When to Consider Rate Control, Rhythm Control, and Catheter Ablation for AF

2013 ◽  
Vol 13 (2) ◽  
pp. 6-7
Author(s):  
W. Kuznar ◽  
R. I. Fogel
Keyword(s):  
Catheter Ablation ◽  
Rate Control ◽  
Rhythm Control ◽  
Control Rhythm

Abstract 18974: Rhythm Control with Catheter Ablation Improves Cardiomyopathy and Heart Failure Compared with Rate Control

Circulation ◽  
2014 ◽  
Vol 130 (suppl_2) ◽  
Author(s):  
Umashankar Lakshmanadoss ◽  
Amrish Deshmukh ◽  
Gunjan Choudhary ◽  
Pramod Deshmukh
Keyword(s):  
Heart Failure ◽  
Catheter Ablation ◽  
Rate Control ◽  
Linear Regression Analysis ◽  
Rhythm Control ◽  
Control Group ◽  
Matched Group ◽  
Rate Controlled ◽  
Control Rhythm

Introduction: Role of rhythm control in addition to rate control, in patients with atrial fibrillation and heart failure reduced EF (HFrEF) is unknown. Objective: We sought to compare catheter ablation with rate control in patients with AF and HFrEF. Methods: Ninety patients with AF and LVEF < 40 % underwent pulmonary vein isolation with or without substrate modification. Follow-up included Holter monitoring and echocardiography at baseline, 3 months and at 6 months. A propensity-matched group of 80 patients with AF and LVEF <40% treated with rate control was used for comparison. Post-matching weighted linear regression analysis was used to compare outcomes. Results: At 6 months, 64% of patients who underwent ablation remained in sinus rhythm. Average heart rate (HR) was similar between groups at baseline and follow up. (79 ± 14.5 to 76 ± 7.7 in ablation group and 82.4 ±8.9 to 78.3 ± 8.8 in rate control group). LVEF significantly improved in patients who underwent ablation (30.9 ± 8.6 to 43.4 ±10.9) compared with no change in patients who were rate controlled (to 25.8 ±19.3 to 25.2 ±6.64) (p=2E-16). NHYA class improved from 2.26 ±0.44 to 1.62 ±0.64 with ablation compared to 2.4 ±0.5 to 2.24 ±0.44 with rate control but did not reach statistical significance. Patients who remained in AF after ablation had minimal change in LVEF and NHYA class. No procedural complications noted. Conclusions: In patients with AF, HFrEF, and adequate HR control, rhythm control by catheter ablation improved LVEF compared with a propensity matched group of patients treated with rate control. Rhythm control with catheter ablation may be considered in patients with AF and HF who are adequately rate controlled

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.

Rhythm control for patients with atrial fibrillation complicated with heart failure in the contemporary era of catheter ablation: a stratified pooled analysis of randomized data

2019 ◽  
Vol 41 (30) ◽  
pp. 2863-2873 ◽  
Author(s):  
Shaojie Chen ◽  
Helmut Pürerfellner ◽  
Christian Meyer ◽  
Willem-Jan Acou ◽  
Alexandra Schratter ◽  
...  
Keyword(s):  
Quality Of Life ◽  
Heart Failure ◽  
Catheter Ablation ◽  
Control Strategy ◽  
Rate Control ◽  
Similar Rate ◽  
Rhythm Control ◽  
Thromboembolic Events ◽  
All Cause Mortality

Abstract Aims The optimal treatment for patients with atrial fibrillation (AF) and heart failure (HF) has been a subject of debate for years. We aimed to evaluate the efficacy and safety of rhythm control strategy in patients with AF complicated with HF regarding hard clinical endpoints. Methods and results Up-to-date randomized data comparing rhythm control using antiarrhythmic drugs (AADs) vs. rate control (Subset A) or rhythm control using catheter ablation vs. medical therapy (Subset B) in AF and HF patients were pooled. The primary outcomes were all-cause mortality, re-hospitalization, stroke, and thromboembolic events. A total of 11 studies involving 3598 patients were enrolled (Subset A: 2486; Subset B: 1112). As compared with medical rate control, the AADs rhythm control was associated with similar all-cause mortality [odds ratio (OR): 0.96, P = 0.65], significantly higher rate of re-hospitalization (OR: 1.25, P = 0.01), and similar rate of stroke and thromboembolic events (OR: 0.91, P = 0.76,); however, as compared with medical therapy, catheter ablation rhythm control was associated with significantly lower all-cause mortality (OR: 0.51, P = 0.0003), reduced re-hospitalization rate (OR: 0.44, P = 0.003), similar rate of stroke events (OR: 0.59, P = 0.27), greater improvement in left ventricular ejection fraction [weighted mean difference (WMD): 6.8%, P = 0.0004], lower arrhythmia recurrence (29.6% vs. 80.1%, OR: 0.04, P &lt; 0.00001), and greater improvement in quality of life (Minnesota Living with Heart Failure Questionnaire score) (WMD: −9.1, P = 0.007). Conclusion Catheter ablation as rhythm control strategy substantially improves survival rate, reduces re-hospitalization, increases the maintenance rate of sinus rhythm, contributes to preserve cardiac function, and improves quality of life for AF patients complicated with HF.

scholarly journals Atrial Fibrillation Ablation in Patients with Heart Failure: One Size Does Not Fit All

2018 ◽  
Vol 7 (2) ◽  
pp. 84 ◽  
Author(s):  
Rahul K Mukherjee ◽  
Steven E Williams ◽  
Mark D O’Neill ◽  
◽  
◽  
...  
Keyword(s):  
Heart Failure ◽  
Atrial Fibrillation ◽  
Catheter Ablation ◽  
Rate Control ◽  
State Of The Art ◽  
Previous Treatment ◽  
Rhythm Control ◽  
Patient Specific ◽  
Limited Efficacy ◽  
Patients With Heart Failure

Atrial fibrillation (AF) is common in patients with heart failure and is associated with poorer clinical outcomes compared with patients with heart failure alone. Recent evidence has challenged previous treatment paradigms in which rate control was considered equivalent to rhythm control in this population. Catheter ablation has emerged as a safe and effective treatment strategy in selected patients and overcomes the issues of limited efficacy and drug toxicities associated with pharmacological rhythm control. Numerous studies have explored the benefits of catheter ablation in patients with heart failure, but these have included heterogeneous patient cohorts and variable ablation strategies. This state-of-the-art review explores the evidence from these trials and examines the need for tailored, patient-specific strategies for AF ablation in patients with heart failure.

Abstract 18172: Rhythm Control with Catheter Ablation Improves Ejection Fraction Compared to Rate Control: A Meta-Analysis of Randomized Controlled Studies

Circulation ◽  
2014 ◽  
Vol 130 (suppl_2) ◽  
Author(s):  
Ajay Vallakati ◽  
Arun Kanmantha Reddy ◽  
Mark Dunlap ◽  
William Lewis
Keyword(s):  
Heart Failure ◽  
Catheter Ablation ◽  
Ejection Fraction ◽  
Rate Control ◽  
Meta Analysis ◽  
Group Analysis ◽  
Rhythm Control ◽  
Significant Heterogeneity ◽  
Heart Failure Patients ◽  
Randomized Controlled

Background: Atrial fibrillation (AF) can exacerbate/worsen heart failure. A randomized study showed that rhythm control with anti-arrhythmic drugs (AADs) is not superior to rate control for heart failure patients who develop AF. However, a recent study revealed catheter ablation can improve the ejection fraction (EF) compared to medical rate control. Hypothesis: We performed a meta-analysis to compare the effect of rhythm control and medical rate control on EF in heart failure patients with AF. Methods: We searched PubMed, Embase, Google Scholar and Cochrane databases for all randomized controlled trials (RCTs) comparing rhythm control versus rate control for AF in heart failure. Primary outcome was change in EF. Random effects model was used to pool and analyze data across the studies. Results: Of a total of 7 RCTs (4 - AADs, 3 - catheter ablation) which compared rhythm control and medical rate control, 4 studies (n=202) reported quantitative data on EF. There was significant heterogeneity between the studies (I2=82%, p <0.001). Compared to rate control, the mean improvement in EF with rhythm control was 5.94% (95% CI 0.63- 11.26, p=0.03). Sub-group analysis revealed catheter ablation improved the EF by 6.67% (95% CI 0.23 -13.11, p=0.04) whereas rhythm control with AADs did not significantly change EF (3.50, -1.76 -8.76). Conclusion: Rhythm control is associated with greater improvement in EF compared to rate control therapy in heart failure patients with AF. Catheter ablation of AF significantly improves the EF in these patients. Further studies are needed to determine if this improvement in EF is associated with decreased morbidity and mortality.

Rate Control vs. Rhythm Control for Atrial Fibrillation

2018 ◽  
pp. 50-54
Keyword(s):  
Atrial Fibrillation ◽  
High Risk ◽  
Rate Control ◽  
Older Patients ◽  
Cardiac Rhythm ◽  
Rhythm Control ◽  
Cardiovascular Risks ◽  
High Risk Patients ◽  
Risk Patients ◽  
Control Rhythm

This case focuses on how to maintain cardiac rhythm in older patients with arterial fibrillation and cardiovascular risks by asking the question: Should patients with atrial fibrillation be managed with a strategy of rate control or rhythm control? In high-risk patients with atrial fibrillation, a strategy of rate control is at least as effective as a strategy of rhythm control. Rhythm control does not appear to obviate the need for anticoagulation. Because the medications used for rate control are usually safer than those used for rhythm control, rate control is the preferred strategy for treating most high-risk patients with atrial fibrillation. These findings do not necessarily apply to younger patients without cardiovascular risk factors who were not included in AFFIRM, however.

scholarly journals Current Evidence and Recommendations for Rate Control in Atrial Fibrillation

2013 ◽  
Vol 2 (1) ◽  
pp. 30 ◽  
Author(s):  
Abhishek Maan ◽  
Moussa Mansour ◽  
Jeremy N Ruskin ◽  
E Kevin Heist ◽  
◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Catheter Ablation ◽  
Rate Control ◽  
Treatment Strategy ◽  
Antiarrhythmic Drugs ◽  
The Elderly ◽  
Rhythm Control ◽  
Ventricular Rate ◽  
Current Evidence ◽  
Substantial Risk

Atrial fibrillation (AF) is the most common cardiac arrhythmia encountered in clinical practice, which is associated with substantial risk of stroke and thromboembolism. As an arrhythmia that is particularly common in the elderly, it is an important contributor towards morbidity and mortality. Ventricular rate control has been a preferred and therapeutically convenient treatment strategy for the management of AF. Recent research in the field of rhythm control has led to the advent of newer antiarrhythmic drugs and catheter ablation techniques as newer therapeutic options. Currently available antiarrhythmic drugs still remain limited by their suboptimal efficacy and significant adverse effects. Catheter ablation as a newer modality to achieve sinus rhythm (SR) continues to evolve, but data on long-term outcomes on its efficacy and mortality outcomes are not yet available. Despite these current developments, rate control continues to be the front-line treatment strategy, especially in older and minimally symptomatic patients who might not tolerate the antiarrhythmic drug treatment. This review article discusses the current evidence and recommendations for ventricular rate control in the management of AF. We also highlight the considerations for rhythm control strategy in the management of patients of AF.

scholarly journals Comparative Effectiveness of Early Rhythm Control Versus Rate Control for Cardiovascular Outcomes in Patients With Atrial Fibrillation

2021 ◽  
Author(s):  
Daehoon Kim ◽  
Pil‐Sung Yang ◽  
Seng Chan You ◽  
Eunsun Jang ◽  
Hee Tae Yu ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Heart Failure ◽  
Atrial Fibrillation ◽  
Rate Control ◽  
Cardiovascular Death ◽  
Population Based ◽  
Cardiovascular Outcomes ◽  
Rhythm Control ◽  
Control Treatment ◽  
Control Rhythm

Background Rhythm control is associated with better cardiovascular outcomes than usual care among patients with recently diagnosed atrial fibrillation (AF). This study investigated the effects of rhythm control compared with rate control on the incidence of stroke, heart failure, myocardial infarction, and cardiovascular death stratified by timing of treatment initiation. Methods and Results We conducted a retrospective population‐based cohort study including 22 635 patients with AF newly treated with rhythm control (antiarrhythmic drugs or ablation) or rate control in 2011 to 2015 from the Korean National Health Insurance Service database. Propensity overlap weighting was used. Compared with rate control, rhythm control initiated within 1 year of AF diagnosis decreased the risk of stroke. The point estimates for rhythm control initiated at selected time points after AF diagnosis are as follows: 6 months (hazard ratio [HR], 0.76; 95% CI, 0.66–0.87), 1 year (HR, 0.78; 95% CI, 0.66–0.93), and 5 years (HR, 1.00; 95% CI, 0.45–2.24). The initiation of rhythm control within 6 months of AF diagnosis reduced the risk of hospitalization for heart failure: 6 months (HR, 0.84; 95% CI, 0.74–0.95), 1 year (HR, 0.96; 95% CI, 0.82–1.13), and 5 years (HR, 2.88; 95% CI, 1.34–6.17). The risks of myocardial infarction and cardiovascular death did not differ between rhythm and rate control regardless of treatment timing. Conclusions Early initiation of rhythm control was associated with a lower risk of stroke and heart failure–related admission than rate control in patients with recently diagnosed AF. The effects were attenuated as initiating the rhythm control treatment later.

A comparison of rate control and rhythm control in tachycardia induced cardiomyopathy patients with persistent atrial flutter

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
S Oka ◽  
T Kai ◽  
K Hoshino ◽  
K Watanabe ◽  
J Nakamura ◽  
...  
Keyword(s):  
Heart Rate ◽  
Catheter Ablation ◽  
Control Strategy ◽  
Rate Control ◽  
Rhythm Control ◽  
Control Group ◽  
Lv Function ◽  
Strategy Group ◽  
Average Heart Rate ◽  
Tachycardia Induced Cardiomyopathy

Abstract Background/Introduction Tachycardia induced cardiomyopathy (TIC) is a potentially reversible dysfunction of the left ventricle (LV) caused by tachyarrhythmias. Early recognition of TIC and treatment of the culprit arrhythmia using pharmacological therapy or catheter ablation results in the recovery of LV function. For atrial flutter (AFL)-induced TIC, rhythm control strategy, such as catheter ablation has been recommended. On the other hand, the efficacy of rate control strategy has remained unclear due to the difficulty of control with arrhythmic medications. However, not all patients can take rhythm control treatments due to their backgrounds. Purpose The aim of this cohort study was to establish whether rate control strategy using β-blocker is as effective as invasive rhythm control strategy for the recovery of LV function in patients with TIC due to AFL. Methods We prospectively assessed 47 symptomatic non-ischaemic heart failure (HF) patients with left ventricular ejection fraction (LVEF) below 50% and suspected TIC induced by persistent AFL. Patients were divided into rhythm control strategy group (n=22, treatment: catheter ablation, electrical cardioversion) and rate control strategy group (n=25, treatment: bisoprolol). As a sub-group study, the rate control strategy group was divided into the strict rate control group (n=12, average heart rate below 80 bpm) and lenient rate control group (n=13, average heart rate below 110 bpm). The primary outcome was the recovery of LV function, defined as an increase of LVEF over 20% or to a value of 55% or greater after 6 months. Results There were no significant differences in baseline AFL heart rate, New York Heart Association class, LVEF, estimated glomerular filtration rate, and brain natriuretic peptide between the two groups. A greater proportion of patients who showed the recovery of LVEF after 6 months belonged to the rhythm control strategy group (90.9% vs. 52.0%, p=0.004). The cumulative incidence of HF re-hospitalization was significantly higher in the rate control strategy group than in the rhythm control strategy group (hazard ratio: 4.90, 95% CI: 1.06–22.69). As a result of sub-group study, LVEF recovery was greater in the strict rate control group compared to the lenient rate control group (75.0% vs. 30.8%, p=0.027) Conclusion Rate control strategy was significantly inferior to rhythm control strategy for the recovery of LVEF in TIC patients with persistent AFL. Rhythm control should be the first choice in the management of TIC with AFL, and strict rate control should be an alternative if rhythm control is not available. Primary outcomes Funding Acknowledgement Type of funding source: None

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