What Should be the Primary Treatment in Atrial Fibrillation: Ventricular Rate Control or Sinus Rhythm Control with Long-term Anticoagulation?

Abstract

Recent trials have favoured ventricular rate control in atrial fibrillation (AF) management, however the present study investigated whether the restoration and maintenance of sinus rhythm with longterm anticoagulation therapy was superior in terms of embolic events and death in 534 patients with an AF duration > 48 h. Patients were randomized and received sinus rhythm control with either aspirin (group 1) or warfarin (group 2), or they were given ventricular rate control (group 3). Cardioversion to sinus rhythm was attempted in 425 patients and was successful in 387 (91.1%) of them. After 3 years' follow-up there were 12, two and 15 embolic events in groups 1, 2 and 3 respectively (significant difference between groups 1 and 2, and 2 and 3) and overall mortalities were four, two and 12, respectively (significant difference between groups 2 and 3). It is concluded that patients with an AF duration > 48 h might benefit considerably from sinus rhythm restoration and long-term warfarin therapy in terms of embolic events and mortality.

Comparative effectiveness of antiarrhythmic drugs on cardiovascular hospitalization and mortality in atrial fibrillation

“…Nineteen (50%) out of the 38 identified articles evaluated individual AADs [13,[16][17][18][19][20][21][22][23][24][25][26][27][28][29][30][31][32][33] and 13 studies (34%) compared multidrug strategies of rate versus rhythm control [34][35][36][37][38][39][40][41][42][43][44][45][46]. The remaining six articles (16%) evaluated multiple agents but did not report outcomes for individual agents [47][48][49][50][51][52].…”

“…Amiodarone 1 [27] 3 [18, 28,31] 2 [25,30] -3 [25,27,31] 3 [18, 28,30] Azimilide 1 [22] Other studies that reported a statistically significant reduction in an end point related to CV mortality or CV hospitalization were rated as fair [21] or poor quality (table 4) [17,23,30].…”

“…When end points related to CV mortality were subcategorized according to specific outcomes, most (13) publications reported arrhythmia-associated mortality (table 3) [13,[17][18][19][20][22][23][24][25][26][27]30,31]. Out of these 13 articles, six reported studies were judged to be good quality by the AHRQ CER criteria [13,17,[22][23][24]27].…”

“…Despite being of generally fair/good quality, most studies reporting the effects of AADs on end points related to CV mortality (18 out of 29) [17-20, [22][23][24][28][29][30]32,36,[38][39][40][41]44,46] had poor applicability to the CER objective of assessing AAD efficacy on CV mortality in paroxysmal/persistent AF in comparison with dronedarone's results in the ATHENA trial [13]. Most studies were conducted in noncomparable populations or examined narrow end points (i.e., mortality owing to one specific CV cause, e.g., heart failure).…”

“…Out of the 29 articles reporting end points related to CV mortality, 15 examined the effects of individual AADs (amiodarone, azimilide, dofetilide, dronedarone, propafenone, quinidine and sotalol; table 2) [13,[17][18][19][20][22][23][24][25][26][27][28][29][30][31]. Eight studies evaluated a single AAD (azimilide, dofetilide, dronedarone and quinidine) versus placebo [13,17,19,[22][23][24]29].…”