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Life sciences · Journal article
Clinical Review for General Practice · July 21, 2026
A consensus or society position rather than new primary data.
This is a narrative clinical review endorsing a paradigm shift from rate control to early proactive rhythm control for atrial fibrillation, supported by large-scale RCTs and current guidelines. It provides an algorithmic approach to selecting antiarrhythmic agents (Vaughan-Williams class I and III) based on patient phenotype, structural substrate, and comorbidity, with emphasis on drugs with robust international evidence (propafenone, flecainide) versus regionally available agents (Allapinin, ethacizine) lacking large-scale trial validation.
Journal article. Patients with atrial fibrillation, stratified by phenotype (paroxysmal or persistent), structural myocardial abnormalities, heart failure, coronary artery disease, and left ventricular hypertrophy..
Current management paradigm has shifted from rate control to early proactive rhythm control, confirmed by large-scale randomized trials and current European and Russian guidelines. Propafenone and flecainide are the globally best-studied class IC agents featured prominently in ESC and ACC/AHA guidelines. Allapinin and ethacizine are used mainly in Russia and CIS countries and are not included in international guidelines due to lack of large-scale randomized trials.
No primary efficacy or safety data, effect sizes, or comparative outcomes reported.
Practitioners in cardiology and arrhythmia care can use the proposed algorithmic approach to personalize antiarrhythmic drug selection, accounting for patient phenotype, atrial remodeling, and comorbidity. The review clarifies that propafenone and flecainide have the strongest international evidence base, whereas regional alternatives lack large-scale validation.
A clinical review synthesizing evidence on rhythm control medications for atrial fibrillation, proposing algorithmic approaches to personalized therapy selection based on patient phenotype and current guidelines.
Practitioners in cardiology and arrhythmia care can use the proposed algorithmic approach to personalize antiarrhythmic drug selection, accounting for patient phenotype, atrial remodeling, and comorbidity. The review clarifies that propafenone and flecainide have the strongest international evidence base, whereas regional alternatives lack large-scale validation.
Graded across the dimensions that decide whether you should act, each from what the source actually supports. There is no single score, and where a dimension was not assessed it says so.
What is missing. This record has no reported figures. That is a gap in the analysis, not a judgement about the study.
Atrial fibrillation (AF) represents the most prevalent supraventricular tachycardia that is associated with the increase in the rate of cardiovascular complications and mortality. The current patient management paradigm is shifted from the “rate control” strategy to the early proactive “rhythm control”, which is confirmed by large-scale randomized trials and current European and Russian guidelines. The review considers pathophysiological basis of arrhythmogenesis in AF, including electrical, mechanical, structural, and autonomic atrial remodeling levels, as well as the key mechanisms underlying arrhythmia initiation and maintenance (ectopic beat, re-entry, trigger activity/delayed afterdepolarizations). Special attention is paid to the pharmacological rhythm control strategy involving the use of Vaughan-Williams class I and III antiarrhythmic agents: molecular targets, pharmacokinetics, clinical efficacy, and safety profile of propafenone, flecainide, lappaconitine hydrobromide (Allapinin), ethacizine, amiodarone, sotalol, etc. are analyzed, including the drugs available mainly in Russia. It is emphasized that propafenone and flecainide are the globally best studied representatives of the IC class featured prominently in the ESC and ACC/AHA guidelines, while Allapinin and ethacizine are used mainly in Russia and CIS countries and are not included in international guidelines due to the lack of large-scale randomized trials. Based on the current data and guidelines, an algorithmic approach to the anti-relapse therapy selection considering the patient’s phenotype (paroxysmal or persistent AF, structural myocardial abnormality, heart failure, coronary artery disease, left ventricular hypertrophy), atrial remodeling level, conduction system features, comorbidity, and drug interaction is proposed. Principles of antiarrhythmic therapy during the early period after cardioversion and after pulmonary vein isolation as part of the hybrid strategy (invasive + drug treatment) are discussed separately. The review presented is intended for practitioners in cardiology and arrhythmia care and is aimed to make personalization of antiarrhythmic agent selection within the framework of safe and effective rhythm control strategy in AF less complex. Keywords: antiarrhythmic therapy, atrial fibrillation, rhythm control, anti-relapse therapy, antiarrhythmic agents, class IС, class III, catheter ablation, comorbidity.
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