Rate or Rhythm Control for Atrial Fibrillation: Update and Controversies


The following are 10 points to remember from this review of treatment options for atrial fibrillation (AF):

1. AF is associated with an increased risk of death, stroke, and heart failure.

2. Nevertheless, several randomized trials have failed to demonstrate any improvement in major outcomes with a rhythm-control strategy compared to a rate-control strategy in patients with AF.

3. Only 26-63% of patients in randomized trials have achieved sinus rhythm with antiarrhythmic drug therapy, and this could account for why a rhythm-control strategy has not been shown to have advantages over a rate-control strategy.

4. The results of randomized trials in which the subjects were elderly and had comorbidities should not be extrapolated to younger individuals with a longer projected life span.

5. A post-hoc analysis of the AFFIRM trial demonstrated that sinus rhythm was independently associated with improved survival, but that this was counteracted by a higher risk of death associated with the use of antiarrhythmic drugs.

6. In randomized comparisons, catheter ablation consistently has been more effective than antiarrhythmic drug therapy for preventing AF.

7. Observational studies have reported that catheter ablation of AF is associated with a lower risk of death, heart failure, and stroke compared to antiarrhythmic drug therapy.

8. An improvement in major outcomes such as mortality with a rhythm-control strategy using catheter ablation as opposed to antiarrhythmic drug therapy remains to be established in ongoing clinical trials.

9. The incremental cost-effectiveness of catheter ablation of AF has been estimated to be close to $50,000/quality-adjusted life year.

10. A rhythm-control strategy for AF should be strongly considered in young individuals and in patients with bothersome symptoms.

Clinical Topics: Heart Failure and Cardiomyopathies, Acute Heart Failure

Keywords: Stroke, Heart Failure

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