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Rhythm Control vs. Rate Control for Patients with Afib

These older patients fared no better with rhythm control than with rate control, and rhythm control was associated with more treatment-related adverse events.

For patients with atrial fibrillation (AF), clinicians either can try to restore sinus rhythm (rhythm control) or can allow persistent AF while controlling ventricular rate (rate control). Although cardiologists often favor rhythm control initially, the lack of supporting evidence for this approach led to these 2 randomized trials.

North American researchers enrolled 4060 patients with recent AF (but generally not more than 6 months of continuous AF) who were at least 65 or had risk factors for stroke. Patients were randomized to rhythm control (antiarrhythmic drugs and cardioversion as necessary) or to rate control (ß-blockers, calcium-blockers, digoxin, or a combination of these) and were followed for an average of 3.5 years. Both groups received warfarin. Estimated 5-year mortality was 23.8% in the rhythm-control group and 21.3% in the rate-control group (P=0.08); in addition, the rhythm-control group had significantly higher rates of hospitalization and adverse events that prompted drug discontinuation.

Dutch researchers also compared rhythm control with rate control in 522 patients (mean age, 68) with recurrent or persistent AF after attempted cardioversion. During an average follow-up of 2.3 years, the primary composite endpoint (cardiovascular death, heart failure, thromboembolism, bleeding, need for pacemaker, or severe drug side effects) occurred more frequently in the rhythm-control group than in the rate-control group (22.6% vs. 17.2%) -- a trend that did not quite reach significance. Women and hypertensive patients had particularly poor outcomes with the rhythm-control strategy.

Comment: The investigators in these landmark trials reached similar conclusions: Older patients with AF -- many of whom had comorbid conditions -- fared no better with rhythm control than with rate control; indeed, the rhythm-control strategy was associated with more treatment-related adverse events. However, an editorialist points out that certain patients (e.g., younger patients with structurally normal hearts, or patients who remain symptomatic during rate control) still might benefit from attempts to restore sinus rhythm.

— Allan S. Brett, MD

Published in Journal Watch General Medicine December 13, 2002

Citation(s):

The Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) Investigators. A comparison of rate control and rhythm control in patients with atrial fibrillation. N Engl J Med 2002 Dec 5; 347:1825-33.

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Van Gelder IC et al. A comparison of rate control and rhythm control in patients with recurrent persistent atrial fibrillation. N Engl J Med 2002 Dec 5; 347:1834-40.

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• Medline abstract (Free)

Falk RH. Management of atrial fibrillation -- Radical reform or modest modification? N Engl J Med 2002 Dec 5; 347:1883-4.

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• Medline abstract (Free)