Clinical Outcomes of Rate vs Rhythm Control for Atrial Fibrillation in Older People: A Systematic Review and Meta-Analysis

  • Laurence Depoorter
  • Liza Sels
  • Mieke Deschodt
  • Bastiaan Van Grootven
  • Lorenz Van der Linden
  • Jos TournoyEmail author
Systematic Review


Background and Objectives

Atrial fibrillation (AF) is highly prevalent in older adults and has been associated with increased morbidity and mortality. To reduce this AF-related morbidity in older adults, antiarrhythmic drugs (AADs) are regularly used for rhythm control, assuming that increasing time in sinus rhythm reduces AF-related morbidity. However, whether AADs can improve clinical outcomes in older adults remains unclear because of the increased risk for adverse drug events compared with rate control. The aim of this study was to determine the impact of rhythm control versus rate control on clinical outcomes in older adults with AF.

Design and Methods

We conducted a systematic review and meta-analysis targeting patients aged ≥65 years with AF and using drugs to control rate or rhythm. Articles that met the following criteria were included: enrolled older patients (sample mean ≥75 years) with AF, compared pharmacological rate versus rhythm control, and reported all-cause mortality, cardiovascular mortality, or ischemic stroke.


Five observational studies were included. In total, 86,926 patients with AF with a mean age ranging from 75 to 92 years were studied. No differences were found between rhythm and rate control for all-cause mortality (odds ratio [OR] 1.11; 95% confidence interval [CI] 0.78–1.59; I2 = 79.6%; n = 28,526; four studies) and cardiovascular mortality (OR 1.09; 95% CI 0.81–1.47; I2 = 0%; n = 2292; two studies). Rhythm control resulted in fewer strokes (OR 0.86; 95% CI 0.80–0.93; I2 = 0%; n = 59,496), although this was mainly determined by one study.


All collected data were observational, which precluded making strong recommendations. Furthermore, all CIs were wide, increasing the uncertainty of the observed effects. As such, evidence was insufficient to recommend rhythm or rate control as the first-line therapy for AF in older adults. As AF is particularly prevalent in older people, more randomized controlled trials are needed in this population.


Compliance with Ethical Standards


No external funding was used in the preparation of this manuscript.

Conflict of interest

L. Depoorter, L. Sels, M. Deschodt, and B. Van Grootven have no potential conflicts of interest that might be relevant to the contents of this manuscript. L. Van der Linden and J. Tournoy have received lecture or consulting fees from Pfizer, Bristol-Meyers Squibb, Bayer, and Daichii Sankyo.

Supplementary material

40266_2019_722_MOESM1_ESM.pdf (143 kb)
Supplementary file1 (PDF 143 kb)
40266_2019_722_MOESM2_ESM.pdf (101 kb)
Supplementary file2 (PDF 101 kb)


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Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  1. 1.Geriatric DepartmentUniversity Hospitals LeuvenLeuvenBelgium
  2. 2.Gerontology and Geriatrics, Department of Chronic Diseases, Metabolism and AgeingKU Leuven-University of LeuvenLeuvenBelgium
  3. 3.Nursing Science, Department of Public HealthUniversity of BaselBaselSwitzerland
  4. 4.Research Foundation FlandersBrusselsBelgium
  5. 5.Department of Public Health and Primary CareKU Leuven-University of LeuvenLeuvenBelgium
  6. 6.Pharmacy DepartmentUniversity Hospitals LeuvenLeuvenBelgium
  7. 7.Department of Pharmaceutical and Pharmacological SciencesKU LeuvenLeuvenBelgium

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