How to Choose Between Rate and Rhythm Control Strategy
AbstractAtrial fibrillation (AF) is common and highly variable in its clinical presenta-tion and evolution. Iit causes substantial morbidity and mortality, including impaired quality of life, heart failure, systemic emboli, and stroke. An ac-curate diagnosis is important and should be distinguished from atrial flutter or other arrhythmias which involves the atrium. Management of patients with AF involves 3 objectives: rate control, rhythm control, and prevention of thromboembolism. A rate control strategy alone, without attempts at restoration or maintenance of sinus rhythm (SR), is reasonable in some patients with AF, especially those who are asymptomatic. In some circum-stances, when the cause of AF is reversible, such as when AF occurs after cardiac surgery, no long-term therapy may be necessary. The CHADS2 scoring system can be used to risk stratify patients with nonvalvular AF to determine the need for warfarin. The risk of thromboembolism or stroke does not differ between pharmacological and electrical CV. Ablation of the AV conduction system and permanent pacing is an option for patients with rapid ventricular rates despite maximum medical therapy. However, there is growing concern about the negative effects of long-term RV pac-ing. Biventricular pacing may overcome many of the adverse hemodynamic effects associated with RV pacing. Pharmacological therapy to maintain SR should be considered in patients who have troublesome symptoms. Drugs should be used to decrease the frequency and duration of episodes, and to improve symptoms. AF recurrence while taking an antiarrhythmic drug is not indicative of treatment failure and does not necessitate a change in antiarrhythmic therapy. Antiarrhythmic drug choice is based on side effect profiles and the presence or absence of structural heart disease, heart failure, and hypertension. Catheter ablation for AF is currently considered a second-line therapy in highly symptomatic patients in whom one or more antiarrhythmic agents have failed.
ACC/A?A/ESC 2006 guidelines for the management of patients with atrial fibrillation. Circulation. 2006;114:e257-354.
National Institute for ?ealth and Clinical Excellence (NICE). Atrial fibrillation. (Clinical guideline CG36.) 2006. www.nice.org.uk/Guidance/CG36.
Knight BP, Sorrentino M, Delaughter MC, Shah DP. Practical Rate and Rhythm Management of Atrial Fibrillation. Pocket Guide ?eart Rhythm Society 2010.
Lafuente-Lafuente C, Mouly S, Longas-Tejero MA, Bergmann JF. Antiarrhythmics for maintaining sinus rhythm after cardioversion of atrial fibrillation. Cochrane Database Syst Rev. 2007;(4):CD005049
Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) Investigators; Wyse DG, Waldo AL, DiMarco JP, Domanski MJ, Rosenberg Y, et al. A comparison of rate control and rhythm control in patients with atrial fibrillation (the AFFIRM STUDY). N Engl J Med. 2002;347:1825-33.
Atrial Fibrillation and Congestive ?eart Failure (AF-C?F) Investigators; Roy D, Talajic M, Nattel S, Wyse DG, Dorian P, et al. Rhythm control versus rate control for atrial fibrillation and heart failure. N Engl J Med. 2008;358:2667-77.
De Denus S, Sanoski CA, Carlsson J, Opolski G, Spinler SA. Rate vs rhythm control in patients with atrial fibrillation: a meta-analysis. Arch Intern Med. 2005;165:258-62.
Testa L, Biondi-Zoccai GG, Russo AD, Bellocci F, Andreotti F, Crea F. Rate-control vs rhythm-control in patients with atrial fibrillation: a meta-analysis. Eur Heart J. 2005;26:2000-6.
Lafuente-Lafuente C, Mahe I, Extramiana F. Management of atrial fibrillation. BMJ. 2010: 340: 40-45.
AFFIRM Investigators. The atrial fibrillation follow-up investigation of 5 rhythm management (AFFIRM) study: approaches to control rate in atrial fibrillation. J Am Coll Cardiol. 2004;43:1201-8.
Hagens VE, Ranchor AV, Van Sonderen E, Bosker ?A, Kamp O, Tijssen JG, Kingma J?, Crijns ?J, Van Gelder IC. Effect of rate or rhythm control on quality of life in persistent atrial fibrillation. Results from the Rate Control versus Electrical Cardioversion (RACE) Study. J Am Coll Cardiol. 2004;43: 241–247.
ACTIVE Investigators; Connolly SJ, Pogue J, Hart RG, Hohnloser S?, Pfeffer M, et al. Effect of clopidogrel added to aspirin in patients with atrial fibrillation. N Engl J Med. 2009;360:2066-78.
Gage BF, Waterman AD, Shannon W, Boechler M, Rich MW, Radford MJ. Validation of clinical classification schemes for predicting stroke: results from the National Registry of Atrial Fibrillation. JAMA. 2001;285:2864-70.
Segal JB, McNamara RL, Miller MR, Kim N, Goodman SN, Powe NR, Robinson K, Yu D, Bass EB. The evidence regarding the drugs used for ventricular rate control. J Fam Pract. 2000;49:47-59.
Wood MA, Brown-Mahoney C, Kay GN, Ellenbogen KA. Clinical outcomes after ablation and pacing therapy for atrial fibrillation: a meta-analysis. Circulation. 2000;101:1138-44.
Haïssaguerre M, Jaïs P, Shah DC, Takahashi A, Hocini M, Quiniou G, Garrigue S, Le Mouroux A, Le Métayer P, Clémenty J. Spontaneous initiation of atrial fibrillation by ectopic beats originating in the pulmonary veins. N Engl J Med. 1998;339:659-66.
ATHENA Investigators; ?ohnloser S?, Crijns HJ, van Eickels M, Gaudin C, Page RL, et al. Effect of dronedarone on cardiovascular events in atrial fibrillation. N Engl J Med. 2009;360:668-78.
Alboni P, Botto GL, Baldi N, Luzi M, Russo V, Gianfranchi L, Marchi P, Calzolari M, Solano A, Baroffio R, Gaggioli G. Outpatient treatment of recent-onset atrial fibrillation with the “pill-in-the-pocket” approach. N Engl J Med. 2004;351:2384-2391.
Noheria A, Kumar A, Wylie Jr, Josephson ME. Catheter ablation vs 26 antiarrhythmic drug therapy for atrial fibrillation: a systematic review. Arch Intern Med. 2008;168:581-586.
Jaïs P, Cauchemez B, Macle L, Daoud E, Khairy P, Subbiah R, ?ocini M, Extramiana F, Sacher F, Bordachar P, Klein G, Weerasooriya R, Clémenty J, ?aïssaguerre M. Catheter ablation versus antiarrhythmic drugs for atrial fibrillation: the A4 study. Circulation. 2008;118:2498-2505.
PABA-C?F Investigators; Khan MN, Jaïs P, Cummings J, di Biase L, Sanders P, et al. Pulmonary-vein isolation for atrial fibrillation in patients with heart failure. N Engl J Med. 2008;359:1778-85.
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