Rate versus rhythm control in atrial fibrillation.
AF remains the most common and most challenging arrhythmia. Although several new treatment modalities are available to restore and maintain sinus rhythm, the long-term success of such a strategy remains disappointing, often making rate control a good alternative. Factors associated with failures to restore and maintain sinus rhythm thereafter are a longer duration of AF, older patient age, atrial dilatation, poor functional class or heart failure, and hypertension. Recent trials comparing rate and rhythm control (see Box 1) could not show superiority of rhythm control and even gave some evidence that rhythm control may even be worse than rate control (more hospitalizations, more adverse drug effects). In general, however, these trials in general included older patients with persistent AF, and, most importantly the success of rhythm control was poor, stressing the fact that attempts to maintain rhythm control cannot be construed as being the same as actual maintenance of sinus rhythm. As mentioned previously, at least 37% to 74% of all patients in these trials were in AF and did not benefit from the possible advantages of sinus rhythm while they were exposed to the possible adverse effects of cardioversions and antiarrhythmic drugs. The decision to choose rhythm or rate control strategies should be individualized and depends on the expected benefit of restoring sinus rhythm, chance on failure to maintain sinus rhythm in the long-term, and the likelihood of adverse drug effects (Fig. 1). In all patients with AF, treatment should focus on underlying heart disease, anticoagulation, and control of ventricular rate during AF. In the authors' opinion, rhythm control remains first choice for patients with a first episode or highly symptomatic episodes of AF and for patients who have AF caused by a reversible cause (eg, hyperthyroidism, postcardiac surgery) or who have a high chance of remaining in long-term sinus rhythm (young patients, no hypertension, normal left atrium size, short preceding AF duration). Also patients with symptomatic AF who are suitable for ablation therapy (eg, focal AF, class IC flutter ), restoration and maintenance of sinus rhythm would be first choice. Rate control, however, will be a good option in asymptomatic patients and in patients in which rhythm control has failed or is very likely to fail. Also, if rhythm control does not improve symptoms or causes unwanted adverse effects (eg, frequent cardioversions, sinus node disease needing pacemaker implantation, or proarrhythmia), it should be abandoned. The present decision to opt for rhythm or rate control is determined mainly by the fact that in general, there is no single treatment that is highly effective and does not cause any adverse effects. If a 100% effective, 100% safe, and inexpensive drug or other treatment becomes available to restore and maintain sinus rhythm, it is more likely that the benefits of maintaining sinus rhythm could be proven, and one likely would opt for rhythm control in most patients.
Department of Cardiology, Academic Hospital Maastricht, Post Office Box 5800 6202 AZ, Maastricht, The Netherlands.
Maurits C E F
MC
Wijffels
Harry J G M
HJ
Crijns
D000889:Anti-Arrhythmia Agents / Q000627:therapeutic use*; D001281:Atrial Fibrillation / Q000628:therapy*; D003663:Decision Trees; D004554:Electric Countershock; D006801:Humans; D016032:Randomized Controlled Trials as Topic
D000889:Anti-Arrhythmia Agents