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Should rhythm control be preferred in younger atrial fibrillation patients?

  • Shaojie ChenEmail author
  • Yuehui YinEmail author
  • Mitchell W. Krucoff
Article

Abstract

Purpose

Rate- and rhythm control are two fundamental strategies to treat atrial fibrillation (AF). However, there are inconsistent results between clinical trials about which treatment should be preferred. The aims of this study were to systematically summarize the clinical trials and compare rate- and rhythm control strategies regarding composite outcome of all cause mortality, worsening heart failure, and thromboembolic and bleeding events.

Methods

English and non-English studies that were published from 1966 onwards were included in this meta-analysis if they were prospective randomized controlled trials which compared rate- and rhythm control strategies in patients with AF. The individual and combined outcomes were analyzed quantitatively with odds ratio and 95 % confidence interval.

Results

Ten prospective randomized controlled trials with 7,876 patients were identified. There was no significant difference regarding primary composite outcome (11.47 vs. 11.03 % per year; odds ratio (OR), 1.03; 95 % confidence interval (CI), 0.90–1.20; P = 0.64) between rate- and rhythm control groups in overall age group. Meta-analysis for studies with mean age <65 years showed that rate control had significantly higher risk in primary composite outcome compared with rhythm control (8.74 vs. 4.80 % per year; OR, 1.89; 95 %CI, 1.26–2.86; P = 0.002).

Conclusions

A significant trend towards that rhythm control may be a preferable strategy for younger AF patients was observed in this study.

Keywords

Atrial fibrillation Treatment strategy 

Abbreviations

ACC

American College of Cardiology

AF

Atrial fibrillation

AHA

American Heart Association

CAD

Coronary artery disease

CI

Confidence interval

ESC

European Society of Cardiology

EH

Essential hypertension

NA

Not available

OR

Odds ratio

RCTs

Randomized controlled trials

Notes

Acknowledgments

We would like to acknowledge all the investigators in those clinical trials that we included in this study.

Conflict and interest

None.

References

  1. 1.
    Feinberg, W. M., Blackshear, J. L., Laupacis, A., Kronmal, R., & Hart, R. G. (1995). Prevalence, age distribution, and gender of patients with atrial fibrillation. Analysis and implications. Archives of Internal Medicine, 155, 469–473.PubMedCrossRefGoogle Scholar
  2. 2.
    Miyasaka, Y., Barnes, M. E., Gersh, B. J., Cha, S. S., Bailey, K. R., Abhayaratna, W. P., et al. (2006). Secular trends in incidence of atrial fibrillation in Olmsted County, Minnesota, 1980 to 2000, and implications on the projections for future prevalence. Circulation, 114, 119–125.PubMedCrossRefGoogle Scholar
  3. 3.
    Go, A. S., Hylek, E. M., Phillips, K. A., Chang, Y., Henault, L. E., Selby, J. V., et al. (2001). Prevalence of diagnosed atrial fibrillation in adults: national implications for rhythm management and stroke prevention: the Anti-coagulation and Risk Factors in Atrial Fibrillation (ATRIA) Study. Journal of the American Medical Association, 285, 2370–2375.PubMedCrossRefGoogle Scholar
  4. 4.
    Fuster, V., Rydén, L. E., Cannom, D. S., Crijns, H. J., Curtis, A. B., Ellenbogen, K. A., American College of Cardiology, American Heart Association Task Force, European Society of Cardiology Committee for Practice Guidelines, European Heart Rhythm Association, Heart Rhythm Society, et al. (2006). ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation: full text: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 guidelines for the management of patients with atrial fibrillation) developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society. Europace, 8, 651–745.PubMedCrossRefGoogle Scholar
  5. 5.
    Anonymous. (1991). Stroke prevention in atrial fibrillation study: final results. Circulation, 84, 527–539.CrossRefGoogle Scholar
  6. 6.
    Wyse, D. G., Waldo, A. L., DiMarco, J. P., Domanski, M. J., Rosenberg, Y., Schron, E. B., Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) Investigators, et al. (2002). A comparison of rate control and rhythm control in patients with atrial fibrillation. The New England Journal of Medicine, 347, 1825–1833.PubMedCrossRefGoogle Scholar
  7. 7.
    Hohnloser, S. H., Kuck, K. H., & Lilienthal, J. (2000). Rhythm or rate control in atrial fibrillation—Pharmacological Intervention in Atrial Fibrillation (PIAF): a randomised trial. Lancet, 356, 1789–1794.PubMedCrossRefGoogle Scholar
  8. 8.
    Carlsson, J., Miketic, S., Windeler, J., Cuneo, A., Haun, S., Micus, S., STAF Investigators, et al. (2003). Randomized trial of rate-control versus rhythm-control in persistent atrial fibrillation: the Strategies of Treatment of Atrial Fibrillation (STAF) study. Journal of the American College of Cardiology, 41, 1690–1696.PubMedCrossRefGoogle Scholar
  9. 9.
    Van Gelder, I. C., Hagens, V. E., Bosker, H. A., Kingma, J. H., Kamp, O., Kingma, T., Rate control versus electrical cardioversion for Persistent Atrial Fibrillation Study Group, et al. (2002). A comparison of rate control and rhythm control in patients with recurrent persistent atrial fibrillation. The New England Journal of Medicine, 347, 1834–1840.PubMedCrossRefGoogle Scholar
  10. 10.
    Opolski, G., Torbicki, A., Kosior, D. A., Szulc, M., Wozakowska-Kaplon, B., Kolodziej, P., Investigators of the Polish How to Treat Chronic Atrial Fibrillation Study, et al. (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.PubMedCrossRefGoogle Scholar
  11. 11.
    Okçün, B., Yigit, Z., Arat, A., & Küçükoglu, S. M. (2004). Comparison of rate and rhythm control in patients with atrial fibrillation and nonischemic heart failure. Japanese Heart Journal, 45, 591–601.PubMedCrossRefGoogle Scholar
  12. 12.
    Shelton, R. J., Clark, A. L., Goode, K., Rigby, A. S., Houghton, T., Kaye, G. C., et al. (2009). A randomised, controlled study of rate versus rhythm control in patients with chronic atrial fibrillation and heart failure: (CAFE-II Study). Heart, 95, 924–930.PubMedCrossRefGoogle Scholar
  13. 13.
    Roy, D., Talajic, M., Nattel, S., Wyse, D. G., Dorian, P., Lee, K. L., Atrial Fibrillation and Congestive Heart Failure Investigators, et al. (2008). Rhythm control versus rate control for atrial fibrillation and heart failure. The New England Journal of Medicine, 358, 2667–2677.PubMedCrossRefGoogle Scholar
  14. 14.
    Ogawa, S., Yamashita, T., Yamazaki, T., Aizawa, Y., Atarashi, H., Inoue, H., J-RHYTHM Investigators, et al. (2009). Optimal treatment strategy for patients with paroxysmal atrial fibrillation: J-RHYTHM study. Circulation Journal, 73, 242–248.PubMedCrossRefGoogle Scholar
  15. 15.
    Kanorskiĭ, S. G., Kruchinova, O. A., & Zingilevskiĭ, K. B. (2006). Advantages of restoration and maintenance of sinus rhythm in middle aged patients with atrial fibrillation and chronic heart failure. Kardiologiia, 46, 31–35.PubMedGoogle Scholar
  16. 16.
    Corley, S. D., Epstein, A. E., DiMarco, J. P., Domanski, M. J., Geller, N., Greene, H. L., et al. (2004). Relationships between sinus rhythm, treatment, and survival in the Atrial Fibrillation Follow-Up Investigation of Rhythm Management (AFFIRM) Study. Circulation, 109, 1509–1513.PubMedCrossRefGoogle Scholar
  17. 17.
    de Denus, S., Sanoski, C. A., Carlsson, J., Opolski, G., & Spinler, S. A. (2005). Rate vs rhythm control in patients with atrial fibrillation: a meta-analysis. Archives of Internal Medicine, 165, 258–262.PubMedCrossRefGoogle Scholar
  18. 18.
    Testa, L., Biondi-Zoccai, G. G., Dello Russo, A., Bellocci, F., Andreotti, F., & Crea, F. (2005). Rate-control vs. rhythm-control in patients with atrial fibrillation: a meta-analysis. European Heart Journal, 26, 2000–2006.PubMedCrossRefGoogle Scholar
  19. 19.
    Liberati, A., Altman, D. G., Tetzlaff, J., Mulrow, C., Gøtzsche, P. C., Ioannidis, J. P., et al. (2009). The PRISMA statement for reporting systematic reviews and meta-analysis of studies that evaluate healthcare interventions: explanation and elaboration. British Med J, 339, b2700.PubMedCrossRefGoogle Scholar
  20. 20.
    Hu, C. L., Jiang, H., Tang, Q. Z., Zhang, Q. H., Chen, J. B., Huang, C. X., et al. (2006). Comparison of rate control and rhythm control in patients with atrial fibrillation after percutaneous mitral balloon valvotomy: a randomised controlled study. Heart, 92, 1096–1101.PubMedCrossRefGoogle Scholar
  21. 21.
    Lee, J. K., Klein, G. J., Krahn, A. D., Yee, R., Zarnke, K., Simpson, C., et al. (2003). Rate-control versus conversion strategy in postoperative atrial fibrillation: trial design and pilot study results. Cardiac Electrophysiology Review, 7, 178–184.PubMedCrossRefGoogle Scholar
  22. 22.
    Lee, J. K., Klein, G. J., Krahn, A. D., Yee, R., Zarnke, K., Simpson, C., et al. (2000). Rate-control versus conversion strategy in postoperative atrial fibrillation: a prospective, randomized pilot study. American Heart Journal, 140, 871–877.PubMedCrossRefGoogle Scholar
  23. 23.
    Vora, A., Karnad, D., Goyal, V., Naik, A., Gupta, A., Lokhandwala, Y., et al. (2004). Control of rate versus rhythm in rheumatic atrial fibrillation: a randomized study. Indian Heart Journal, 56, 110–116.PubMedGoogle Scholar
  24. 24.
    Vora, A., Karnad, D., Goyal, V., Naik, A., Gupta, A., Lokhandwala, Y., et al. (2004). Control of heart rate versus rhythm in rheumatic atrial fibrillation: a randomized study. Journal of Cardiovascular Pharmacology and Therapeutics, 9, 65–73.PubMedCrossRefGoogle Scholar
  25. 25.
    Yildiz, A., Yigit, Z., Okcun, B., Baskurt, M., Ortak, K., Kaya, A., et al. (2008). Comparison of rate and rhythm control in hypertension patients with atrial fibrillation. Circulation Journal, 72, 705–708.PubMedCrossRefGoogle Scholar
  26. 26.
    Hohnloser, S. H., Crijns, H. J., Van Eickels, M., Gaudin, C., Page, R. L., Torp-Pedersen, C., et al. (2009). Effect of dronedarone on cardiovascular events in atrial fibrillation. The New England Journal of Medicine, 360, 668–678.PubMedCrossRefGoogle Scholar
  27. 27.
    Van Gelder, I. C., Groenveld, H. F., Crijns, H. J., Tuininga, Y. S., Tijssen, J. G., Alings, A. M., et al. (2010). Lenient versus strict rate control in patients with atrial fibrillation. The New England Journal of Medicine, 362, 1363–1373.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2012

Authors and Affiliations

  1. 1.Department of CardiologyThe Second Affiliated Hospital of Chongqing Medical UniversityChongqingChina
  2. 2.Duke University Medical CenterDurhamUSA
  3. 3.Duke Clinical Research InstituteDurhamUSA

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