Benefit and concern about the "pill-in-the-pocket".

Restoring sinus rhythm (SR) in patients with atrial fibrillation (AF) relies on three main objectives: 1) to find and treat a predisposing factor; 2) to prevent thromboembolic complications and 3) to cardiovert as soon as possible to avoid atrial remodeling and obtain SR more easily [1-2]. For this last purpose, pharmacological or electrical cardioversion may be used. However, electrical cardioversion requires a short general anesthesia and pharmacological cardioversion requires antiarrythmic drugs (AAD) with potential short-term side effects. Hospitalization is therefore recommended to monitor patients in both cases. In 2003, Capucci et al. reported a first series of 212 consecutive patients who achieved safe cardioversion in response to oral propafenone under close supervision in the hospital. AF recurred in 65 of these patients who underwent a new in-hospital oral propafenone treatment without significant side effects [3]. These results suggested to safely use the pill-in-the pocket approach in selected patients. In 2005, Alboni et al. reported a prospective study evaluating a strategy of rhythm control by a self-administration of AAD (flecainide or propafenone) in selected patients with paroxysmal AF [4]. Using this strategy shortly after the onset of arrhythmia, this study showed decreased hospital admissions, decreased management costs and improved quality of life. These encouraging results led to the inclusion of the pill-in-the-pocket strategy in selected patients in recent American and European guidelines [1-2].