Revisiting Rate versus Rhythm Control in Atrial Fibrillation — Timing Matters

Treatment approaches for atrial fibrillation are broadly categorized into "rhythm control" (maintaining sinus rhythm) and "rate control" (slowing ventricular rate). Early trials, such as the Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM), showed no significant differences in mortality or ischemic stroke between rhythm and rate control at 5 years, leading to preferential use of rate-control strategies. However, post hoc analysis in AFFIRM suggested a lower risk of death with the presence of sinus rhythm , and limitations of previous trials included the efficacy and risks of antiarrhythmic drugs. Advances in rhythm control, including newer antiarrhythmic drugs like dronedarone and the widespread availability of catheter ablation, have improved safety and effectiveness. The CABANA trial showed that ablation was associated with a lower risk of recurrent atrial fibrillation, mortality, or hospitalization for cardiovascular causes compared to antiarrhythmic drugs. The Early Treatment of Atrial Fibrillation for Stroke Prevention Trial (EAST-AFNET 4) investigated whether earlier rhythm control improves clinical outcomes. This trial, involving patients with recently diagnosed atrial fibrillation and cardiovascular risk factors, found that early rhythm control led to a lower risk of death from cardiovascular causes, stroke, or hospitalization due to worsening heart failure or acute coronary syndrome.

Treatment approaches for atrial fibrillation are broadly categorized into "rhythm control" (maintaining sinus rhythm) and "rate control" (slowing ventricular rate). Early trials, such as the Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM), showed no significant differences in mortality or ischemic stroke between rhythm and rate control at 5 years, leading to preferential use of rate-control strategies. However, post hoc analysis in AFFIRM suggested a lower risk of death with the presence of sinus rhythm , and limitations of previous trials included the efficacy and risks of antiarrhythmic drugs. Advances in rhythm control, including newer antiarrhythmic drugs like dronedarone and the widespread availability of catheter ablation, have improved safety and effectiveness. The CABANA trial showed that ablation was associated with a lower risk of recurrent atrial fibrillation, mortality, or hospitalization for cardiovascular causes compared to antiarrhythmic drugs. The Early Treatment of Atrial Fibrillation for Stroke Prevention Trial (EAST-AFNET 4) investigated whether earlier rhythm control improves clinical outcomes. This trial, involving patients with recently diagnosed atrial fibrillation and cardiovascular risk factors, found that early rhythm control led to a lower risk of death from cardiovascular causes, stroke, or hospitalization due to worsening heart failure or acute coronary syndrome. See more See less