The effects of rhythm control strategies versus rate control strategies for atrial fibrillation and atrial flutter: A systematic review with meta-analysis and Trial Sequential Analysis

Abstract

BackgroundAtrial fibrillation and atrial flutter may be managed by either a rhythm control strategy or a rate control strategy but the evidence on the clinical effects of these two intervention strategies is unclear. Our objective was to assess the beneficial and harmful effects of rhythm control strategies versus rate control strategies for atrial fibrillation and atrial flutter.MethodsWe searched CENTRAL, MEDLINE, Embase, LILACS, Web of Science, BIOSIS, Google Scholar, clinicaltrials.gov, TRIP, EU-CTR, Chi-CTR, and ICTRP for eligible trials comparing any rhythm control strategy with any rate control strategy in patients with atrial fibrillation or atrial flutter published before November 2016. Our primary outcomes were all-cause mortality, serious adverse events, and quality of life. Our secondary outcomes were stroke and ejection fraction. We performed both random-effects and fixed-effect meta-analysis and chose the most conservative result as our primary result. We used Trial Sequential Analysis (TSA) to control for random errors. Statistical heterogeneity was assessed by visual inspection of forest plots and by calculating inconsistency (I2) for traditional meta-analyses and diversity (D2) for TSA. Sensitivity analyses and subgroup analyses were conducted to explore the reasons for substantial statistical heterogeneity. We assessed the risk of publication bias in meta-analyses consisting of 10 trials or more with tests for funnel plot asymmetry. We used GRADE to assess the quality of the body of evidence.Results25 randomized clinical trials (n = 9354 participants) were included, all of which were at high risk of bias. Meta-analysis showed that rhythm control strategies versus rate control strategies significantly increased the risk of a serious adverse event (risk ratio (RR), 1.10; 95% confidence interval (CI), 1.02 to 1.18; P = 0.02; I2 = 12% (95% CI 0.00 to 0.32); 21 trials), but TSA did not confirm this result (TSA-adjusted CI 0.99 to 1.22). The increased risk of a serious adverse event did not seem to be caused by any single component of the composite outcome. Meta-analysis showed that rhythm control strategies versus rate control strategies were associated with better SF-36 physical component score (mean difference (MD), 6.93 points; 95% CI, 2.25 to 11.61; P = 0.004; I2 = 95% (95% CI 0.94 to 0.96); 8 trials) and ejection fraction (MD, 4.20%; 95% CI, 0.54 to 7.87; P = 0.02; I2 = 79% (95% CI 0.69 to 0.85); 7 trials), but TSA did not confirm these results. Both meta-analysis and TSA showed no significant differences on all-cause mortality, SF-36 mental component score, Minnesota Living with Heart Failure Questionnaire, and stroke.ConclusionsRhythm control strategies compared with rate control strategies seem to significantly increase the risk of a serious adverse event in patients with atrial fibrillation. Based on current evidence, it seems that most patients with atrial fibrillation should be treated with a rate control strategy unless there are specific reasons (e.g., patients with unbearable symptoms d...

Comparative occurrence of ischemic stroke with the rhythm versus rate control strategy in a national prospective cohort of atrial fibrillation

“…After the propensity score matched analysis for comparison between these treatment strategies, the incidence rate of ischemic stroke (0.1% vs. 1.0%) in [26,27]. Classic trials comparing the rate versus rhythm control strategy with only antiarrhythmic drugs such as the Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) trial, RAte Control versus Electrical cardioversion (RACE), and The Atrial Fibrillation and Congestive Heart Failure (AF-CHF) trial showed a non-statistically significant higher incidence of ischemic stroke in the rate control strategy, and recent comparisons of the differences between the rhythm and rate control strategy also showed that the occurrence of stroke seems to be similar with an overall odds ratio of 0.99 (95% confidence interval [CI], 0.75 to 1.30) and a risk ratio (RR) of 0.96 (95% CI, 0.68 to 1.34) [9,28,29].…”

Treatment strategies for new‐onset atrial fibrillation in critically ill patients: Protocol for a systematic review

“…Previous studies have not found superiority of rhythm control over rate control in broad patient populations with sustained types of AF 40‐42 . Moreover, some interventions could also worsen the outcome due serious adverse effects, 17,18 but the impact on patient‐important outcomes are unknown.…”

Gender differences in atrial fibrillation risk factors, presentation, and management in Tabuk, Kingdom of Saudi Arabia

“…Atrial fibrillation was diagnosed by cardiologists depending on clinical findings or irregular pulse and a pulse deficit of >15, the diagnosis was confirmed by electrocardiogram according to the American College of Cardiology Guidelines (10). The data were collected by the first and second authors.…”