"Management Strategies for Atrial Fibrillation". The New England Journal of Medicine. Date published/updated. Volume(Issue):Page range.

Clinical Question:

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?

Bottom Line:

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.

Major Points:

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.

Guidelines:

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.

Design:

Multicenter, randomized, controlled trial comparing rhythm-control to rate-control strategies in patients with AF.

Population:

- 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.

Interventions:

- 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.

Outcomes:

- Primary Outcome: Overall mortality
- Secondary Outcomes: Composite of death, disabling stroke, disabling anoxic encephalopathy, major bleeding, or cardiac arrest.

Criticisms:

- 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).

Funding:

Supported by the National Heart, Lung, and Blood Institute.

Further Reading:

Published results in leading medical journals and guidelines for AF management.