Rhythm versus Rate Control Trials in Atrial Fibrillation

The recent completion of five trials comparing the strategy of rhythm control versus the strategy of rate control in the management of recurrent atrial fibrillation has advanced considerably our understanding of the treatment of this common clinical problem. The background to this research question is outlined, followed by an overview of the five trials and their results. Data on important clinical events from four of the trials are pooled and presented. The aggregate results of the trials do not demonstrate any clear advantage of the rhythm control approach. The findings elevate rate control to the position of an acceptable primary therapy in the types of patients studied and underline the concept that the primary goal of antiarrhythmic therapy for atrial fibrillation at this time is control of symptoms. Under these circumstances, a "safety first" approach is prudent and monitoring for adverse drug effects is mandatory. The results underscore the importance of continuous anticoagulation in patients with stroke risk factors. Finally, the results from these trials help to set the agenda for future research on rhythm management in atrial fibrillation.