Current Evidence and Recommendations for Rate Control in Atrial Fibrillation

Abstract

Atrial fibrillation (AF) is the most common cardiac arrhythmia encountered in clinical practice.1 It has been estimated that >3 million people in the US and >4.5 million in the EU have paroxysmal or persistent AF.2-4 AF is associated with an approximately fivefold increased risk of stroke, 5 threefold risk of heart failure, 6 diminished quality of life 7 and increased healthcare costs. 8,9 Ventricular rate control strategy has been a traditional front-line and well-tolerated therapeutic option for the management of patients with AF.Although seemingly preferable in terms of potential advantages related to improved cardiac function and avoidance of unfavourable atrial electrical and mechanical remodelling, the currently available trial and other studies on the utility of dronedarone as a newer antiarrhythmic agent also suggest its limited efficacy and significant potential for adverse events. 11-13Catheter ablation, although generally superior to antiarrhythmic drug therapy in achieving SR, still remains limited by non-trivial recurrence rates for AF as well as the potential for procedural complications and the lack of currently available data on very long-term efficacy and mortality. [14][15][16][17][18] In the meantime, it continues to be an area of intensive research in terms of its role as an evolving therapeutic option to achieve sinus rhythm.In this review article we aim to discuss recommendations for ventricular rate control strategy in the management of patients with AF based on currently available data and the relevance of a rhythm control strategy with the advent of recent treatment advances in the field of antiarrhythmic drug therapy and catheter ablation. Rate ControlVentricular rate control has been an area of continuous investigation over the years. Until the results of Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) trial were published, rhythm control was widely believed to be a superior therapy with the rationale of SR being associated with better exercise tolerance, superior symptom control and possible decrease in morbidity (see Figure 1). 19 Despite these potential benefits of rhythm control, rate control was found to be non-inferior to rhythm control in the AFFIRM trial, with a trend toward reduced mortality with rate control. Results AbstractAtrial fibrillation (AF) is the most common cardiac arrhythmia encountered in clinical practice, which is associated with substantial risk of stroke and thromboembolism. As an arrhythmia that is particularly common in the elderly, it is an important contributor towards morbidity and mortality. Ventricular rate control has been a preferred and therapeutically convenient treatment strategy for the management of AF.Recent research in the field of rhythm control has led to the advent of newer antiarrhythmic drugs and catheter ablation techniques as newer therapeutic options. Currently available antiarrhythmic drugs still remain limited by their suboptimal efficacy and significant adverse effects. Catheter ablation as a newer modality...

Managing Atrial Fibrillation in Patients With Heart Failure and Reduced Ejection Fraction: A Scientific Statement From the American Heart Association

“…In patients with refractory AF with difficult-to-control ventricular rates, atrioventricular node ablation followed by permanent pacemaker implantation is a recognized treatment to alleviate symptoms and to improve outcomes. 89…”

“…In patients with refractory AF with difficult-to-control ventricular rates, atrioventricular node ablation followed by permanent pacemaker implantation is a recognized treatment to alleviate symptoms and to improve outcomes. 89 Although the role of CRT in patients with HFrEF, sinus rhythm, QRS duration >120 milliseconds, and NYHA class II, III, or ambulatory class IV HF on maximally tolerated medical therapy is established, its use and benefit in the setting of AF, narrow QRS, and HFrEF are not as well defined. AF can decrease the efficacy of CRT by reducing biventricular capture, and atrioventricular node ablation would ensure optimal biventricular pacing.…”

Inhibition of BKCanegatively alters cardiovascular function

“…It seems that many of the cardiac effects we observed were likely related to the BK Ca channels in SNACs and coronary arteries. This opens the door for BK Ca channels blockade as a means of antiarrhythmic control in patients who do not tolerate beta blockers or other classes of heart rate-controlling medications (Zimetbaum 2012;Maan et al 2013). An optimal dose of BK Ca channels blocker/inhibitor such as PAX could therapeutically lower heart rate without significantly affecting other cardiac variables could prove useful.…”

Diagnosis and Management of Atrial Fibrillation in Acute Ischemic Stroke in the Setting of Reperfusion Therapy: Insights and Strategies for Optimized Care

“…When AF is diagnosed, there are various options to achieve rhythm control (restoring sinus rhythm) and/or rate control (slowing the heart rate). Pharmacological rhythm control is useful in preventing AF progression and harmful remodelling, whilst rate control reduces hospitalisation but is less effective at resolving the arrhythmia itself [83]. Catheter ablation is a common procedure used to treat AF and is reported to have a higher success rate than pharmacological therapy [84][85][86][87].…”