Rhythm Control Versus Rate Control of Atrial Fibrillation : Pharmacologic and Non-Pharmacologic Therapy

Kim, Young Hoon

Abstract

Considerable controversy exists as to whether rhythm or rate control is the more appropriate management for the patients with persistent atrial fibrillation (AF). Until recently, it was our belief that the initial approach to rhythm management should give primary consideration to the restoration and maintenance of the sinus rhythm (SR), which provides the potential benefits of reducing the risk of thromboembolism and the need for anticoagulants, and improved the hemodynamics and quality of life. However, there are negative aspects of rhythm control, including the poor efficacy of the antiarrhythmic drugs and the potential of adverse effects. Five recent clinical trials; AFFIRM (The Atrial Fibrillation Follow-Up Investigation of Rhythm Management), RACE (Rate Control versus Electrical Cardioversion), PIAF (Pharmacological Intervention in Atrial Fibrillation), HOT CAFE (How to Treat patients with Chronic Atrial Fibrillation) and STAF (The Strategies of Treatment of Atrial Fibrillation), have looked specifically at the issue of the balance between the benefits and risks of restoration and maintenance of the SR, primarily with drug therapy. The conclusions of these trials were consistent, although the study subjects were heterogeneous;1) Rhythm control, with anti-arrhythmics, does not lead to an improvement in the symptom control, quality of life or a reduction in the short to median term clinical events, in fact, in the longer term the mortality may increase. 2) Maintenance of the SR remains poor, even with an aggressive strategy. Hence, long term anticoagulation is needed for most patients treated with rhythm control, even if the SR is restored in the short term. A number of non-pharmacological therapies have emerged, such as catheter ablation and pacing, for patients remaining highly symptomatic, despite the use of several anti-arrhythmics and serial electrical cardioversion. In conclusions, rate control should be considered as the initial strategy in the majority of the patients with persistent AF. For the minority that remain highly symptomatic, aggressive rhythm control, with invasive treatments, such as pulmonary vein isolation or rate control, with atrioventricular nodal ablation and ventricular pacing, should be considered.