title: Rate- and rhythm-control therapies in patients with atrial fibrillation: a systematic review.
abstract: BACKGROUND
  The comparative effectiveness of treatments for atrial fibrillation (AF) is uncertain.
  
  
  OBJECTIVE
  To evaluate the comparative effectiveness of rate- and rhythm-control therapies.
  
  
  METHODS
  English-language studies in PubMed, EMBASE, and the Cochrane Database of Systematic Reviews between January 2000 and November 2013.
  
  
  METHODS
  Two reviewers independently screened citations to identify comparative studies that assessed rate- or rhythm-control therapies in patients with AF.
  
  
  METHODS
  Reviewers extracted data on study design, participant characteristics, interventions, outcomes, applicability, and quality.
  
  
  RESULTS
  200 articles (162 studies) involving 28,836 patients were included. When pharmacologic rate- and rhythm-control strategies were compared, strength of evidence (SOE) was moderate supporting comparable efficacy with regard to all-cause mortality (odds ratio [OR], 1.34 [95% CI, 0.89 to 2.02]), cardiac mortality (OR, 0.96 [CI, 0.77 to 1.20]), and stroke (OR, 0.99 [CI, 0.76 to 1.30]) in older patients with mild AF symptoms. Few studies compared rate-control therapies and included outcomes of interest, which limited conclusions. For the effect of rhythm-control therapies in reducing AF recurrence, SOE was high favoring pulmonary vein isolation versus antiarrhythmic medications (OR, 5.87 [CI, 3.18 to 10.85]) and the surgical maze procedure (including pulmonary vein isolation) done during other cardiac surgery versus other cardiac surgery alone (OR, 7.94 [CI, 3.63 to 17.36]).
  
  
  CONCLUSIONS
  Studies were heterogeneous in interventions, populations, settings, and outcomes.
  
  
  CONCLUSIONS
  Pharmacologic rate- and rhythm-control strategies have comparable efficacy across outcomes in primarily older patients with mild AF symptoms. Pulmonary vein isolation is better than antiarrhythmic medications at reducing recurrences of AF in younger patients with paroxysmal AF and mild structural heart disease. Future research should address uncertainties related to subgroups of interest and the effect of different therapies on long-term clinical outcomes.
  
  
  BACKGROUND
  Agency for Healthcare Research and Quality.
authors.forename: Sana M
authors.initials: SM
authors.lastname: Al-Khatib
authors.forename: Nancy M
authors.initials: NM
authors.lastname: Allen LaPointe
authors.forename: Ranee
authors.initials: R
authors.lastname: Chatterjee
authors.forename: Matthew J
authors.initials: MJ
authors.lastname: Crowley
authors.forename: Matthew E
authors.initials: ME
authors.lastname: Dupre
authors.forename: David F
authors.initials: DF
authors.lastname: Kong
authors.forename: Renato D
authors.initials: RD
authors.lastname: Lopes
authors.forename: Thomas J
authors.initials: TJ
authors.lastname: Povsic
authors.forename: Shveta S
authors.initials: SS
authors.lastname: Raju
authors.forename: Bimal
authors.initials: B
authors.lastname: Shah
authors.forename: Andrzej S
authors.initials: AS
authors.lastname: Kosinski
authors.forename: Amanda J
authors.initials: AJ
authors.lastname: McBroom
authors.forename: Gillian D
authors.initials: GD
authors.lastname: Sanders
mesh_terms: D000889:Anti-Arrhythmia Agents / Q000627:therapeutic use*; D001281:Atrial Fibrillation / Q000188:drug therapy / Q000628:therapy*; D017115:Catheter Ablation; D004554:Electric Countershock; D006339:Heart Rate; D006801:Humans
chemical_list: D000889:Anti-Arrhythmia Agents