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The authors consider the use of flecai- nide, quinidine, sotalol, amiodarone and propafenone, and they note that a large proportion of patients who re- ceived these antiarrhythmic drugs had conditions that constitute drug-related contraindications or warrant warnings and precautions. They suggest that the results point to a need for safer drugs, with fewer contraindica- tions, precautions and warnings, with which to treat AF. A number of important factors need to be considered when we analyze the results of this interesting and signif- icant study. The CARAF trial enrolled patients whose AF was diag- nosed between 1991 and 1996. The results presented by Humphries and associates were obtained at baseline and at 3-month follow-up. Thus, most of the data reflect prac- tices in use before 1996. The precautions, warnings and contraindications for the 5 antirrhythmic drugs studied are taken from the 1996 Compendium of Pharmaceuticals and Specialties (CPS), which was published after most treatment decisions had been made. Although most of the informa- tion might have applied in earlier versions of the CPS, this does not appear to have been assessed, which presents a limitation of the analysis. The characteristics of the patient population also need to be considered. The study was limited to patients with paroxysmal AF, for which heart-rate control is particularly difficult, 3 making sinus-rhythm maintenance more often a primary objective. In addition, the vast majority of patients (83%) were symptomatic at first presentation, which fur- ther justified the use of antiarrhythmic drugs to prevent AF recurrence. Given the decision to use an antiarrhythmic drug, an examination of the list of precautions, warnings and contraindications in Table 1 of the research article 2

Antiarrhythmic drugs for atrial fibrillation: Do we need better use, better drugs or a randomized trial of ablation as primary therapy?