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[Atrial fibrillation: rhythm or rate control?]
Jean-Yves Le Heuzey1, Mina Ait Saïd, Olivier Paziaud
1Service de cardiologie A Hôpital européen Georges-Pompidou 75908 Paris. jean-yves.le-heuzey@hop.egp.ap-hop-paris.fr
Insights
Maintaining normal heart rhythm (sinus rhythm) in atrial fibrillation is challenging. Rate control may offer a safer alternative with a trend towards lower mortality, especially in high-risk patients.
Area of Science:
- Cardiology
- Pharmacology
Context:
- Atrial fibrillation management traditionally focused on rhythm control using antiarrhythmic drugs.
- Drug selection for rhythm control is complex, with potential for poor therapeutic indices and contraindications in specific patient groups (e.g., heart failure, coronary artery disease).
Purpose:
- To review treatment strategies for atrial fibrillation, comparing rhythm control with rate control.
- To discuss the safety and efficacy of different antiarrhythmic drugs and rate-controlling agents.
Summary:
- Rhythm control for atrial fibrillation (AF) involves cardioversion and antiarrhythmic drug therapy, but drug choice is difficult and safety concerns exist, particularly with Class I agents.
- Rate control, achieved with calcium channel blockers, beta-blockers, or digitalis, is a viable alternative, especially when rhythm control is contraindicated or poorly tolerated.
- Anticoagulation is crucial regardless of the chosen strategy (rhythm or rate control) due to the persistent risk of stroke in AF patients.
Impact:
- Recent trials comparing rhythm and rate control strategies show no definitive superiority of one over the other.
- However, available data suggest a potential trend towards lower mortality in patients managed with a rate control strategy for atrial fibrillation.
Abstract:
For many years it has been considered that it was necessary, whenever possible, to cardiovert atrial fibrillation and to maintain the sinus rhythm with antiarrhythmic drugs. There are many theoretical advantages to this maintenance of the sinus rhythm. Nevertheless the choice of the drugs used to maintain rhythm is often difficult and the therapeutical index of these drugs may be poor. It is necessary to avoid class I antiarrhythmic drugs in patients with congestive heart failure and coronary artery disease. In these cases, only sotalol and amiodarone can be used. The safety index of these drugs being low, plain rate control with persistence of atrial fibrillation has been proposed as a treatment alternative. Several drugs may be used: calcium inhibitors, beta-blockers, digitalis. It is always necessary to associate anticoagulation: of course if rate control is chosen, but also if rhythm control is obtained, owing to the possible risk of relapse. Several trials of comparison between these 2 strategies have been recently performed. Available results show no clear superiority of a strategy above the other but there is a tendency towards a lower mortality in the rate control group.