Rate control or rhythm control strategies for stroke prevention in atrial fibrillation: a systematic review and...

Atrial fibrillation (AF) is a major cause of stroke and thromboembolic events. We aimed to assess whether, in patients with AF, rate or rhythm control strategies reduce the risk for stroke or cardiovascular events.

Randomized controlled trials (RCTs) comparing rate control versus rhythm control strategies were systematically searched and included in a network meta-analysis (NMA). Co-primary outcomes were stroke within 1 year and stroke beyond 1 year from randomization. Twenty-one RCTs (35,447 patients) were included in the analyses. When stroke occurring any time after randomization was considered, antiarrhythmic drugs (AAD-Alone) had lower risk (OR 0.35, 95% CI 0.15-0.80), AAD plus electrical cardioversion had higher risk (OR 4.01, 95% CI 1.32-12.13), while AAD plus rate control and ablation had similar risks, all in comparison to rate control. These differences disappeared in studies with use of anticoagulation ≥ 70% of patients. No differences were observed between rate control and individual rhythm control strategies concerning the risk for stroke within 1 year (seven studies; 19,339 patients) and beyond 1 year (10 studies; 10,325 patients). Ablation reduced the risk of heart failure hospitalization (OR 0.38, 95% CI 0.17-0.85).

In patients with AF, the benefit of rhythm control over rate control for prevention of stroke disappears with appropriate anticoagulation. Catheter ablation reduces hospitalizations for heart failure compared to rate control. Rhythm control may offer benefits beyond stroke prevention, supporting a personalized treatment approach.