Do Restoring and Maintaining Sinus Rhythm Have a Beneficial Effect on Secondary Prevention of Stroke in Patients With Atrial Fibrillation? A Pilot Study

Angiology ◽  
2019 ◽  
Vol 70 (10) ◽  
pp. 916-920 ◽  
Author(s):  
Cenk Conkbayir ◽  
Zerrin Yigit ◽  
Refika Hural ◽  
Murat Ugurlucan ◽  
Didem Melis Oztas ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Secondary Prevention ◽  
Sinus Rhythm ◽  
Beneficial Effect ◽  
Rate Control ◽  
Recurrent Stroke ◽  
Rhythm Control ◽  
Control Group ◽  
Echocardiographic Examination ◽  
Ischemic Attack

We aimed to determine whether attempts to restore and maintain sinus rhythm will reduce recurrent stroke in patients with atrial fibrillation (AF). Patients (n = 245) between March 1998 and May 2002 with AF who had an ischemic stroke including transient ischemic attack 1 to 12 months before transesophageal echocardiographic examination and had been followed for 3 years were retrospectively reviewed. Cardioversion was attempted in 130 patients; 117 (90%) patients were successfully cardioverted (rhythm control group). The 13 patients who could not be cardioverted and 115 patients who did not undergo cardioversion were assigned to the rate control group. Age, gender, ischemic heart disease, hypertension, diabetes mellitus, congestive heart failure, mitral valve disease, and left atrial diameter were similar in both groups. The rhythm control group included 56 patients (48.7%) who were still in sinus rhythm after 3 years. During follow-up, there were 2 embolic events (3.4%) and 2 deaths (3.4%) in the rhythm control group, whereas 18 embolic events (14.6%) and 18 deaths (14.6%) occurred in the rate control group ( P = .049 and P = .049, respectively). Restoration and maintenance of sinus rhythm seems to have a beneficial effect on secondary prevention of stroke in patients with AF.

scholarly journals Recent advances in rhythm control for atrial fibrillation

F1000Research ◽  
2017 ◽  
Vol 6 ◽  
pp. 1796 ◽  
Author(s):  
Richard Bond ◽  
Brian Olshansky ◽  
Paulus Kirchhof
Keyword(s):  
Atrial Fibrillation ◽  
Catheter Ablation ◽  
Sinus Rhythm ◽  
Pulmonary Vein ◽  
Pulmonary Vein Isolation ◽  
Rate Control ◽  
Rhythm Control ◽  
Management Problem ◽  
Recent Trial ◽  
Control Therapy

Atrial fibrillation (AF) remains a difficult management problem. The restoration and maintenance of sinus rhythm—rhythm control therapy—can markedly improve symptoms and haemodynamics for patients who have paroxysmal or persistent AF, but some patients fare well with rate control alone. Sinus rhythm can be achieved with anti-arrhythmic drugs or electrical cardioversion, but the maintenance of sinus rhythm without recurrence is more challenging. Catheter ablation of the AF triggers is more effective than anti-arrhythmic drugs at maintaining sinus rhythm. Whilst pulmonary vein isolation is an effective strategy, other ablation targets are being evaluated to improve sinus rhythm maintenance, especially in patients with chronic forms of AF. Previously extensive ablation strategies have been used for patients with persistent AF, but a recent trial has shown that pulmonary vein isolation without additional ablation lesions is associated with outcomes similar to those of more extensive ablation. This has led to an increase in catheter-based technology to achieve durable pulmonary vein isolation. Furthermore, a combination of anti-arrhythmic drugs and catheter ablation seems useful to improve the effectiveness of rhythm control therapy. Two large ongoing trials evaluate whether a modern rhythm control therapy can improve prognosis in patients with AF.

Rate versus rhythm control therapy for atrial fibrillation

2018 ◽  
Author(s):  
Albert L. Waldo
Keyword(s):  
Atrial Fibrillation ◽  
Sinus Rhythm ◽  
Control Strategy ◽  
Rate Control ◽  
Anticoagulation Therapy ◽  
Rhythm Control ◽  
Rate Versus ◽  
Ventricular Response ◽  
Tachycardia Induced Cardiomyopathy ◽  
Stable Sinus Rhythm

Based on data from several clinical trials, either rate control or rhythm control is an acceptable primary therapeutic strategy for patients with atrial fibrillation. However, since atrial fibrillation tends to recur no matter the therapy, rate control should almost always be a part of the treatment. If a rhythm control strategy is selected, it is important to recognize that recurrence of atrial fibrillation is common, but not clinical failure per se. Rather, the frequency and duration of episodes, as well as severity of symptoms during atrial fibrillation episodes should guide treatment decisions. Thus, occasional recurrence of atrial fibrillation despite therapy may well be clinically acceptable. However, for some patients, rhythm control may be the only strategy that is acceptable. In short, for most patients, either a rate or rhythm control strategy should be considered. However, for all patients, there are two main goals of therapy. One is to avoid stroke and/or systemic embolism, and the other is to avoid a tachycardia-induced cardiomyopathy. Also, because of the frequency of atrial fibrillation recurrence despite the treatment strategy selected, patients with stroke risks should receive anticoagulation therapy despite seemingly having achieved stable sinus rhythm. For patients in whom a rate control strategy is selected, a lenient approach to the acceptable ventricular response rate is a resting heart rate of 110 bpm, and probably 90 bpm. The importance of achieving and maintaining sinus rhythm in patients with atrial fibrillation and heart failure remains to be clearly established.

Rate versus rhythm control therapy for atrial fibrillation

ESC CardioMed ◽  
2018 ◽  
pp. 2177-2180
Author(s):  
Albert L. Waldo
Keyword(s):  
Atrial Fibrillation ◽  
Sinus Rhythm ◽  
Control Strategy ◽  
Rate Control ◽  
Anticoagulation Therapy ◽  
Rhythm Control ◽  
Rate Versus ◽  
Ventricular Response ◽  
Tachycardia Induced Cardiomyopathy ◽  
Stable Sinus Rhythm

Based on data from several clinical trials, either rate control or rhythm control is an acceptable primary therapeutic strategy for patients with atrial fibrillation. However, since atrial fibrillation tends to recur no matter the therapy, rate control should almost always be a part of the treatment. If a rhythm control strategy is selected, it is important to recognize that recurrence of atrial fibrillation is common, but not clinical failure per se. Rather, the frequency and duration of episodes, as well as severity of symptoms during atrial fibrillation episodes should guide treatment decisions. Thus, occasional recurrence of atrial fibrillation despite therapy may well be clinically acceptable. However, for some patients, rhythm control may be the only strategy that is acceptable. In short, for most patients, either a rate or rhythm control strategy should be considered. However, for all patients, there are two main goals of therapy. One is to avoid stroke and/or systemic embolism, and the other is to avoid a tachycardia-induced cardiomyopathy. Also, because of the frequency of atrial fibrillation recurrence despite the treatment strategy selected, patients with stroke risks should receive anticoagulation therapy despite seemingly having achieved stable sinus rhythm. For patients in whom a rate control strategy is selected, a lenient approach to the acceptable ventricular response rate is a resting heart rate of 110 bpm or less, and probably 90 bpm or less. The importance of achieving and maintaining sinus rhythm in patients with atrial fibrillation and heart failure remains to be clearly established.

scholarly journals Rhythm Versus Rate Control for Atrial Fibrillation: A Meta-analysis of Randomized Controlled Trials

2018 ◽  
Vol 11 (2) ◽  
pp. 609-620 ◽  
Author(s):  
Abdelrahman Ibrahim Abushouk ◽  
Aya Ashraf Ali ◽  
Ahmed Abdou Mohamed ◽  
Loalo'a El-Sherif ◽  
Mennat-Allah Abdelsamed ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Major Bleeding ◽  
Rate Control ◽  
Control Strategies ◽  
Meta Analysis ◽  
Rhythm Control ◽  
Control Group ◽  
Effect Estimate ◽  
Increased Risk ◽  
All Cause Mortality

Atrial fibrillation (AF) is a common, sustained tachyarrhythmia, associated with an increased risk of mortality and thromboembolic events. We performed this meta-analysis to compare the clinical efficacy of rate and rhythm control strategies in patients with AF in a meta-analysis framework. A comprehensive search of PubMed, OVID, Cochrane-CENTRAL, EMBASE, Scopus, and Web of Science was conducted, using relevant keywords. Dichotomous data on mortality and other clinical events were extracted and pooled as risk ratios (RRs), with their 95% confidence-interval (CI), using RevMan software (version 5.3). Twelve studies (8451 patients) were pooled in the final analysis. The overall effect-estimate did not favor rate or rhythm control strategies in terms of all-cause mortality (RR= 1.13, 95% CI [0.88, 1.45]), stroke (RR= 0.97, 95% CI [0.79, 1.20]), thromboembolism (RR= 1.06, 95% CI [0.64, 1.76]), and major bleeding (RR= 1.10, 95% CI [0.90, 1.35]) rates. These findings were consistent in AF patients with concomitant heart failure (HF). The rate of rehospitalization was significantly higher (RR= 0.72, 95% CI [0.57, 0.92]) in the rhythm control group, compared to the rate control group. In younger patients (<65 years), rhythm control was superior to rate control in terms of lowering the risk of all-cause mortality (p=0.0003), HF (p=0.003) and major bleeding (p=0.02). In older AF patients and those with concomitant HF, both rate and rhythm control strategies have similar rates of mortality and major clinical outcomes; therefore, choosing an appropriate strategy should consider individual variations, such as patient preferences, comorbidities, and treatment cost.

scholarly journals Current Drug Treatment Strategies for Atrial Fibrillation and TASK-1 Inhibition as an Emerging Novel Therapy Option

2021 ◽  
Vol 12 ◽  
Author(s):  
Manuel Kraft ◽  
Antonius Büscher ◽  
Felix Wiedmann ◽  
Yannick L’hoste ◽  
Walter E. Haefeli ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Sinus Rhythm ◽  
Rate Control ◽  
Antiarrhythmic Drugs ◽  
Heart Diseases ◽  
Pulmonary Veins ◽  
Treatment Strategies ◽  
Rhythm Control ◽  
Electrical Cardioversion ◽  
Adequate Treatment

Atrial fibrillation (AF) is the most common sustained arrhythmia with a prevalence of up to 4% and an upwards trend due to demographic changes. It is associated with an increase in mortality and stroke incidences. While stroke risk can be significantly reduced through anticoagulant therapy, adequate treatment of other AF related symptoms remains an unmet medical need in many cases. Two main treatment strategies are available: rate control that modulates ventricular heart rate and prevents tachymyopathy as well as rhythm control that aims to restore and sustain sinus rhythm. Rate control can be achieved through drugs or ablation of the atrioventricular node, rendering the patient pacemaker-dependent. For rhythm control electrical cardioversion and pharmacological cardioversion can be used. While electrical cardioversion requires fasting and sedation of the patient, antiarrhythmic drugs have other limitations. Most antiarrhythmic drugs carry a risk for pro-arrhythmic effects and are contraindicated in patients with structural heart diseases. Furthermore, catheter ablation of pulmonary veins can be performed with its risk of intraprocedural complications and varying success. In recent years TASK-1 has been introduced as a new target for AF therapy. Upregulation of TASK-1 in AF patients contributes to prolongation of the action potential duration. In a porcine model of AF, TASK-1 inhibition by gene therapy or pharmacological compounds induced cardioversion to sinus rhythm. The DOxapram Conversion TO Sinus rhythm (DOCTOS)-Trial will reveal whether doxapram, a potent TASK-1 inhibitor, can be used for acute cardioversion of persistent and paroxysmal AF in patients, potentially leading to a new treatment option for AF.

Rhythm or Rate Control in Atrial Fibrillation: Insights from the Randomized Controlled Trials

2003 ◽  
Vol 8 (1_suppl) ◽  
pp. S39-S44 ◽  
Author(s):  
Gerian Gronefeld ◽  
Stefan H. Hohnloser
Keyword(s):  
Atrial Fibrillation ◽  
Sinus Rhythm ◽  
Randomized Controlled Trials ◽  
Rate Control ◽  
Normal Sinus Rhythm ◽  
Persistent Atrial Fibrillation ◽  
Rhythm Control ◽  
Controlled Trials ◽  
Initial Approach ◽  
Randomized Controlled

Pharmacologic treatment remains the mainstay of therapy in patients with atrial fibrillation for the maintenance of normal sinus rhythm. Initial therapy of atrial fibrillation is often directed toward the maintenance of sinus rhythm by means of cardioversion and the use of antiarrhythmic drugs. Heart rate control is often only pursued when rhythm control fails. Four randomized controlled trials have carefully evaluated the yield of these two treatment strategies as the initial approach to patients with paroxysmal or persistent atrial fibrillation. In essence, all four trials demonstrated that an initial strategy of rate control is equally effective compared to the rhythm control approach in terms of clinically important outcome measures including mortality, stroke prevention, or quality of life. Accordingly, rate control can be considered as an initial approach to therapy in patients with paroxysmal or persistent atrial fibrillation. The four randomized trials clearly demonstrate that continuous anticoagulation is mandatory in all patients with atrial fibrillation and risk factors for stroke, irrespective of the initial therapeutic approach of rhythm or rate control.

scholarly journals Rhythm or rate control strategy in CRT recipients with long-standing persistent atrial fibrillation - preliminary results of the PilotCRAfT study

EP Europace ◽  
2021 ◽  
Vol 23 (Supplement_3) ◽  
Author(s):  
JB Ciszewski ◽  
M Tajstra ◽  
E Gadula-Gacek ◽  
I Kowalik ◽  
A Maciag ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Control Strategy ◽  
Rate Control ◽  
Left Ventricular ◽  
Rhythm Control ◽  
Left Ventricular Ejection ◽  
Control Group ◽  
The Mean ◽  
Crt Response

Abstract Funding Acknowledgements Type of funding sources: Public Institution(s). Main funding source(s): National Institute of Cardiology in Warsaw Statutory Grant Background The presence of atrial fibrillation (AF) in cardiac resynchronization therapy (CRT) recipients is common and AF is a marker of poorer CRT response. The negative influence of AF on CRT efficacy is mediated mainly by the drop of the effectively captured biventricular paced beats percentage (BiVp%) which should exceed 95-98% to warrant good CRT response.  Sinus rhythm (SR) restoration may improve CRT efficacy which in turn may protect AF recurrence. However, there is lack of randomized studies comparing rhythm and rate control strategies in these patients. Purpose The purpose of the Pilot-CRAfT study (NCT01850277) was to compare the efficacy of rhythm vs rate control strategy in CRT patients with long-standing persistent or permanent atrial fibrillation. Methods The study included patients with CRT and permanent or persistent AF lasting for ≥6 months, resulting in BiVp% &lt;95%, who were randomly assigned to rhythm or rate control strategy. The rhythm control strategy comprised of external electrical cardioversion (EEC). The rate control strategy included pharmacotherapy and atrioventricular node ablation (AVNA) as needed. Both of the study arms received amiodarone. The follow-up lasted 12 months. The primary endpoint was the 12-month BiVp%. The patients underwent ECHO, cardiopulmonary test, quality of live (QoL) and clinical outcomes assessment.   Results The study included 43 CRT patients (97,7% males) aged 68,4 (SD: ±8,3) years with mean BiVp% 82,4% ±9,7% at baseline. The mean duration of AF paroxysm was 25 ±19 months. The mean baseline left ventricular ejection fraction (LVEF), left atrium area and maximal oxygen uptake (VO2max) were: 30 ±8%, 33 ±7 cm2, 14 ±5 mL/(kg*min), respectively. The EEC was performed in 19 out of 22 patients assigned to the rhythm control arm. The immediate success rate of EEC was 58%. 42% of  the rhythm control arm patients remained in SR after 12 months. In the rate control group 1 person underwent AVNA and in 1 patient spontaneous SR resumption was observed. After 12 months there was significant BiVp% increase in both the rhythm and the rate control arms (98,1 ±2,3 vs 96,3 ±3,9%, respectively. The BiVp% differences between the groups were not significant (P = 0,093). However, in the per protocol analysis, the rhythm control group had greater LVEF after 12 months as opposed to the rate control arm (36,8% vs 29,9% respectively, P = 0,039). The LVEF raised significantly in the rhythm control group (ΔLVEF 5,0 (95%CI: 1,54; 8,46)). No significant differences between the groups in the VO2max, QoL, clinical and safety end-points were noticed. Conclusions Structured follow-up of CRT patients with long-standing persistent or permanent AF leads to significant BiVp% increase exceeding 95%. The rate control strategy did not improve CRT effectivness, irrespective of high BiVp%. However limited in the efficacy, the rhythm control strategy may improve CRT outcome in these patients, resulting in LVEF increase.

Optimizing Heart Rate and Controlling Symptoms in Atrial Fibrillation

2016 ◽  
Vol 10 (1) ◽  
pp. 26
Author(s):  
Pragnesh Parikh ◽  
◽  
KL Venkatachalam ◽  
Keyword(s):  
Risk Factors ◽  
Atrial Fibrillation ◽  
Rate Control ◽  
Stroke Risk ◽  
Symptom Control ◽  
Review Article ◽  
Rhythm Control ◽  
Ventricular Rate ◽  
Control Methods ◽  
Novel Approaches

Atrial fibrillation (AF) is the most common arrhythmia noted in clinical practice and its incidence and prevalence are on the rise. The single most important intervention is the evaluation and treatment of stroke risk. Once the risk for stroke has been minimized, controlling the ventricular rate and treating symptoms become relevant. In this review article, we emphasize the importance of confirming and treating the appropriate arrhythmia and correlating symptoms with rhythm changes. Furthermore, we evaluate some of the risk factors for AF that independently result in symptoms, underlining the need to treat these risk factors as part of symptom control. We then discuss existing and novel approaches to rate control in AF and briefly cover rhythm control methods.

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