"Management Strategies for Atrial Fibrillation". The New England Journal of Medicine. Date published/updated. Volume(Issue):Page range.
Links to original sources: Wiki Journal Post Full Journal Article
Does a rhythm-control strategy offer a survival advantage over a rate-control strategy in patients with atrial fibrillation and a high risk of stroke or death?
In patients with atrial fibrillation and a high risk for stroke, a rhythm-control strategy does not offer a survival advantage over a rate-control strategy, and may be associated with a higher risk of adverse drug effects. Continuous anticoagulation is important in this population, even when sinus rhythm is restored and maintained.
The study compared two approaches for managing atrial fibrillation (AF) in patients at high risk of stroke: rhythm-control (aimed at maintaining sinus rhythm through antiarrhythmic drugs) versus rate-control (allowing AF to persist while controlling heart rate with rate-controlling medication). No significant mortality benefit was observed with rhythm-control despite higher hospitalizations and adverse drug events, suggesting rate-control strategy may offer equivalent outcomes with potentially lower risk.
Existing guidelines recommend the use of anticoagulation in the management of AF in high-risk patients. The choice between rhythm-control and rate-control strategies should be made based on individual patient factors without an inherent preference for one strategy over another based on survival.
Multicenter, randomized, controlled trial comparing rhythm-control to rate-control strategies in patients with AF.
- Patients enrolled: 4,060 - Mean age: 69.7 years - Inclusion Criteria: Patients with AF and high risk of stroke or death, age ≥65 or other risk factors for stroke. - Exclusion Criteria: Patients for whom anticoagulant therapy was contraindicated or for whom either strategy was inappropriate.
- Rhythm-control group: Use of antiarrhythmic drugs (e.g., amiodarone, sotalol) and possible cardioversion. - Rate-control group: Use of rate-controlling drugs (e.g., beta-blockers, calcium-channel blockers) with the option of AV nodal ablation and pacing if necessary.
- Primary Outcome: Overall mortality - Secondary Outcomes: Composite of death, disabling stroke, disabling anoxic encephalopathy, major bleeding, or cardiac arrest.
- Cross-over rates were higher among the rhythm-control group, reflecting difficulty in maintaining sinus rhythm. - Anticoagulation treatment adherence varied throughout the trial. - Study results may not apply to younger patients without risk factors for stroke (e.g., lone AF).
Supported by the National Heart, Lung, and Blood Institute.
Published results in leading medical journals and guidelines for AF management.