Rhythm or Rate Control in Atrial Fibrillation-Pharmacological Intervention in Atrial Fibrillation (PIAF): A Randomised Trial - PIAF


Rhythm or Rate Control in Atrial Fibrillation-Pharmacological Intervention in Atrial Fibrillation (PIAF): A Randomised Trial.


What is the best therapeutic strategy in patients with symptomatic atrial fibrillation (AF): rate control or maintenance of sinus rhythm?

Study Design

Study Design:

Patients Enrolled: 252

Drug/Procedures Used:

This was a multicenter trial in which 252 patients with persistent AF for 7-360 days were randomized to therapy aimed at rate control (Group A, n = 125) or rhythm control (Group B, n = 127). Diltiazem was used for rate control, and amiodarone +/- electrical cardioversion were used for rhythm control. In both groups, additional therapy was at the discretion of the treating physicians. All patients were anticoagulated and followed for 1 year. The primary endpoint of the study was improvement in symptoms.

Principal Findings:

At the end of 1 year, 10% of patients in Group A were in sinus rhythm, compared to 56% in Group B. The death rate was 1.6% in both groups. The degree of symptomatic improvement was similar in the two groups. Exercise tolerance (measured with the 6-minute walk test) improved in Group B but not in Group A. Quality of life improved to a similar degree in both groups. Hospitalization was required for more patients in Group B (69%) than in Group A (24%). A drug-related side effect occurred more often in Group B (64%) than in Group A (47%).

Among patients with AF, rate and rhythm control result in a similar degree of improvement in symptoms and quality of life. Exercise tolerance is better with rhythm control, but hospital admissions and drug-related side effects are more common than with rate control.


In the absence of any clear-cut clinical advantage of one AF treatment strategy over the other, it is appropriate for clinicians to select either rate or rhythm control on an individualized basis. It should be noted that this study was underpowered to detect a difference in mortality. To learn whether there is a survival advantage with one strategy or the other, we must await the results of the larger AFFIRM trial.


1. Hohnloser S, Kuck KH, Lilienthal J, et al. Lancet 2000;356:1789-94.

Clinical Topics: Arrhythmias and Clinical EP, EP Basic Science

Keywords: Exercise Tolerance, Diltiazem, Quality of Life, Electric Countershock, Calcium Channel Blockers

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