Abstract
The management of patients with atrial fibrillation involves three main areas: anticoagulation, rate control and rhythm control. Importantly, these are not mutually exclusive of each other. Anticoagulation is necessary for patients who are at a high risk of stroke; for example, those who are older than 75 years, or those who have hypertension, severe left ventricular dysfunction, previous cerebrovascular events, or diabetes. It is now clear that patients who are at a high risk of stroke require long-term anticoagulation with warfarin regardless of whether a rate-control or rhythm-control strategy is chosen. One possible exception might be patients who are apparently cured with catheter ablation. Several published trials comparing rate-control and rhythm-control strategies for the treatment of patients with atrial fibrillation have shown no difference in mortality between these approaches. The patients enrolled in these studies were typically over 65 years of age. Data comparing rate and rhythm strategies in patients who are younger than 60 years of age are limited. For more elderly patients, it seems reasonable to consider rate control as a primary treatment option and to reserve rhythm control for those who do not respond to rate control. For younger patients, we prefer to start with a rhythm-control approach and to reserve rate-control approaches for patients in whom antiarrhythmic drugs, ablation, or both, do not ameliorate the symptoms.
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References
Fuster V et al. (2001) ACC/AHA/ESC Guidelines for the Management of Patients with Atrial Fibrillation: Executive Summary. Circulation 104: 2118–2150
Pappone C and Santinelli V (2004) The who, what, why and how-to guide for circumferential pulmonary vein ablation. J Cardiovasc Electrophysiol 15: 1226–1230
Hocini M et al. (2004) Techniques for curative treatment of atrial fibrillation. J Cardiovasc Electrophysiol 15: 1467–1471
Verma A et al. (2004) Pulmonary vein antrum isolation: intracardiac echocardiography-guided technique. J Cardiovasc Electrophysiol 15: 1335–1340
Madrid AH et al. (2002) Use of irbesartan to maintain sinus rhythm in patients with long-lasting persistent atrial fibrillation: a prospective and randomized study. Circulation 106: 331–336
Pedersen OD et al. (1999) Trandolapril reduces the incidence of atrial fibrillation after acute myocardial infarction in patients with left ventricular dysfunction. Circulation 100: 376–380
Anne W et al. (2004) Atrial fibrillation after radiofrequency ablation of atrial flutter: preventive effect of angiotensin converting enzyme inhibitors, angiotensin II receptor blockers, and diuretics. Heart 90: 1025–1030
Goldstein RN et al. (2004) A new antiarrhythmic drug with predominant effects on the atria effectively terminates and prevents reinduction of atrial fibrillation and flutter in the sterile pericarditis model. J Cardiovasc Electrophysiol 15: 1444–1450
Vos MA (2004) Atrial-specific drugs: the way to treat atrial fibrillation? J Cardiovasc Electrophysiol 15: 1451–1452
Wolf PA et al. (1991) Atrial fibrillation as an independent risk factor for stroke: the Framingham Study. Stroke 22: 983–988
Hart RG et al. (1999) Antithrombotic therapy to prevent stroke in patients with atrial fibrillation: a meta-analysis. Ann Intern Med 131: 492–501
Flacker GC and Schutz J (2004) Why is warfarin underutilized in patients with atrial fibrillation? J Interv Card Electrophysiol 10: 21–25
Kowey PR et al. (2003) Overview of the management of atrial fibrillation: what is the current state of the art? J Cardiovasc Electrophysiol 14: S275–S280
Page RL et al. (2002) Bi-Card investigators: biphasic versus monophasic shock waveform for conversion of atrial fibrillation. The results of an international randomized, double-blind multicenter trial. J Am Coll Cardiol 39: 1956–1963
Alboni P et al. (2004) Outpatient treatment of recent onset atrial fibrillation with the “pill in the pocket” approach. N Engl J Med 351: 2384–2391
Boriani G et al. (2004) Pharmacological cardioversion of atrial fibrillation. Drugs 64: 2741–2762
Prystowsky EN and Katz A (2002) Atrial fibrillation. In Textbook of Cardiovascular Medicine, 1403–1408 (Ed Topol EJ) Philadelphia: Lippincott-Raven
Prystowsky EN et al. (2003) Clinical experience with dofetilide in the treatment of patients with atrial fibrillation. J Cardiovasc Electrophysiol 14: S287–S290
Roy D et al. (2000) Amiodarone to prevent recurrent of atrial fibrillation. Canadian Trial of Atrial Fibrillation Investigators. N Engl J Med 342: 913–920
Greenbaum RE et al. (1998) Conversion of atrial fibrillation and maintenance of sinus rhythm by dofetilide. The EMERALD (European and Australian Multicenter Evaluative Research on Atrial Fibrillation Dofetilide) study. Circulation 98 (Suppl 1): 633
Chimienti M et al. (1996) Flecainide and Propafenone Italian Study (FAPIS) Investigators: safety of long-term flecainide and propafenone in the management of patients with symptomatic paroxysmal atrial fibrillation: Report from the Flecainide and Propafenone Italian Study Investigators. Am J Cardiol 77: 60A–65A
Naccarelli GV et al. (1996) Flecainide Multicenter Atrial Fibrillation Study Group: prospective comparison of flecainide versus quinidine for the treatment of paroxysmal atrial fibrillation. Am J Cardiol 77: 53A–59A
Padanilam BJ and Prystowsky EN (2005) Atrial fibrillation—should ablation be first-line therapy and for whom: antagonist position. Circulation 112: 1223–1229
Packer DL et al. (2003) Progress in nonpharmacologic therapy of atrial fibrillation. J Cardiovasc Electrophysiol 14: S296–S309
Pappone C et al. (2003) Mortality, morbidity, and quality of life after circumferential pulmonary vein ablation for atrial fibrillation. J Am Coll Cardiol 42: 185–197
Corley SD et al. and the AFFIRM Investigators (2004) Relationship between sinus rhythm, treatment, and survival in the Atrial Fibrillation Follow-Up Investigation of Rhythm Management (AFFIRM) study. Circulation 109: 1509–1513
Hsu LF et al. (2004) Catheter ablation for atrial fibrillation in congestive heart failure. N Engl J Med 351: 2373–2383
Farsh R et al. (1999) Ventricular control in chronic atrial fibrillation during daily activity and programmed atrial fibrillation during daily activity and programmed exercise: a crossover open-label study of five drug regimes. J Am Coll Cardiol 33: 304–310
Atwood JE et al. (1987) Effect of β-adrenergic blockade on exercise performance in patients with chronic atrial fibrillation. J Am Coll Cardiol 10: 314–320
Steinberg JS et al. (1987) Efficacy of oral diltiazem to control ventricular response in chronic atrial fibrillation at rest and during exercise. J Am Coll Cardiol 9: 405–411
Lang R et al. (1983) Superiority of oral verapamil therapy to digoxin in treatment of chronic atrial fibrillation. Chest 83: 491–499
Lang R et al. (1983) Verapamil improves exercise capacity in chronic atrial fibrillation: double-blind crossover study. Am Heart J 105: 820–825
Olansky B et al. (2004) and the AFFIRM Investigators. The Atrial Fibrillation Follow-Up Investigation of Rhythm Management (AFFIRM) study. J Am Coll Cardiol 43: 1201–1208
Joshi AK et al. (2005) First experience with a Mobile Cardiac Outpatient Telemetry (MCOT) system for the diagnosis and management of cardiac arrhythmia. Am J Cardiol 95: 878–887
Kay GN et al. and the APT Investigators (1998) The Ablate and Pace trial: a prospective study of catheter ablation of the AV conduction system and permanent pacemaker implantation for treatment of atrial fibrillation. J Interv Card Electrophysiol 2: 121–135
Brignole M et al. (1997) Assessment of atrioventricular junction ablation and DDDR mode-switching pacemaker versus pharmacological treatment in patients with severely symptomatic paroxysmal atrial fibrillation. Circulation 96: 2617–2624
Wood MA et al. (2000) Clinical outcomes after ablation and pacing therapy for atrial fibrillation. A meta-analysis. Circulation 101: 1138–1144
Opolski G et al. for the Investigators of the Polish HOT CAFE Trial (2004) Rate control vs rhythm control in patients with nonvalvular persistent atrial fibrillation. The results of the Polish How to Treat Chronic Atrial Fibrillation (HOT CAFE) Study. CHEST 126: 476–486
Carlsson J et al. for the STAF Investigators (2003) Randomized trial of rate-control versus rhythm-control in persistent atrial fibrillation. The strategies of treatment of atrial fibrillation (STAF). J Am Coll Cardiol 41: 1690–1696
Hohnloser SH et al. for the PIAF Investigators (2000) Rhythm or rate control in atrial fibrillation—Pharmacological intervention in atrial fibrillation (PIAF): a randomized trial. Lancet 356: 1789–1794
Van Gelder IC et al. for the Rate Control Versus Electrical Cardioversion for Persistent Atrial Fibrillation Study Group (2002) A comparison of rate control and rhythm control in patients with recurrent persistent atrial fibrillation. N Engl J Med 347: 1834–1840
The Atrial Fibrillation Follow Up Investigation of Rhythm Management (AFFIRM) Investigators (2002) A comparison of rate control and rhythm control in patients with atrial fibrillation. N Engl J Med 347: 1825–1833
deDenus S et al. (2005) Rate vs rhythm control in patients with atrial fibrillation. Arch Intern Med 165: 258–262
Steinberg JS et al. and the AFFIRM Investigators (2004) Analysis of cause-specific mortality in the atrial fibrillation follow-up investigation of rhythm management (AFFIRM) study. Circulation 109: 1973–1980
Hejna M et al. (1999) Inhibition of metastases by anticoagulants. J Natl Cancer Inst 91: 22–36
The AFFIRM Investigators (2005) Quality of life in atrial fibrillation: the AFFIRM Study. Am Heart J 149: 112–120
Hagens VE et al. for the RACE Study Group (2004) Effect of rate or rhythm control on quality of life in persistent atrial fibrillation. J Am Coll Cardiol 43: 241–247
Hagens VE et al. for the RACE Study Group (2004) Rate control is more cost-effective than rhythm control for patients with persistent atrial fibrillation—results from the Rate Control versus Electrical Cardioversion (RACE) study. Eur Heart J 25: 1542–1549
Marshall AD et al. from the AFFIRM Investigators (2004) Cost-effectiveness of rhythm versus rate control for treatment of atrial fibrillation: Results from the AFFIRM study. Ann Intern Med 141: 653–661
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The authors appreciate the secretarial skills of MK Franklin in the preparation of this manuscript.
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Pelargonio, G., Prystowsky, E. Rate versus rhythm control in the management of patients with atrial fibrillation. Nat Rev Cardiol 2, 514–521 (2005). https://doi.org/10.1038/ncpcardio0320
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DOI: https://doi.org/10.1038/ncpcardio0320