Risk of syncope and permanent pacing with rate vs rhythm control of atrial fibrillation: A systematic review and...

Rhythm control therapy for patients with new-onset atrial fibrillation (AF) reduces major adverse cardiovascular events. However, bradycardia-related complications may be higher with rhythm control strategies, particularly when antiarrhythmic drugs (AADs) are used.

The aim of this systematic review and meta-analysis was to compare the rate of syncope, falls, or pacemaker implantation among patients with AF treated with rate control as compared with rhythm control.

A systematic search was conducted for studies published from inception to January 14, 2025, in PubMed, Embase, and CENTRAL. Included studies compared the rate of the composite of syncope, falls, or pacemaker implantation in patients with AF treated with rate control vs rhythm control strategies. Secondary outcomes were the individual components of the primary composite outcome. Odds ratios (OR) were pooled with a random-effects model.

We identified 3 randomized controlled trials and 6 cohort studies, encompassing a total of 522,841 patients with AF (348,831 treated with rate control and 174,010 with rhythm control). Rhythm control was associated with a significantly higher risk of the primary composite outcome of syncope, falls, or pacemaker implantation compared with rate control (OR 1.28; 95% confidence interval [CI] 1.14-1.44; P < .0001; I² = 20%). Rhythm control was associated with a significantly higher risk of syncope compared with rate control (OR 1.64, 95% CI 1.16-2.32, P = .005, I² = 85%). There was a trend toward a higher rate of pacemaker implantation with rhythm control (OR 1.96, 95% CI 0.98-3.93, P = .06, I² = 97%).

In this meta-analysis, rhythm control was associated with an increased risk of syncope, falls, or pacemaker implantation compared with rate control. These risks should be carefully weighed when choosing between rate control and rhythm control strategies.