Atrial fibrillation: the rate versus rhythm management controversy

The fundamental management strategy for atrial fibrillation (AF) is still debated. There is no doubt that those patients at risk of thromboembolic events should be offered anticoagulant therapy. However, it is uncertain whether rhythm control (restoration and maintenance of sinus rhythm) or rate control (adjustment to a physiological ventricular rate while allowing AF to continue) is the preferred primary treatment option for the reduction of symptoms and major cardiovascular (CV) outcomes associated with AF. Several well conducted trials comparing the two strategies led to the conclusion that there was little to choose between them. However, guidelines leaned towards recommending rate control as the initial strategy, and reserved rhythm control for those who remained symptomatic. Recently this status quo is being increasingly challenged by the clear demonstration that left atrial catheter ablation is effective at suppressing AF resistant to traditional antiarrhythmic drugs, such as those that failed to demonstrate any superiority when compared with rate control. Also, recently introduced antiarrhythmic therapy may have superior efficacy with regard to reducing unexpected CV hospitalization, CV mortality and stroke. In addition, there is a growing perception that atrial remodelling should be best prevented by early rhythm control rather than delaying until rate control has proven unsatisfactory. For these reasons the results of large randomised clinical trials, which recruit patients soon after the presentation of AF and compare 'aggressive' modern rhythm control against the guideline approach of primary rate control, are eagerly awaited. In the meantime the pendulum of clinical opinion has begun to swing towards a rhythm control strategy.