What are the effects of long-term treatment with antiarrhythmic drugs on death, stroke, drug adverse effects, and recurrence of atrial fibrillation (AF) in people who have recovered to sinus rhythm after cardioversion of AF?Atrial fibrillation (AF) is one of the most commonly diagnosed cardiac arrhythmias. Estimates show that more than 10 million people worldwide will be diagnosed with AF by 2030. People in whom AF is left untreated or not managed appropriately have an increased risk of stroke, heart failure, and death.1 Atrial fibrillation disrupts the normal heart rhythm with periods of quivering and irregularity, often with tachycardia. This irregularity causes dyssynchrony between the atrium and ventricles, affecting both the filling and the pumping mechanisms. These impaired mechanisms in turn can result in blood pooling that can lead to the formation of blood clots, which can potentially lead to a stroke.2For patients in whom AF does not spontaneously convert back to a normal rhythm, electrical and pharmacological cardioversions are very effective. That said, a main issue with treating AF is the high frequency of recurrence, which can be as high as 70% to 80% within a year after conversion.3 Treatment options include antiarrhythmic medications that are categorized within 4 main groups: sodium channel blockers, β-blockers, medications that prolong repolarization, and calcium channel blockers.Several studies and a few older systematic reviews (before 2011) have investigated treatment options for AF. The systematic review for this summary included updated studies and analyses that provide a strong foundation that can guide clinicians in determining treatment options.This summary is based on an update to a previously published systematic review conducted in 2007.4 As new evidence on a topic becomes available, updates are necessary to account for the results that the new evidence presents. This update, conducted by Valembois et al,5 included 59 randomized controlled trials comprising 20 981 adult participants. Patients in the intervention group within each of these 59 trials received just 1 type of oral antiarrhythmic medication after their AF converted to sinus rhythm. The full systematic review, however, included various antiarrhythmic medications: quinidine, disopyramide, propafenone, flecainide, metoprolol, amiodarone, dofetilide, dronedarone, and sotalol.Valembois et al5 investigated 3 main primary outcomes: all-cause mortality, proarrhythmia, and stroke. They also investigated 1 main secondary outcome: recurrence of AF. They independently assessed the risk of bias for each study, including selection, performance, detection, attrition, reporting, and publication biases. They resolved any disagreements by reviewing the data together and through discussion.Valembois et al5 used risk ratios (RRs) with 95% CIs for dichotomous outcomes as measures of treatment effect between various comparisons and outcomes. They used the internationally approved Grading of Recommendations Assessment, Development and Evaluation approach to determine the certainty of evidence—high, moderate, low, or very low—for each outcome6: This review showed that when compared to placebo or no treatment, there was high-certainty evidence of higher mortality associated with sotalol, moderate-certainty evidence of increased proarrhythmia and adverse effects with flecainide, and low-certainty evidence suggesting high mortality with quinidine when these medications are used for maintaining sinus rhythm in people with AF. This evidence can affect providers’ clinical decisions when they are creating treatment plans for patients in this population.Overall, evidence shows that long-term use of antiarrhythmic drugs may increase the number of adverse events and proarrhythmic events, and some antiarrhythmics may increase the risk of mortality. Although antiarrhythmics can reduce the recurrence of AF, no evidence indicates any benefit for other clinical outcomes. As such, to reduce the number of potential adverse events in these patients, nurses and providers helping to develop plans of care to maintain sinus rhythm should evaluate all treatment options, including rate-control strategies, ablation, and short-term regimens of antiarrhythmic drugs.As nurses caring for critically ill patients, advocating for the best evidence-based treatment remains an important piece of our role. We must always consider the best available evidence and understand the feasibility, appropriateness, meaningfulness, and effectiveness of any intervention to determine whether it is most appropriate to implement in our individual context.