Atrial Fibrillation: Rhythm or Rate Control?

Atrial fibrillation is the most common sustained cardiac arrhythmia. Its prevalence increases with age, reaching 5% among subjects over 65 years of age. Recently, evaluation of the best therapeutic approach to patients with atrial fibrillation has been the object of two multicenter clinical trials that have compared a strategy of rhythm control and one of rate control. The Atrial Fibrillation Follow-up Investigation of Rhythm Management trial enrolled a total of 4,060 patients with a mean age of 69.7 years. After a mean follow-up of 5 years, total mortality was 24% in the rhythm control group and 21% in the rate control group, leading to a hazard ratio of 1.15 (p = 0.08). Similar results were found in the smaller Rate Control versus Electrical Cardioversion for Persistent Atrial Fibrillation study. The two studies clearly indicate that rate control is not inferior to rhythm control in the general population of patients with atrial fibrillation and that the restoration of sinus rhythm should not be pursued aggressively. The data also suggest the opportunity for adequate anticoagulation among patients assigned to the rhythm control strategy. The characteristics of the patients enrolled as well as the analysis of subgroups suggest that the preference toward a rate control strategy may not apply to young patients who are moderately or highly symptomatic for atrial fibrillation, nor to patients with heart failure, in whom the arrhythmia may contribute to the progression of the disease. For these two classes of patients, rhythm control may still be an attractive option.