrial fibrillation and an increased risk of stroke, congestive heart failure, and mortality. Since 1980, the mortality rate due to AF has increased at a rate of 5% per year, while the hospitalization rate has also increased at a rate of 2-3 times. There are numerous treatments for atrial fibrillation, and traditional antiarrhythmic drugs play an important role in the treatment of atrial fibrillation, but they are difficult to satisfy because of their limited efficacy, low safety profile, and tendency to develop drug resistance. Catheter ablation, which has become generally popular in recent years, is a major advance in the treatment of atrial fibrillation. Not only can it cure some patients, there is evidence that it can also lead to improvements in cardiac function. However, catheter ablation is not suitable for all patients, and the procedure is not simple and carries risks. Among the novel drug therapies for atrial fibrillation, three classes of drugs are mentioned in the literature: improved Ш-class antiarrhythmics; novel antiarrhythmics; and upstream drugs that act on the substrate. In this article, we will describe the present-day treatment of atrial fibrillation. Atrial fibrillation is the most common type of sustained arrhythmia. It is not a single disease, but a series of clinical symptoms with electrocardiographic changes as the main manifestation. It can occur in people without organic heart disease (isolated atrial fibrillation) or, more commonly, in the setting of hypertension, heart failure, or valvular disease. Atrial fibrillation is extremely dangerous and is currently one of the main risk factors for sudden death, especially in people over 80 years of age. Atrial fibrillation occurs with rapid, disturbed electrical impulses in the heart muscle, resulting in ineffective contraction of the atria. On the electrocardiogram, atrial fibrillation is characterized by irregular P waves. If atrial fibrillation persists and is not corrected, it will lead to atrial remodeling. Although atrial fibrillation may also occur in younger individuals, it is generally an age-related condition. The incidence of atrial fibrillation increases significantly with age: less than 1% for those younger than 60 years, about 5% for those 70-70 years, and about 10% for those older than 80 years. About half of the patients with atrial fibrillation are older than or equal to 75 years of age, and most of them have insignificant symptoms. As the aging of the population increases, the form of treating atrial fibrillation tends to become more severe. 1. sinus rhythm maintenance and ventricular rate control therapy for atrial fibrillation While it is advisable to treat patients with first-episode atrial fibrillation with reconstruction and maintenance of sinus rhythm, there are no very specific criteria for maintaining sinus rhythm or controlling ventricular rate in patients with recurrent atrial fibrillation, as suggested by John Cammd et al. in their article, shown in Figure 1. Maintenance of sinus rhythm is usually indicated in paroxysmal AF, especially in younger patients. In patients with permanent atrial fibrillation, ventricular rate control is considered the first-line treatment. If ventricular rate control fails, then re-establishment of sinus rhythm is worth pursuing. Persistent atrial fibrillation is the greatest therapeutic challenge. Usually, resuscitation is the treatment of choice in most cases, but if the patient is asymptomatic or not suitable for resuscitation, ventricular rate control therapy should be considered. Antithrombotic therapy according to guidelines Clinical evaluation, ECG, echocardiography, thyroid function measurements, etc. The latest published randomized studies suggest that initial ventricular rate control is no less effective than maintaining sinus rhythm, which is costly and inconvenient. Rhythm control is no longer advocated in patients who can tolerate abnormal rhythms when the ventricular rate is fully controlled. Basic ventricular rate control and anticoagulation are feasible in the asymptomatic elderly who comprise approximately 60% of patients with atrial fibrillation. Antiarrhythmics are a complex form of therapy in the treatment of atrial fibrillation that requires rigorous patient screening, frequent monitoring for side effects, and dose or drug adjustments for optimal efficacy. Although controversial, amiodarone is considered to be the most effective antiarrhythmic agent, outperforming placebo and other antiarrhythmic agents in comparative trials. Sotalol, flecainide, and propafenone have also shown good results in individual studies. However, these drugs are not always effective and, because they do not act selectively on the atria, can cause some serious adverse effects, especially noteworthy because they also act on the ventricles and therefore have the potential to cause proarrhythmias and tip-twisting arrhythmias, among others. Implementation of ventricular rate control is relatively simple. Non-dihydropyridine calcium antagonists or beta-blockers are usually used as monotherapy, except in resting patients in whom digoxin is mandatory. In active patients, the heart rate lowering effect of digoxin on the parasympathetic nervous system is inhibited by the activation of the sympathetic nervous system, so the effect is not satisfactory. In this group of patients, a combination of digoxin, beta-blockers and calcium antagonists may be necessary. 2, Non-pharmacological treatment of atrial fibrillation 2.1 Catheter ablation The main strategies for catheter ablation of atrial fibrillation currently include the following three: pulmonary vein electrical isolation, pulmonary vein vestibular electrical isolation, and linear ablation of the left atrium. Pulmonary vein electrical isolation for paroxysmal atrial fibrillation is achieved by blocking the rapid repetitive ectopic electrical activity emanating from the atrial muscle sleeves present in the pulmonary veins. Recently reported randomized clinical trials have demonstrated the benefits of pulmonary vein electrical isolation over pharmacologic rhythm control. In patients with clinical five structural heart disease, this approach resulted in heart rate compliance in 75-85% of patients, compared to only 5-35% with antiarrhythmic drugs. However, randomized studies of ablation are relatively small, usually with a soft endpoint such as an event like atrial fibrillation recurrence, and only in the most specialized centers. One quarter to one-third of patients require antiarrhythmic drugs to prevent recurrence, and approximately 25-35% may require a second procedure. Although the ultimate impact of pulmonary vein electrical isolation is unpredictable, it can be successfully applied in young patients with paroxysmal atrial fibrillation and in patients with near-normal hearts. However, there is not good enough evidence that pulmonary vein isolation is also indicated for the treatment of persistent AF. the ACC/AHA/ESC guidelines elevate the position of catheter ablation as a second option for patients who have failed at least one antiarrhythmic drug. 2.2 Surgical vagotomy Surgical vagotomy involves the use of freezing or high-frequency energy applied to the left or right atrium as a means of blocking the most common foldback that causes atrial fibrillation. This is usually done by isolating the pulmonary veins and removing or suturing the left auricle. This approach is limited to patients undergoing cardiac surgery (e.g., mitral valve repair or replacement). Some studies have shown that patients with atrial fibrillation undergoing mitral valve surgery in conjunction with surgical bypass can improve sinus rhythm by two-thirds compared with mitral valve surgery alone, while reducing the risk of stroke by 56%. As this type of procedure becomes less invasive and more effective, it is likely to become more widely used. 2.3 Prophylactic atrial pacing therapy Atrial pacing reduces the occurrence of atrial fibrillation by altering the matrix surrounding cardiomyocytes, or by overdrive pacing to inhibit agitation at potential atrial fibrillation trigger points. Although tempting in theory, atrial fibrillation is a controversial indication for the application of prophylactic atrial pacing. In the 2002 guidelines for pacemaker and antiarrhythmic device implantation, prevention of atrial fibrillation by pacemakers is only a Class IIb indication. If pacemaker implantation is required, true atrial-based “physiological” pacing, i.e., AAI pacing, should be preferred over simple ventricular pacing or atrial sequential pacing (DDD), because it has been shown that increasing the proportion of ventricular pacing increases the incidence of atrial fibrillation. The results of the EURIDIS and ADONIS studies showed that dronedarone 400 mg twice a day was better than placebo in preventing AF and was also effective in controlling ventricular rate. Also, the risk of death and cardiac hospitalization rates were reduced by 27% in patients taking dronedarone. 3.2 Delayed atrial repolarization agents The genes controlling potassium delayed currents are mainly expressed in atrial tissue rather than ventricular tissue. Therefore, it is feasible to prolong the atrial nonresponse period without prolonging the ventricular action potential and QT interval and without increasing the risk of polymorphic ventricular tachycardia. Vemakalant hydrochloride is a hybrid sodium/potassium channel blocker that selectively acts on atrial ion channels. In animal studies, it was effective in converting atrial fibrillation to normal sinus rhythm in experimental animals and did not cause proarrhythmias or tip-twisting arrhythmias. In a randomized, placebo-controlled phase II clinical trial in subjects with atrial fibrillation episodes of 3-72 hours, Vemakalant resulted in termination of atrial fibrillation in 61% of patients, compared to only 6% in the placebo group. 3.3 Upstream therapeutic agents Upstream therapeutic agents are mainly Boai-extended angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, aldosterone receptor antagonists, statins, corticosteroids, and omega-3 polyunsaturated fatty acids. Antihypertensives, especially those acting on the renin-angiotensin system, are representatives of non-antiarrhythmics. Much evidence suggests that these drugs significantly reduce cardiac load in atrial fibrillation. Data from a retrospective analysis of the AFFIRM trial showed that patients with atrial fibrillation with a history of heart failure who received either an angiotensin-converting enzyme inhibitor or an angiotensin receptor blocker had a significantly lower incidence of recurrent atrial fibrillation than those who did not. (HR 0.63, CI 0.43-0.94, P=0.2). There is evidence that the inflammatory marker C-reactive protein is elevated in patients with AF, and Dernellis and Panaretou demonstrated that elevated C-reactive protein is a risk factor for AF recurrence and permanent AF. The anti-inflammatory and antioxidant effects of statins play an important role in the treatment of atrial fibrillation. During myocardial ischemia with increased atrial rate, statins protect the atrial muscle by increasing endothelial nitric oxide synthesis. Statins are used to regulate various matrix-degrading enzymes, which in turn attenuate extracellular matrix remodeling. Omega-3 polyunsaturated fatty acids (PUFAs) are considered to possess anti-inflammatory properties and anti-arrhythmic effects and have great potential in the prevention and treatment of atrial fibrillation. In addition to these drugs, reducing alcohol consumption, weight control, and treating bradycardia and sleep apnea can also help reduce the load of AF. Conclusion The ultimate goal of atrial fibrillation treatment is to end atrial fibrillation and prevent recurrence. Despite our knowledge of the electrophysiological mechanisms and triggers of atrial fibrillation, we have not been able to fully achieve these goals. There are advantages and disadvantages of each method of treating AF. Although conventional drugs can control AF, they have high toxic side effects and are prone to drug resistance; catheter ablation can cure some patients, but is not suitable for all AF patients. The treatment of patients with atrial fibrillation should be tailored to each individual, and the best treatment plan should be developed after a comprehensive evaluation of various factors. The emergence of new drugs is undoubtedly a major advance in the treatment of atrial fibrillation. Although some are still in the clinical research stage, their multichannel action and high atrial muscle adhesion give us new hope.