Rhythm Versus Rate Control Therapy and Subsequent Stroke or Transient Ischemic Attack in Patients With Atrial Fibrillation

Study Questions:

Does a rhythm-control strategy lower the risk of stroke or transient ischemic attack (TIA) in patients with atrial fibrillation (AF)?


In this population-based observational study, 57,518 patients 65 years or older (mean age 78 years) with AF were identified from a large-scale hospital discharge database. Rhythm-control and rate-control medications prescribed within 1 week of hospital discharge were noted. The primary outcome was the first medical encounter for stroke/TIA.


Only rhythm-control therapy was used in 9,091 patients, rhythm- plus rate-control therapy was used in 7,234 patients, and only rate-control therapy was used in 41,193 patients. The most common rhythm-control medication was amiodarone (55%), and the most common rate-control medication was a beta-blocker (57%). Fifty-nine percent of patients in both groups were anticoagulated with warfarin. During a mean follow-up of approximately 3 years, the incidence of stroke/TIA was significantly lower in the rhythm-control group (1.74/100 person-years) than in the rate-control group (2.49/100 person-years). Rhythm-control therapy was independently associated with a 20% lower risk of stroke/TIA.


The risk of stroke/TIA in patients with AF is lower with rhythm-control therapy than with rate-control therapy.


None of the randomized trials, including AFFIRM, that compared a rate-control strategy to a rhythm-control strategy in patients with AF showed a reduction in stroke risk with rhythm-control therapy. Although observational in nature, the present study had a much larger sample size than the prior randomized trials, perhaps accounting for why this study was able to show an advantage with rhythm-control therapy.

Clinical Topics: Anticoagulation Management

Keywords: Incidence, Follow-Up Studies, Ischemic Attack, Transient, Warfarin, Antimicrobial Cationic Peptides

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