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 Ranolazine alone or as a complement to the amiodarone for both prevention and cardioversion of atrial fibrillation: A meta-analysis of the literature

2017 ◽  
Author(s):  
Renato De Vecchis ◽  
Carmelina Ariano
Keyword(s):  
Atrial Fibrillation ◽  
Adverse Events ◽  
Sinus Rhythm ◽  
Randomized Controlled Trials ◽  
Meta Analysis ◽  
Artery Bypass ◽  
Controlled Trials ◽  
Cabg Surgery ◽  
Randomized Controlled ◽  
New Onset

Introduction Recent evidence from relatively small randomized controlled trials would seem to support a useful role of ranolazine for the prevention and treatment of atrial fibrillation (AF). The present study is aimed at providing information about the possible beneficial anti-arrhythmic properties of   ranolazine. In particular, the meta-analysis carried out in this study focuses on the application of ranolazine to prophylaxis and treatment of atrial fibrillation.Methods Both  randomized controlled trials (RCTs) and  non randomized observational  studies concerning the effects of ranolazine on AF were included in the meta-analysis. In each of the considered studies, a comparison was made between a group of patients taking ranolazine and a second group treated instead with another antiarrhythmic therapy , or assigned to placebo. Efficacy outcomes were the risk of new- onset AF, the probability of conversion to sinus rhythm of patients with recent occurrence(≤ 48 h)of AF and the time to conversion to sinus rhythm. Safety endpoints were death, adverse events, QTc  prolongation and hypotension.Results Ten studies ( 8 RCTs and 2 nonrandomized observational studies) were gathered on the whole.  Ranolazine was effective in preventing the occurrence of AF when compared to controls (RR= 0.60; 95% CI: 0.43–0.83; p = 0.002). Subgroup analysis showed a more  pronounced preventive effect  of ranolazine against AF in the postoperative setting of coronary artery bypass grafting(CABG) surgery (RR= 0.39; 95% CI: 0.18-0.83; p=0.02) when compared to non- postoperative AF (RR= 0.76; 95% CI: 0.63-0.92; p=0.04). Ranolazine enhanced the chances of successful cardioversion when added to intravenous amiodarone compared to amiodarone alone  (RR 1.18; 95% CI: 1.05–1.33; p = 0.004) and  significantly decreased the  time to cardioversion(SMD= −10.35 h; 95% CI: −18.13 hours to − 2.57 hours; p < 0.001). Overall risks of death, adverse events, and QTc prolongation were shown to be similar in the comparison between patients treated with ranolazine and controls. Conclusions Ranolazine given orally at appropriate doses showed the property to significantly quicken the conversion of AF to sinus rhythm when combined with the iv amiodarone, compared to iv amiodarone alone . Furthermore, in patients in sinus rhythm, ranolazine   proved to reduce the frequency of new onset AF as well as of its recurrences, especially in patients undergone CABG surgery, known to be at high risk of developing postoperative AF. In addition, ranolazine use seems to be safe and associated with relatively few adverse events.

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