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Rate control versus rhythm control
Humberto Vidaillet1, Robert T Greenlee
1Department of Cardiology, Marshfield Clinic, Marshfield, Wisconsin, USA. vidaillet.humberto@marshfieldclinic.org
Purpose Of Review:
The results of five randomized clinical trials comparing rate control with rhythm control in the management of atrial fibrillation have been published recently. The purpose of this report is to review their main results and selected subanalyses and other related data to offer practical recommendations regarding the treatment of patients with this common arrhythmia.
Recent Findings:
In the aggregate, the five trials enrolled a total of 5175 subjects and accumulated 16,186 patient-years of follow-up. All these trials have had similar results in that each of them failed to demonstrate a clear advantage of the rhythm control approach over that of rate control. The largest of the studies, the Atrial Fibrillation Follow-Up Investigation of Rhythm Management (AFFIRM) study, enrolled 79% of all the cases in the five trials and accounts for 88% of the cumulative follow-up experience and for 92% of all deaths. Among AFFIRM participants, antiarrhythmic drug use did not improve survival, stroke risk, quality of life, or functional capacity but was associated with increased resource use. In several of the trials, however, the presence of sinus rhythm was associated with improved outcomes.
Summary:
The evidence is now overwhelming that for most patients with atrial fibrillation, rhythm control using currently available antiarrhythmic drugs is more expensive but not more effective than the rate control strategy in the prevention of major adverse events. Further research is needed to determine whether maintaining sinus rhythm by other means can improve outcomes.
Insights
For most patients with atrial fibrillation, rhythm control is more expensive and not more effective than rate control for preventing adverse events. Further research is needed to explore alternative methods for maintaining sinus rhythm.
Area of Science:
- Cardiology
- Clinical Trials
- Atrial Fibrillation Management
Background:
- Atrial fibrillation is a common arrhythmia requiring effective management strategies.
- Rate control and rhythm control are two primary approaches to treating atrial fibrillation.
Purpose of the Study:
- To review results from five randomized clinical trials comparing rate and rhythm control in atrial fibrillation.
- To provide practical recommendations for managing atrial fibrillation based on current evidence.
Main Methods:
- Analysis of five major randomized clinical trials involving over 5000 patients.
- Review of aggregated data and selected subanalyses, including the AFFIRM study.
Main Results:
- No clear advantage of rhythm control over rate control was demonstrated across the trials.
- Antiarrhythmic drug use in the AFFIRM study did not improve survival or reduce stroke risk.
- Maintaining sinus rhythm was associated with improved outcomes in some trials.
Conclusions:
- Rhythm control with current antiarrhythmic drugs is more costly and not more effective than rate control for preventing major adverse events in most atrial fibrillation patients.
- Further investigation is required to determine if alternative methods of maintaining sinus rhythm can improve patient outcomes.
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