Rate vs rhythm control in patients with atrial fibrillation: a meta-analysis.
BACKGROUND
The 2 fundamental approaches to the management of atrial fibrillation (AF) are reestablishing and maintaining sinus rhythm (rhythm control) and controlling ventricular rate with atrioventricular node blocking agents (rate control). We performed a meta-analysis of randomized controlled trials comparing these strategies in patients with AF to add precision to the relative merits of both strategies on the risk of all-cause mortality and to evaluate the consistency of the results between trials.


METHODS
We performed a literature search in MEDLINE (1966 to May 2003), the Cochrane Controlled Trial Registry (first quarter of 2003), and International Pharmaceutical Abstracts (1970 to May 2003). Eligible trials were randomized controlled trials comparing pharmacologic rhythm and rate control strategies as first-line therapy in patients with AF.


RESULTS
Five trials were identified that included a total of 5,239 patients with persistent AF or AF that was considered likely to be recurrent. No significant difference was observed between the rate and the rhythm control groups regarding all-cause mortality, although a strong trend in favor of a rate control approach was observed (13.0% vs 14.6%; odds ratio, 0.87; 95% confidence interval, 0.74-1.02; P=.09). No heterogeneity was apparent between the trials (Q value=2.97; P=.56).


CONCLUSIONS
In patients with persistent AF or with AF that is likely to be recurrent, a strategy of ventricular rate control, in combination with anticoagulation in appropriate patients, appears to be at least equivalent to a strategy of maintaining sinus rhythm by using currently available antiarrhythmic drugs in preventing clinical outcomes.
de Denus
Simon
S
Pharmacy Department, Montreal Heart Institute/Faculty of Pharmacy, University of Montreal, Montreal, Quebec.
Sanoski
Cynthia A
CA
Carlsson
Jörg
J
Opolski
Grzegorz
G
Spinler
Sarah A
SA
D000368:Aged; D000889:Anti-Arrhythmia Agents / Q000627:therapeutic use*; D000925:Anticoagulants / Q000627:therapeutic use; D001281:Atrial Fibrillation / Q000150:complications / Q000401:mortality / Q000628:therapy*; D002317:Cardiovascular Agents / Q000627:therapeutic use*; D003131:Combined Modality Therapy; D004359:Drug Therapy, Combination; D004554:Electric Countershock; D005260:Female; D006339:Heart Rate; D006801:Humans; D008297:Male; D016017:Odds Ratio; D016032:Randomized Controlled Trials as Topic; D012008:Recurrence; D020521:Stroke / Q000453:epidemiology / Q000517:prevention & control
D000889:Anti-Arrhythmia Agents; D000925:Anticoagulants; D002317:Cardiovascular Agents