What Should be the Primary Treatment in Atrial Fibrillation: Ventricular Rate Control or Sinus Rhythm Control with Long-term Anticoagulation?

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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Recent advances in rhythm control for atrial fibrillation

F1000Research ◽

10.12688/f1000research.11061.1 ◽

2017 ◽

Vol 6 ◽

pp. 1796 ◽

Cited By ~ 6

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.

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

Angiology ◽

10.1177/0003319719856455 ◽

2019 ◽

Vol 70 (10) ◽

pp. 916-920 ◽

Cited By ~ 5

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.

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Rate versus rhythm control therapy for atrial fibrillation

10.1093/med/9780198784906.003.0511 ◽

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.

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Antiarrhythmic Drug Therapy for Rhythm Control in Atrial Fibrillation

Journal of Cardiovascular Pharmacology and Therapeutics ◽

10.1177/1074248416651722 ◽

2016 ◽

Vol 22 (1) ◽

pp. 3-19 ◽

Cited By ~ 9

Author(s):

Jonathan W. Waks ◽

Peter Zimetbaum

Keyword(s):

Atrial Fibrillation ◽

Sinus Rhythm ◽

Synergistic Effects ◽

Rhythm Control ◽

Cardiac Implantable Electronic Devices ◽

Randomized Controlled Studies ◽

Life Threatening ◽

Safe Discontinuation ◽

Term Maintenance

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia and affects over 33 million people worldwide. AF is associated with stroke and systemic thromboembolism, unpleasant symptoms and reduced quality of life, heart failure, and increased mortality, and treatment of AF and its complications are associated with significant cost. Antiarrhythmic drugs (AADs) can suppress AF, allowing long-term maintenance of sinus rhythm, and have the potential to relieve symptoms and reverse or prevent adverse effects associated with AF. However, large randomized controlled studies evaluating use of AADs have not demonstrated a clear benefit to maintaining sinus rhythm, and AADs often have significant limitations, including a modest rate of overall success at maintaining sinus rhythm, frequent side effects, and potentially life-threatening toxicities. Although some of the currently available AADs have been available for almost 100 years, better tolerated and more efficacious AADs have recently been developed both for long-term maintenance of sinus rhythm and for chemical cardioversion of AF to sinus rhythm. Advances in automated AF detection with cardiac implantable electronic devices have suggested that AADs might be useful for suppressing AF to allow safe discontinuation of anticoagulation in select patients who are in sinus rhythm for prolonged periods of time. AADs may also have synergistic effects with catheter ablation of AF. This review summarizes the pharmacology and clinical use of currently available AADs for treatment of AF and discusses novel AADs and future directions for rhythm control in AF.

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Management strategies for atrial fibrillation and flutter in patients with transthyretin cardiac amyloidosis

European Heart Journal ◽

10.1093/eurheartj/ehab724.1810 ◽

2021 ◽

Vol 42 (Supplement_1) ◽

Author(s):

Z Dale ◽

P Chandrashekar ◽

L Al-Rashdan ◽

M Kim ◽

A Masri ◽

...

Keyword(s):

Atrial Fibrillation ◽

Rate Control ◽

Cardiac Amyloidosis ◽

Control Strategies ◽

Nyha Class ◽

Management Strategies ◽

Symptomatic Improvement ◽

Rhythm Control ◽

Ventricular Rate ◽

Ventricular Response

Abstract Background Atrial fibrillation (AF) and flutter (AFL) are common in transthyretin cardiac amyloidosis (ATTR-CM). Ventricular rate control drugs in ATTR-CM are poorly tolerated but data addressing tolerability and efficacy of rhythm control strategies is limited. Purpose We report characteristics and outcomes of AF/AFL in a cohort with ATTR-CM. Methods A single center observational study of patients seen at our Amyloidosis Center with wild-type or hereditary ATTR-CM diagnosed between 2005–2019. Treatment was prescribed as per treating cardiologists. Results Eighty-four patients with ATTR-CM (average age 74±10 years, 94% male) had mean follow-up of 27.6±22.8 months. AF/AFL occurred in 61 patients (73%). Clinically significant rapid ventricular response (RVR) was common as well attempted rate control with AV node blockers (Table 1). However, discontinuation was frequent (80%), often for adverse effects of hypotension (33%), bradycardia (15%), or presyncope/syncope (10%). Rhythm control was initiated in 64%, most often with cardioversion (DCCV) or ablation (Table 2). Post-DCCV recurrence was common (91%) and time to recurrence did not differ with use of anti-arrhythmic drugs (AAD; 5.8 months (IQR 1.9–12.5) vs without AAD 6.2 months (IQR 1.9–12.5) p=0.83). TEE was performed for 33% of DCCV with thrombus seen in 11% of cases – all patients who were not anticoagulated at the time. TEE was otherwise deferred due to known AF/AFL duration <48 hours (13%) or adequate anticoagulation (54%). Ablation was performed in 23% of patients with AFL (all for typical AFL) with 2 patients (14%) having recurrence after mean of 60.9 months. Pulmonary vein isolation for AF was performed in 12% (86% for persistent AF) with 86% recurrence after median of 6.2 months (IQR 5.6–12.3). Most patients (62%) with rhythm control had subjective improvement (≥1 NYHA class or resolved palpitations). Among AAD, amiodarone was most well tolerated with only 8% of patient discontinuing due to side effects. DCCV and ablation resulted in no direct complications although one patient had a perforation of a previously unknown Zenker diverticulum during TEE pre-DCCV. Conclusions In our ATTR-CM cohort, AF/AFL was common. Rate control was poorly tolerated and often abandoned. While rhythm control of AF/AFL had a favorable safety profile and successful conversion to sinus rhythm led to symptomatic improvement in a majority of cases, durable success with rhythm control was limited, often requiring multiple therapies. DCCV is only modestly successful and not significant improved with AAD. Ablation was successful in cases of cavo-tricuspid isthmus dependent AFL but had limited success in AF. FUNDunding Acknowledgement Type of funding sources: None.

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Rate versus rhythm control therapy for atrial fibrillation

ESC CardioMed ◽

10.1093/med/9780198784906.003.0511_update_001 ◽

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.

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Clinical Review : Update on Atrial Fibrillation: Restoration of Sinus Rhythm or Ventricular Rate Control?

Journal of Cardiovascular Pharmacology and Therapeutics ◽

10.1177/107424849800300211 ◽

1998 ◽

Vol 3 (2) ◽

pp. 185-194 ◽

Cited By ~ 1

Author(s):

Yi-Gang Li ◽

Stefan H. Hohnloser

Keyword(s):

Atrial Fibrillation ◽

Sinus Rhythm ◽

Clinical Review ◽

Rate Control ◽

Ventricular Rate

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Treatment of Acute Atrial Fibrillation: Ventricular Rate Control and Restoration of Sinus Rhythm

Hong Kong Journal of Emergency Medicine ◽

10.1177/102490790000700205 ◽

2000 ◽

Vol 7 (2) ◽

pp. 85-95

Author(s):

Ht Fung ◽

Cw Kam

Keyword(s):

Atrial Fibrillation ◽

Emergency Department ◽

Cardiac Output ◽

General Population ◽

Sinus Rhythm ◽

Rate Control ◽

Electrical Cardioversion ◽

Ventricular Rate ◽

The Past ◽

Definite Risk

Atrial fibrillation (AF) is a familiar arrhythmia seen in the emergency department and the general population. In the past it was treated in the majority of cases by controlling the ventricular rate, whether the AF is acute or chronic. However, ventricular rate control alone does not address the underlying problem and the patients still remain in AF, cardiac output and symptoms have not been optimally corrected. There is definite risk of thromboembolism. Restoration of sinus rhythm is the only way of resuming the normal conduction physiology of the heart and correcting these problems This article provides a review of the two major principles of rhythm treatment of acute AF: rate control and restoration of sinus rhythm. Transthoracic electrical cardioversion is the mainstay of treatment in haemodynamically unstable AF, whereas in stable AF, there is a choice between rate control and restoration of sinus rhythm, or they can be carried out in conjunction with each other.

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