Rate Control Strategy Elevated To Primary Treatment For Atrial Fibrillation: Has The Last Word Already Been Spoken?

In the last decade, we were able to see the light shed by several trials and observational studies that dealt with the appropriate manner of treating patients with atrial fibrillation (AF). Recently the AF management by cardiologists has become more aggressive, in part because of an improved comprehension of this rhythm disturbance, as well as, the availability of new treatment strategies. Increasing awareness of AF as a disease rather than as an acceptable alternative to sinus rhythm has led to search for clear arguments to support a certain strategy as a gold standard. In this respect, the decision of whether to restore sinus rhythm, or to control the ventricular rate and allow AF to persist is of critical importance. The results of randomized, controlled trials addressing this matter shed some light on the proper way of treatment for these AF patients. The AFFIRM and RACE trials and their respective sub-studies showed surprising results. The vast majority of physicians were surprised to learn that the rate control strategy was elevated to the position of primary treatment for the AF management instead of the all-time recognized rhythm control approach to restoration and maintenance of sinus rhythm. The use of anticoagulants in the trials was different in the treatment strategies. There was a greater anticoagulant use in the rate control arm because of the belief that anticoagulation can be discontinued in the rhythm control arm when sinus rhythm was restored and maintained for one month. On the other hand, only pharmacological agents were used to maintain sinus rhythm in those trials, however, there is increasing evidence that AF ablation can restore and maintain sinus rhythm in a great proportion of patients. Indeed, there are some limitations and several interesting aspects of these trials and other studies that will be discussed. The last word has not been spoken yet.