Persistent atrial fibrillation: rate control or rhythm control. Rate control is not inferior to rhythm control

WITHDRAWN: Pharmacological cardioversion for atrial fibrillation and flutter

BACKGROUND

Atrial fibrillation is the commonest cardiac dysrhythmia. It is associated with significant morbidity and mortality. There are two approaches to the management of atrial fibrillation: controlling the ventricular rate or converting to sinus rhythm in the expectation that this would abolish its adverse effects.

OBJECTIVES

To assess the effects of pharmacological cardioversion of atrial fibrillation in adults on the annual risk of stroke, peripheral embolism, and mortality.

SEARCH METHODS

We searched the Cochrane Controlled Trials Register (Issue 3, 2002), MEDLINE (2000 to 2002), EMBASE (1998 to 2002), CINAHL (1982 to 2002), Web of Science (1981 to 2002). We hand searched the following journals: Circulation (1997 to 2002), Heart (1997 to 2002), European Heart Journal (1997-2002), Journal of the American College of Cardiology (1997-2002) and selected abstracts published on the web site of the North American Society of Pacing and Electrophysiology (2001, 2002).

SELECTION CRITERIA

Randomised controlled trials or controlled clinical trials of pharmacological cardioversion versus rate control in adults (>18 years) with acute, paroxysmal or sustained atrial fibrillation or atrial flutter, of any duration and of any aetiology.

DATA COLLECTION AND ANALYSIS

One reviewer applied the inclusion criteria and extracted the data. Trial quality was assessed and the data were entered into RevMan.

MAIN RESULTS

We identified two completed studies AFFIRM (n=4060) and PIAF (n=252). We found no difference in mortality between rhythm control and rate control relative risk 1.14 (95% confidence interval 1.00 to 1.31).Both studies show significantly higher rates of hospitalisation and adverse events in the rhythm control group and no difference in quality of life between the two treatment groups.In AFFIRM there was a similar incidence of ischaemic stroke, bleeding and systemic embolism in the two groups. Certain malignant dysrhythmias were significantly more likely to occur in the rhythm control group. There were similar scores of cognitive assessment.In PIAF, cardioverted patients enjoyed an improved exercise tolerance but there was no overall benefit in terms of symptom control or quality of life.

AUTHORS' CONCLUSIONS

There is no evidence that pharmacological cardioversion of atrial fibrillation to sinus rhythm is superior to rate control. Rhythm control is associated with more adverse effects and increased hospitalisation. It does not reduce the risk of stroke. The conclusions cannot be generalised to all people with atrial fibrillation. Most of the patients included in these studies were relatively older (>60 years) with significant cardiovascular risk factors.

Atrial fibrillation: Rhythm control offers no advantage over rate control for some, but not all

Atrial fibrillation (AF) is not a benign condition. Although AF is the most common sustained cardiac arrhythmia, the management of AF remains controversial. In recent years, several clinical trials comparing rhythm control with rate control for AF management found that rhythm control offers no advantage over rate control, but the findings may not apply equally to all patients. The main point is the high risk of AF recurrence in these trials and the toxic effects and poor efficacy of presently available antiarrhythmic drugs negate the benefit of rhythm control. Rhythm control should be considered as the preferred initial therapy if sinus rhythm had been maintained in a higher proportion of patients. For the moment, the optimal strategy to treat AF should be individualized, with a bias towards rate control if patients are at high risk for arrhythmias or can be kept asymptomatic. Rhythm control may still be justified in younger patients or patients who still have symptoms despite adequate rate control. In addition, patients with new or first-episode AF often warrant at least an initial trial of rhythm control.

Comparison of rate control and rhythm control in patients with atrial fibrillation after percutaneous mitral balloon valvotomy: a randomised controlled study

OBJECTIVE

To compare rate control and rhythm control strategies in patients with atrial fibrillation (AF) after percutaneous mitral balloon valvotomy (PMV).

METHODS

183 patients with AF after successful PMV, with AF duration <or= 12 months and post-PMV left atrial (LA) size <or= 45 mm, were studied in a prospective, randomised trial. The primary end point was improvement in AF-related symptoms. Secondary study end points were 6 min walk tests, quality of life (QOL), normalisation of LA size, number of hospital admissions and duration of hospital stay.

RESULTS

Over one year, 2% patients in the rate control group had sinus rhythm, as compared with 96% of patients in the rhythm control group (p < 0.001). A greater proportion of patients reported improvement in symptoms in the rhythm control group than in the rate control group (p < 0.0001 at every visit time). Walking distance in a 6 min walk test, QOL and LA size normalisation were better in the rhythm control group than in the rate control group. The strategy of rhythm control was associated with similar numbers of hospital admissions but with longer duration of hospital admissions. Drug-related side effect did not differ between the rate control and rhythm control groups. During the follow-up period, no patients in either group had embolic or transitory ischaemic neurological events.

CONCLUSIONS

In patients with AF after PMV, AF duration <or= 12 months and post-PMV LA size <or= 45 mm, sinus rhythm was easy and safe to achieve and maintain. Moreover, patients benefited from restoration and maintenance of sinus rhythm in terms of improved AF-related symptoms, 6 min walk tests and QOL, and of LA size normalisation. Rhythm control should therefore be considered as the preferred initial therapy for this group of patients. The optimal strategy to treat AF after PMV should be individualised.

Is atrial fibrillation an inflammatory disorder?

There is mounting evidence to support the influence of inflammation in the pathogenesis of atrial fibrillation (AF). Indeed, AF is associated with increased levels of known inflammatory markers, even after adjustment for confounding factors. The renin-angiotensin-aldosterone system (RAAS) appears to play a key role in this process. Atrial biopsies from patients with AF have also confirmed the presence of inflammation. Furthermore, there is preliminary evidence to support a number of drug therapies that have the potential to reduce the clinical burden of AF. In this review, we present an overview of the evidence supporting a link between inflammation and AF, and some of the drug therapies, such as the angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, steroids, fish oils, and vitamin C, that might be efficacious in the prevention of AF by modulating inflammatory pathways.

Rhythm vs. rate control of atrial fibrillation meta-analysed by number needed to treat

BACKGROUND

Whenever feasible, rhythm control of atrial fibrillation (AF) was generally preferred over rate control, in the belief that it offered better symptomatic relief and quality of life, and eliminated the need for anticoagulation. However, recent trials appear to challenge these assumptions.

AIMS

To explore the desirability of rhythm vs. rate control of AF by systematic review of pertinent, published, randomized controlled trials (RCTs) and a meta-analysis by number needed to treat (NNT) year(-1), with respect to diverse clinically important outcomes.

METHODS

RCTs of outcome primarily comparing rate vs. rhythm control in patients with spontaneous AF were identified. For each outcome and assuming rhythm control to be the active treatment, relative risk reduction (RRR) and NNT year(-1) were derived for individual trials together with an NNT year(-1) for all trials combined; corresponding 95% confidence intervals (CI) were also calculated. Adverse drug reaction (ADR) and quality of life reporting were also assessed.

RESULTS

In all, data from five suitable RCTs (entailing 5239 patients) were analysed. For hospitalization, available RRRs and NNT year(-1) values were all clinically and statistically significant. Overall, one additional patient was hospitalized for every 35 assigned to rhythm control (95% CI 27, 48). For the endpoints of death, 'ischaemic' stroke and 'non-CNS' bleeding, there was no significant difference. ADRs were significantly more common in rhythm control patients, whereas quality of life assessments revealed no difference. Thromboembolism was associated with cessation of or subtherapeutic anticoagulation, irrespective of treatment assignment.

CONCLUSION

Reduced risk of hospitalization and non-inferiority for other endpoints all favour rate control, the less costly strategy. If symptoms of AF are not a problem, treatment should target optimizing rate control and more widespread and effective prophylactic anticoagulation.

Pharmacological cardioversion for atrial fibrillation and flutter

BACKGROUND

Atrial fibrillation is the commonest cardiac dysrhythmia. It is associated with significant morbidity and mortality. There are two approaches to the management of atrial fibrillation: controlling the ventricular rate or converting to sinus rhythm in the expectation that this would abolish its adverse effects.

OBJECTIVES

To assess the effects of pharmacological cardioversion of atrial fibrillation in adults on the annual risk of stroke, peripheral embolism, and mortality.

SEARCH STRATEGY

We searched the Cochrane Controlled Trials Register (Issue 3, 2002), MEDLINE (2000 to 2002), EMBASE (1998 to 2002), CINAHL (1982 to 2002), Web of Science (1981 to 2002). We hand searched the following journals: Circulation (1997 to 2002), Heart (1997 to 2002), European Heart Journal (1997-2002), Journal of the American College of Cardiology (1997-2002) and selected abstracts published on the web site of the North American Society of Pacing and Electrophysiology (2001, 2002).

SELECTION CRITERIA

Randomised controlled trials or controlled clinical trials of pharmacological cardioversion versus rate control in adults (>18 years) with acute, paroxysmal or sustained atrial fibrillation or atrial flutter, of any duration and of any aetiology.

DATA COLLECTION AND ANALYSIS

One reviewer applied the inclusion criteria and extracted the data. Trial quality was assessed and the data were entered into RevMan.

MAIN RESULTS

We identified two completed studies AFFIRM (n=4060) and PIAF (n=252). We found no difference in mortality between rhythm control and rate control relative risk 1.14 (95% confidence interval 1.00 to 1.31). Both studies show significantly higher rates of hospitalisation and adverse events in the rhythm control group and no difference in quality of life between the two treatment groups. In AFFIRM there was a similar incidence of ischaemic stroke, bleeding and systemic embolism in the two groups. Certain malignant dysrhythmias were significantly more likely to occur in the rhythm control group. There were similar scores of cognitive assessment. In PIAF, cardioverted patients enjoyed an improved exercise tolerance but there was no overall benefit in terms of symptom control or quality of life.

AUTHORS' CONCLUSIONS

There is no evidence that pharmacological cardioversion of atrial fibrillation to sinus rhythm is superior to rate control. Rhythm control is associated with more adverse effects and increased hospitalisation. It does not reduce the risk of stroke. The conclusions cannot be generalised to all people with atrial fibrillation. Most of the patients included in these studies were relatively older (>60 years) with significant cardiovascular risk factors.

Warfarin for non-rheumatic atrial fibrillation: five year experience in a district general hospital

OBJECTIVES

To assess the long term efficacy of and risks associated with computer aided oral anticoagulation for non-rheumatic atrial fibrillation (NRAF) in a district hospital setting.

DESIGN

Retrospective, age stratified, event driven clinical database analysis.

SETTING

District general hospital.

PARTICIPANTS

739 patients receiving warfarin for NRAF between 1996 and 2001. Patients were selected from an anticoagulation database through appropriate filter settings.

MAIN OUTCOME MEASURES

Anticoagulation control (international normalised ratio (INR)) and hospitalisations for bleeding complications, thromboembolic events, and stroke.

RESULTS

Over 1484 patient-years, computer assisted anticoagulation was uncontrolled in 38.3% of patients (INR < 2.0 or > 3.0). No significant differences in INR control were observed with respect to patient age (< 65, 65-75, and > 75 years), although to achieve adequate control of anticoagulation, the frequency of testing increased significantly with age. Annual risks of bleeding complications, thromboembolism, and stroke were 0.76%, 0.35%, and 0.84%, respectively. No significant differences in these events were observed between the three age groups studied. Patients who had thromboembolic events and haemorrhagic complications were significantly more likely to have been under-anticoagulated (INR < 2.0) and over-anticoagulated (INR > 3.0), respectively, at the time of their clinical event.

CONCLUSIONS

Computerised long term oral anticoagulation for NRAF in a community setting of elderly and diverse patients is safe and effective. Anticoagulation control, bleeding events, thromboembolic episodes, and stroke rates are directly comparable with those reported in major clinical trials. The authors therefore support the strategy of rate control with long term oral anticoagulation for NRAF in general clinical practice.

Rate or rhythm control in persistent atrial fibrillation?

Atrial fibrillation (AF) is the most common sustained tachyarrhythmia encountered in clinical practice, with the majority of patients aged > 65 years. With an increasingly ageing population, the burden of AF in society continues to rise. One of the principal controversies in AF management is whether to control the ventricular rate and accept the underlying rhythm, or to attempt to achieve sinus rhythm. Until recently there were no clinical trial data directly comparing a rate versus rhythm strategy, and most physicians have opted for rhythm control, based on its theoretical benefits. We present an up-to-date evidence-based overview of the relative merits of rate versus rhythm control in AF, including data from five recent randomized trials. We draw conclusions from these studies and present evidence-based guidance on when to adopt which approach in routine clinical practice.