A review of the literature on atrial fibrillation: rate reversion or control?

AIMS: The aim of this paper is to review the current literature describing the aetiology of atrial fibrillation and to examine the evidence for rate reversion and rate control. BACKGROUND: Atrial fibrillation is the most commonly seen arrhythmia within the clinical setting. Treatment depends on severity of symptoms, which are predominantly palpitations and shortness of breath. The primary complications from atrial fibrillation are thrombo-embolic events (such as a pulmonary embolus or stroke). OBJECTIVES AND METHODS: A comprehensive literature review on atrial fibrillation, rate reversion and rate control was undertaken to examine the incidence of atrial fibrillation, to review research on management of atrial fibrillation and to determine if rate reversion was superior to rate control in the treatment of atrial fibrillation. RESULTS: Many studies have been carried out to determine the best treatment for this condition. The choices are currently pharmacological and electrical cardioversion in conjunction with anticoagulant therapy. Drug therapies are not without their problems, especially toxicity and the need for close clinical monitoring. Transaesophageal echocardiography has been used to establish the presence of left atrial thrombi and aims to reduce the anticoagulation time and reduce the risk of thrombo-embolic events. A randomized comparative study of transaesophageal echocardiography and conventional anticoagulation therapy prior to cardioversion demonstrated statistically significant reduction in haemorrhagic events and a shorter time to cardioversion in those in the transaesophageal echocardiography group compared with the conventional group. For those with persistent atrial fibrillation, surgery is an option with valve repair or replacement carried out in conjunction with a bi-atrial surgical ablation. CONCLUSIONS: The management of atrial fibrillation is dependent on many factors and to date there are no proven clinical rationale for rate control or reversion. RELEVANCE TO CLINICAL PRACTICE: Atrial fibrillation requires immediate attention in order to avoid thrombo-embolic complications and the use of transaesophageal echocardiography and conventional anticoagulation therapy can significantly reduce these complications.