Risks and benefits of rate control versus maintenance of sinus rhythm

There are 2 fundamental approaches to managing patients with recurrent atrial fibrillation (AF): to restore and maintain sinus rhythm with cardioversion and/or antiarrhythmic drugs, or to control the ventricular rate only. Over the past few years, there have been several important prospective clinical trials comparing rate control with rhythm control in patients with recurrent AF. The Pharmacological Intervention in Atrial Fibrillation (PIAF) trial was the first prospective randomized study to test the hypothesis of equivalency between the 2 management strategies for AF. The trial demonstrated that rate control was not inferior to rhythm control with respect to symptoms, quality of life, or number of hospitalizations in patients with persistent AF. The Strategies of Treatment in Atrial Fibrillation (STAF) trial was a pilot study that enrolled approximately 200 patients with AF who were randomized to either ventricular rate control or cardioversion and maintenance of sinus rhythm. The results showed that over a 1-year period there was little difference in outcome in terms of morbidity or symptoms. In the Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) trial, patients with AF and risk factors for stroke were randomized to either rhythm control or rate control, with both groups receiving anticoagulation with warfarin. There was no difference in the composite end point of death, disabling stroke or anoxic encephalopathy, major bleeding, or cardiac arrest between the 2 arms. In addition, no major differences were noted in functional status or quality of life. The Rate Control Versus Electrical Cardioversion (RACE) trial also reached a similar conclusion. Thus, rate control is an acceptable primary strategy for management of patients with recurrent AF.