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41.18 Rate versus rhythm control therapy for atrial fibrillation
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Published:July 2018
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This version:November 2019
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Abstract
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.
Update:
In the interim since the first publication of this text, there have been three important clinical trials regarding rate versus rhythm control ...More
Update:
In the interim since the first publication of this text, there have been three important clinical trials regarding rate versus rhythm control in patients with atrial fibrillation. Two, CASTLE AF and CABANA, were ultimately disappointing, and one, CAMERA AF, was quite encouraging, but was relevant for a unique group of patients, those with atrial fibrillation and heart failure, the latter despite adequate ventricular rate control, but with no other cause for the heart failure except for the presence of atrial fibrillation.
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