Rate control versus rhythm control for the management of atrial fibrillation: the verdict of the AFFIRM trial

Atrial fibrillation is the most common sustained cardiac arrhythmia encountered in clinical practice that affects cardiovascular morbidity and mortality and generates significant healthcare costs. There are two approaches for the management of atrial fibrillation: rate control and rhythm control. Rate-control strategy involves using rate-controlling agents such as beta-blockers, calcium channel blockers or digoxin, or a combination thereof to control symptoms while allowing atrial fibrillation to persist. Rhythm-control strategy involves cardioversion and treatment with antiarrhythmic drugs to maintain sinus rhythm. Although each strategy has its own advantages as well as limitations, it has long been debated which of the strategies offers better long-term outcomes and thus should be the preferred and recommended approach for the management of patients with atrial fibrillation. The Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) study was the first large-scale randomised study to address this important issue. In this article, the long awaited verdict of the AFFIRM study with its implications for the clinical management of patients with atrial fibrillation is discussed.