INTRODUCTION — Atrial fibrillation (AF) is the most common sustained arrhythmia. It may cause significant symptoms that impair both functional status and quality of life. A key decision in the treatment of patients with AF is whether to institute a strategy primarily aimed at keeping the ventricular rate within a goal range or to do rhythm control in order to achieve and maintain sinus rhythm.
Advantages, disadvantages, and our preferences for rhythm and rate control, as well as whether there are subgroups of patients for whom one or the other should be preferred, will be discussed here.
The methods to achieve rhythm or rate control and the management of patients with AF and heart failure are discussed in detail separately. (See "Control of ventricular rate in patients with atrial fibrillation who do not have heart failure: Pharmacologic therapy".)
●Rhythm control – A rhythm-control strategy typically employs one or more of the following therapies to maintain sinus rhythm:
•Antiarrhythmic drug therapy (see "Antiarrhythmic drugs to maintain sinus rhythm in patients with atrial fibrillation: Recommendations")
•Electrical cardioversion (see "Atrial fibrillation: Cardioversion")
•Radiofrequency catheter ablation of the left atrium (see "Atrial fibrillation: Catheter ablation")
•Surgical ablation procedure performed at the time of open-heart surgery (see "Atrial fibrillation: Surgical ablation")
The following are reasons that rhythm control can fail, at least in the short term:
•Unsuccessful cardioversion – This includes failure to achieve sinus rhythm or immediate recurrence of AF after sinus rhythm has been restored (from an electrical cardioversion or catheter ablation of AF).
•AF recurrence – When AF recurs sometime after initial successful rhythm control.
●Rate control – A rate-control strategy uses one or more of the following strategies to keep the ventricular rate within a goal range:
•Medications that block (slow conduction through) the atrioventricular (AV) node such as beta blockers, rate-slowing nondihydropyridine calcium channel blockers, or digoxin.
•AV nodal ablation plus ventricular pacing to control symptoms is also considered when pharmacologic therapy is ineffective. This is used more rarely. (See "Atrial fibrillation: Atrioventricular node ablation".)
Rate control goals are discussed elsewhere. (See "Control of ventricular rate in patients with atrial fibrillation who do not have heart failure: Pharmacologic therapy", section on 'Evaluation and goal ventricular rate'.)
Definitions for different subtypes of AF, including paroxysmal and persistent, are described in detail separately. (See "Atrial fibrillation: Overview and management of new-onset atrial fibrillation", section on 'Classification and terminology'.) .
GOALS OF THERAPY
Preventing adverse cardiac remodeling — Although AF is not usually an acute life-threatening illness, it does cause a loss of the regular and effective left atrial contraction, short- and long-term deterioration in hemodynamics secondary to this increased heart rate, and loss of atrial contribution to cardiac output. These changes can lead to left atrial dilation and progressive dysfunction, as well as possible left ventricular dysfunction, which can reverse with restoration of sinus rhythm. (See "Hemodynamic consequences of atrial fibrillation and cardioversion to sinus rhythm" and "Arrhythmia-induced cardiomyopathy".)
Thus, both rate- and rhythm-control strategies are aimed at alleviating these pathophysiologic consequences or AF and alleviating a patient’s symptoms of AF.
For patients with AF, the long-term choice between rhythm or rate control should be made after a detailed shared decision-making discussion between patient and their provider(s) regarding the benefits and risks of each approach.
Prevention of cardiovascular disease and mortality — AF is associated with increased mortality and other sequelae. (See "Atrial fibrillation: Overview and management of new-onset atrial fibrillation", section on 'Sequelae'.)
Among high-cardiovascular-risk patients who are treated early in the course of their disease, rhythm control has been shown to improve cardiovascular outcomes and survival when compared with rate control. This is discussed in detail separately. (See 'High cardiovascular risk' below.)
Alleviation of symptoms — Symptoms of AF can include palpitations, dyspnea, lightheadedness, angina, decreased exercise tolerance, and near syncope. These can occur in patients with rate-controlled AF and those with rapid AF. Many patients with AF who are symptomatic will have a strong desire to be in sinus rhythm. For instance, among some physically active patients, being in AF rather than sinus rhythm can lower their exercise capacity . Many active individuals or those who need to carry out activities requiring optimal cardiac performance generally do not tolerate AF.
Even patients who are not physically active can be very symptomatic from AF and/or report low AF-related quality of life . For many such patients, the benefits of achieving and maintaining sinus rhythm outweigh the risks of a rhythm-control strategy. Still, not every patient will feel better when in sinus rhythm compared with AF.
Thromboembolic risk — While thromboembolism, especially stroke, is the most important adverse outcome of AF, prevention of thromboembolism is not a reason for choosing a rhythm- versus a rate-control strategy. Regardless of which strategy is chosen, patients remain at risk for thromboembolism, and each must undergo risk stratification to determine their thromboembolic and bleeding risks and whether antithrombotic therapy is indicated. This is discussed in detail separately. (See "Atrial fibrillation in adults: Use of oral anticoagulants".)
Studies are somewhat inconsistent in their findings as to whether rhythm-control therapy reduces embolic risk. Both the AFFIRM and RACE trials demonstrated that embolic events occurred with similar frequency regardless of whether a rate- or rhythm-control strategy was pursued. Furthermore, most embolic events (113 of 157 ischemic strokes in AFFIRM and 29 of 35 embolic events in RACE) occurred after warfarin had been stopped or when the international normalized ratio was subtherapeutic (less than 2) [3,4]. In contrast, the EAST-AF NET trial showed a lower risk of stroke for patients assigned to rhythm versus rate control; stroke risk was elevated in both groups compared with baseline stroke risk in patients without AF. These findings are discussed below. (See 'High cardiovascular risk' below.)
One reason that a rhythm-control approach may not reduce the embolic risk is that AF frequently recurs after treatment in 35 to 60 percent at one year with intermittent monitoring (figure 1) [5,6] and in up to 88 percent of those with continuous monitoring for more than 18 months on antiarrhythmic therapy . In the AFFIRM trial described below, there was a high crossover rate from rhythm to rate control (17 and 38 percent of patients at one and five years), due primarily to an inability to maintain sinus rhythm and drug intolerance .
URGENT MANAGEMENT — The clinical decision regarding whether to employ a rate- versus rhythm-control strategy in the urgent setting is required for patients who are clinically unstable. Unstable patients with AF include those with hypotension, altered mental status, ischemia, heart failure, cardiogenic shock, or very rapid ventricular rates (eg, patients with preexcitation and anterograde conduction of AF through an accessory pathway). (See "Atrial fibrillation: Overview and management of new-onset atrial fibrillation", section on 'Unstable patients' and "Wolff-Parkinson-White syndrome: Anatomy, epidemiology, clinical manifestations, and diagnosis" and "Treatment of arrhythmias associated with the Wolff-Parkinson-White syndrome".)
In most patients who require urgent management, we first employ a rate-control strategy. Exceptions are if the patient is hemodynamically unstable and successful ventricular rate control cannot be achieved.
The decision about rate or rhythm control may change once the patient becomes stable and requires long-term management of AF. (See 'Elective and long-term management' below.)
ELECTIVE AND LONG-TERM MANAGEMENT
Indications for initial rhythm control
Symptomatic patients — Alleviation of symptoms from AF despite adequate ventricular rate control is a major pillar of management of the patient with AF. Therefore, we try an initial rhythm-control strategy. For some patients who are highly symptomatic, AF can limit activity and adversely affect quality of life even for those without a rapid heart rate. For such patients, it is reasonable to attempt a long-term rhythm-control strategy. Typically, a rate-control strategy may alleviate some of the symptoms of AF, especially at rest, but commonly a decline in exercise tolerance remains, often due to rapid rise of heart rate with exertion. In addition, for some patients, loss of atrial contribution to cardiac output can play a major role in symptoms. (See 'Alleviation of symptoms' above.)
Quality-of-life scores have been assessed as substudies of some randomized AF trials. The Canadian Trial of Atrial Fibrillation (CTAF) randomized persistent AF patients to either amiodarone or propafenone . The authors found that by three months, global well-being was significantly worse for patients who had recurrent AF compared with those who did not. In addition, they noted the main clinical variable that correlated with improved subjective quality of life was restoration and maintenance of sinus rhythm. The RACE study randomized patients to rate versus rhythm control. The quality-of-life substudy demonstrated that patients with AF had worse quality of life compared with healthy controls . The treatment strategy did not affect quality of life. However, the presence of sinus rhythm at the end of the follow-up interval (instead of the assigned strategy) was associated with an improvement in quality of life.
Age ≤80 years — Younger patients generally have fewer side effects with pharmacologic rhythm control and catheter ablation compared with older patients. Younger patients are also less likely to have permanent AF, which increases the likelihood of a successful cardioversion and maintenance of sinus rhythm. Also, in younger patients, there is concern that being in AF for longer may lead to adverse long-term consequences such as adverse cardiac remodeling.
High cardiovascular risk — We prefer rhythm control for any patient, regardless of symptoms, who is at high risk for cardiovascular disease. High risk for cardiovascular disease is defined age >80 years, prior transient ischemic attack or stroke, or two of the following criteria: age >65 years, female sex, heart failure, hypertension, diabetes, severe coronary artery disease, chronic kidney disease, and left ventricular hypertrophy (diastolic septal wall width >15 mm). It is important to mention that these age cutoffs provide guidance but are not meant to be absolute. The management of AF in patients with heart failure is discussed in detail separately (See "The management of atrial fibrillation in patients with heart failure", section on 'Preference for rhythm over rate control' and 'Patient preference' below.)
●Higher survival with early (within 12 months of initial AF diagnosis) rhythm control in patients who are at high risk for cardiovascular disease outcome in the EAST-AF NET trial – The EAST-AFNET 4 trial demonstrated slightly improved survival with rhythm control in 2789 high-cardiovascular-risk patients if this strategy is employed within 12 months of the initial diagnosis . High risk was defined as >75 years of age, prior transient ischemic attack or stroke, or two of the following criteria: age >65 years, female sex, heart failure, hypertension, diabetes, severe coronary artery disease, chronic kidney disease, and left ventricular hypertrophy (diastolic septal wall width >15 mm). This study randomly assigned patients with early AF (diagnosed ≤12 months before enrollment; median time since diagnosis, 36 days) to either early rhythm control with antiarrhythmic drugs or ablation or to usual care, which limited rhythm control to patients with unacceptable symptoms after rate control. The trial was stopped early for efficacy after a median of 5.1 years of follow-up. The following findings were reported:
•The primary composite outcome (eg, cardiovascular death, stroke, or serious adverse events related to rhythm-control therapy) occurred less often with rhythm control versus usual care (249 versus 316 events; 3.9 versus 5 events per 100 person-years; hazard ratio [HR] 0.79; 95% CI 0.66-0.94).
•Death from cardiovascular causes occurred less often in the rhythm-control group (67 versus 94 events; 1 versus 1.3 percent; HR 0.72; 95% CI 0.52-0.98).
•Stroke occurred less often in the rhythm-control group (40 versus 62 events; 0.6 versus 0.9 percent; HR 0.65; 95% CI 0.44-0.97). Causal mediation analysis in this study showed that sinus rhythm at 12 months explained 81 percent of the treatment benefit of early rhythm control therapy on stroke reduction during the remainder of follow-up.
•More than 70 percent of patients were asymptomatic in both treatment groups at one and two years.
•There was no significant difference between the two groups in the rate of the primary safety outcome (eg, death, stroke, and serious adverse event related to the rhythm-control strategy).
•Serious adverse events related to rhythm-control therapy were uncommon but were more frequent in the rhythm-control group (4.9 versus 1.4 percent).
●EAST-AF NET trial results did not differ according to the presence of symptoms – In a post-hoc analysis of EAST-AFNET4, rates of the primary composite outcome did not differ between asymptomatic and symptomatic patients . Among asymptomatic patients, patients randomized to early rhythm control had lower risk of the primary composite outcome compared with those assigned to usual care (HR 0.76; 95% CI 0.6-1.03) that was not statistically significant. Among symptomatic patients, a similar benefit from early rhythm control was seen (HR 0.79; 95% CI 0.6-0.98). The study was not powered to detect a difference between patients with and without symptoms. However, this does suggest that symptoms may be underreported by patients with AF, and there is some clinical improvement with maintaining sinus rhythm.
●Early studies suggested a higher mortality with pharmacologic rhythm versus rate control, whereas later meta-analyses show equivalent outcomes – This is discussed separately. (See '>80 years, asymptomatic, and low cardiovascular disease risk' below.)
Heart failure — This is discussed in detail separately. (See "The management of atrial fibrillation in patients with heart failure".)
Initial cardioversion — For the majority of patients with persistent AF, we try rhythm control with early cardioversion as the initial elective or long-term management strategy (algorithm 1) . Many patients undergoing rhythm control may still require long-term rate-slowing drugs (in the event of return to AF), as well as chronic antithrombotic therapy. (See "Atrial fibrillation in adults: Use of oral anticoagulants" and "Atrial fibrillation in adults: Selection of candidates for anticoagulation".)
Rhythm control can also be achieved with pharmacologic (ie, antiarrhythmic drug therapy and/or pharmacologic cardioversion) or nonpharmacologic methods (ie, electrical cardioversion, catheter, or surgical ablation). These approaches are discussed in detail separately.
Unsuccessful initial cardioversion or AF recurrence — A minority of patients will have an unsuccessful cardioversion, and some can experience early AF recurrence. If a patient does not convert successfully to sinus rhythm after cardioversion, further treatment strategy depends on the patient’s symptom burden, age, and comorbidities.
Age >80 years and low cardiovascular disease risk — We switch to rate control in these patients. This is discussed in detail separately. (See '>80 years, asymptomatic, and low cardiovascular disease risk' below.)
Age ≤80 years and/or high cardiovascular disease risk — In these patients, we will continue with a rhythm-control strategy and add an antiarrhythmic medication or pursue a catheter ablation. These are discussed in detail separately.
We reassess patient comorbidities, age, and preferences during routine follow-up. This will inform continuation with rhythm control versus switching to a rate-control strategy.
Rate control — This can be done with oral beta blocker, rate-slowing nondihydropyridine calcium channel blocker, or with use of digoxin. This is discussed in detail separately. (See "Control of ventricular rate in patients with atrial fibrillation who do not have heart failure: Pharmacologic therapy".)
For selected patients who do not respond to pharmacologic rate control, AV node ablation with pacing is another option for rate control of AF. This is discussed in detail separately. (See "Atrial fibrillation: Atrioventricular node ablation".)
>80 years, asymptomatic, and low cardiovascular disease risk — In this group of patients with AF, we pursue a rate-control strategy; this is particularly true if the patient has long-standing or recurrent AF. Patients over age 80 account for approximately 35 percent of patients with AF, and the prevalence of AF in this group is about 10 percent (figure 2) . In the group of patients >80 years of age who are asymptomatic and at low risk of cardiovascular disease, we choose rate control for the following reasons:
●Less side effects with rate control – There are more potential side effects from rhythm than with rate control. Patients >80 years of age are more sensitive to the proarrhythmic effects of antiarrhythmics. These include proarrhythmia that can occur with antiarrhythmic drugs [14,15] and vascular and other procedural complications that can result from catheter ablation.
●Early studies suggested a lower mortality with rate versus pharmacologic rhythm control, whereas later meta-analyses show equivalent outcomes – Two trials that were conducted prior to the widespread use of catheter ablation suggested that pharmacologic rhythm control was associated with higher mortality than rate control. Among patients with long-standing AF, the results from AFFIRM and RACE show at least equivalent and possibly better outcomes with rate compared with rhythm control with antiarrhythmic medications (figure 3 and figure 4) [3,4]. Half of the patients in AFFIRM had a low symptom burden, with symptoms of AF occurring less than once a month . A subsequent meta-analysis of five trials comparing rate versus pharmacologic rhythm control, in which AFFIRM accounted for 77 percent of the patients, showed a trend toward a reduction in all-cause mortality with rate control (13 versus 14.6 percent with rhythm control; odds ratio 0.87; 95% CI 0.74-1.02) . The proportion of patients who had an ischemic stroke was similar with the two approaches (3.5 versus 3.9 percent). An important caveat is that these studies were conducted prior to the widespread use of catheter ablation as a rhythm-control method.
At least seven randomized trials have compared rate and rhythm control using antiarrhythmic drug therapy in a broad population of patients with AF [3,4,17-19]. In the aggregate, these studies demonstrated equivalent health outcomes (such as the rates of death or embolism) in both arms. One trial demonstrated improved quality-of-life scores with rhythm control .
Unsuccessful pharmacologic rate control — In selected patients who do not respond adequately and/or cannot tolerate pharmacologic rate control, we consider switching to either a rhythm-control strategy or ablation of the AV node with pacemaker implant. We generally prefer use of antiarrhythmics or catheter ablation of AF to maintain sinus rhythm over an ablate-and-pace strategy for younger patients or those without a long history of AF. For older patients or those with significant comorbidities, long history of AF, or very large atria, AV node ablation and physiologic pacing (His bundle or left bundle pacing) may be preferable given the lower likelihood of being able to maintain sinus rhythm. (See "Atrial fibrillation: Atrioventricular node ablation" and "Atrial fibrillation: Catheter ablation" and 'Failure of rate control' below.)
Changing management strategies — In patients with AF, there are several reasons we may make a switch from rate to rhythm control or vice versa.
Patient preference — One reason for making a switch is if the patient expresses a strong preference for trying another approach. For example, some patients will have a strong preference to be in sinus rhythm due to persistent symptoms with a rate-control strategy. Long-term monitoring to assess the adequacy of rate control is useful to confirm adequacy of ventricular rate control and/or that symptoms correlate with rapid ventricular rates. It is reasonable to try a given approach for a few months and no longer than one year prior to considering switching approaches. (See 'Alleviation of symptoms' above.)
Failure of rhythm control — Rhythm control has the highest chance of success if the patient has been in AF for less than one year continuously. This is because the AF-related atrial structural and electrical cardiac remodeling are less pronounced if the duration of AF is <1 year.
If a patient does not respond to rhythm control after a reasonable attempt, we may decide to pursue rate control instead. Another reason to switch to rate control would be due to medication side effects or intolerances (eg, antiarrhythmics).
There is a substantial rate of recurrent AF and frequent crossover to a rate-control strategy when antiarrhythmic drugs are used for maintenance therapy after conversion to sinus rhythm. Recurrence is detected clinically in 20 to 60 percent at one year (figure 1) . Furthermore, a study of patients who had continuous electrocardiographic monitoring found that recurrent episodes occurred in approximately 90 percent of people; many of these episodes were asymptomatic, including some lasting more than 48 hours . The risk of recurrent AF is highest in patients who have hypertension, an enlarged left atrium, AF for more than one year, or heart failure .
Failure of rate control — In patients who do not respond adequately to initial rate control, we may switch to a rhythm-control strategy. Clinical scenarios that signal the failure of rate control are described below:
●Bothersome symptoms – Some patients have persistent palpitations, dyspnea, lightheadedness, angina, and near syncope despite adequate rate control. In these patients we often try a rhythm-control strategy. (See "Hemodynamic consequences of atrial fibrillation and cardioversion to sinus rhythm".)
●Inability to achieve adequate rate control – In patients who cannot achieve low enough resting or exertional heart rates despite therapy, we prefer rhythm control in order to prevent tachycardia-mediated cardiomyopathy). (See "Arrhythmia-induced cardiomyopathy" and "Control of ventricular rate in patients with atrial fibrillation who do not have heart failure: Pharmacologic therapy", section on 'Evaluation and goal ventricular rate'.)
RECOMMENDATIONS OF OTHERS — Recommendations regarding the choice between rate and rhythm control are available from the American Heart Association/American College of Cardiology (2014, 2019) and the European Society of Cardiology (2016) [23-26].
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Atrial fibrillation" and "Society guideline links: Arrhythmias in adults".)
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, “The Basics” and “Beyond the Basics.” The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on “patient info” and the keyword(s) of interest.)
●Beyond the Basics topic (see "Patient education: Atrial fibrillation (Beyond the Basics)")
SUMMARY AND RECOMMENDATIONS
●Rationale and goals of therapy – Both rate- and rhythm-control strategies are aimed at alleviating pathophysiologic consequences or symptoms and atrial fibrillation (AF). Patients with AF are at increased risk for stroke and other embolic events from left atrial thrombi; however, neither rate nor rhythm control has great efficacy at preventing this consequence. (See 'Goals of therapy' above.)
●Urgent management – We prefer to use rate rather than rhythm control for the acute management of new-onset AF, acute episodes of paroxysmal AF, and for long-standing AF with rapid ventricular rates. (See 'Urgent management' above.)
●Elective and long-term management
•Goals of therapy – For patients with AF, the long-term choice between rhythm or rate control should be made after a detailed shared decision-making discussion between the patient and their provider(s) regarding the benefits and risks of each approach. Important factors to consider in this discussion are patient symptoms, quality of life, and any potential cardiovascular, mortality and safety benefits associated with the chosen strategy. In many cases, the benefits and risks will be closely balanced, and either strategy will be a reasonable choice.
All patients with AF, irrespective of rate versus rhythm control, must undergo risk stratification for their thromboembolic and bleeding risks and be considered for antithrombotic therapy; this is discussed in detail separately. (See "Atrial fibrillation in adults: Use of oral anticoagulants".)
•Preference for rhythm control – For patients who are at high risk for cardiovascular disease and especially if the patient is symptomatic, we suggest a rhythm- rather than a rate-control strategy, provided it can be initiated within 12 months of AF onset (algorithm 1) (Grade 2C). High risk is defined as >80 years of age, prior transient ischemic attack or stroke, or two of the following criteria: age >65 years, female sex, heart failure, hypertension, diabetes, severe coronary artery disease, chronic kidney disease, and left ventricular hypertrophy (diastolic septal wall width >15 mm). (See 'High cardiovascular risk' above.)
We also suggest initial cardioversion in patients with symptoms (for symptom relief) and in patients who are <80 years of age (since they have a higher likelihood of maintaining sinus rhythm after a cardioversion). (See 'Symptomatic patients' above and 'Age ≤80 years' above.)
For patients who have an unsuccessful initial cardioversion, if they are ≤80 years of age and at high cardiovascular disease risk, we will continue with a rhythm-control strategy and add an antiarrhythmic medication or pursue a catheter ablation to maintain sinus rhythm. If they are >80 years of age and at low cardiovascular disease risk, we switch to rate control. (See 'Unsuccessful initial cardioversion or AF recurrence' above.)
•Preference for rate control
-In selected patients who do not respond adequately and/or cannot tolerate pharmacologic rate control, we consider switching to a rhythm-control strategy. (See 'Unsuccessful pharmacologic rate control' above.)
•Changing management strategies – If a patient has a strong preference to pursue another management strategy, or if there is a failure of the initial chosen strategy after a reasonable attempt, we often switch to another approach. (See 'Changing management strategies' above.)
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