Editors

PekkaRaatikainen

Treatment Approach for Atrial Fibrillation: Rate Control or Rhythm Control?

Essentials

The treatment of atrial fibrillation (AF) is chosen individually for each patient taking into consideration the symptoms, co-existing illnesses, factors that predispose to atrial fibrillation and thromboembolic complications, the duration of the arrhythmia and the anticipated benefits and risks of the treatment. The choice of treatment may only be made after a careful assessment of the patient (table T1).
The elimination of factors that predispose to the arrhythmia or trigger it as well as the appropriate management of any underlying illnesses form an essential part in the management of atrial fibrillation regardless of the treatment approach chosen.

Examinations and investigations in AF. In most cases, the decision regarding the treatment approach may be taken by the primary care physician on the basis of the first-line investigations. Echocardiogram is the most important second-line investigation.

First-line investigations
1. History and clinical examination
Thrombosis risk factors (CHA₂DS₂VASc score, see Indications for and Implementation of Anticoagulant Therapy in Atrial Fibrillation) Severity of symptoms (EHRA score) Type of atrial fibrillation (paroxysmal, persistent, permanent) Cardiac diseases and other factors predisposing to atrial fibrillation Rough assessment of cognitive functioning (memory test as required) Medication and other forms of treatment How does the arrhythmia begin and end, frequency, duration? Careful clinical cardiovascular examination
2. ECG
To diagnose the arrhythmia and to monitor treatment To diagnose other cardiac conditions (left ventricular hypertrophy, bundle branch block, old infarction, delta wave) To assess the effect of medication
3. Laboratory investigations
Basic blood count with platelet count, plasma sodium, potassium, creatinine, fasting glucose, TSH and lipids, urinary screening (proteinuria, glucosuria), to be taken after the first episode of AF, when planning prophylactic treatment and when AF recurs unexpectedly. In addition, drug-specific safety tests may be necessary (e.g. amiodarone, dronedarone).
4. Echocardiography
Once for all patients with atrial fibrillation to exclude structural heart diseases Always when planning to start actual anti-arrhythmic medication (group I or III drugs) May be omitted, at discretion, in elderly patients with no signs suggestive of heart diseases, if rate control is chosen as the line of treatment.

Second-line investigations
1. Other imaging studies
Chest x-ray if there is a suspicion of other heart or lung disease CT or MRI scan of the heart, as considered necessary by a cardiologist

2. Ambulatory ECG recording or an event ECG recording
To diagnose the arrhythmia and to monitor treatment
3. Clinical exercise test
To diagnose the arrhythmia and to monitor treatment To rule out coronary disease when the initiation of flecainide medication is being planned.
4. Transoesophageal echocardiogram (TEE)
When early (TEE-guided) cardioversion is being planned Prior to catheter-induced ablation for AF
5. Electrophysiological studies
To diagnose the arrhythmia (to analyse the mechanism of broad complex tachycardia, to identify an underlying primary arrhythmia) When catheter ablation is being planned (underlying primary arrhythmia that triggers AF, focal AF or ablation of the atrioventricular node)
Modified from source: Atrial fibrillation. Current Care Guideline, Duodecim. 2021.

Treatment choices Warfarin or Antiplatelet Therapy for Stroke Prevention in Patients with Non-Valvular Atrial Fibrillation, Restoration of Sinus Rhythm in Atrial Fibrillation

Rhythm control consists of cardioversion and the use of medication, or other treatment forms, to prevent the recurrence of AF (see Prevention of Atrial Fibrillation).The planning and initiation of antiarrhythmic drugs and invasive therapy should be carried out by a specialist physician, but primary care physicians may usually manage the follow-up care.
Rate control denotes a treatment approach where cardioversions and prophylactic medication against AF are abandoned and permanent AF is accepted (see Rate Control in Permanent Atrial Fibrillation).
- Using the guidelines given below, a primary care physician may as well make the decision to follow the rate control approach.
- If rate control is chosen, the patient must be carefully monitored because a ventricular rate that is too fast will predispose the patient to cardiac insufficiency (tachycardia-induced cardiomyopathy).
Anticoagulant therapy must be considered during both rhythm control and rate control; it is the only form of treatment which has been shown to improve the prognosis of a patient with AF (see Indications for and Implementation of Anticoagulant Therapy in Atrial Fibrillation). The implementation of anticoagulant therapy is principally the responsibility of primary health care personnel.
The subjective harm caused by the arrhythmia is among the most significant factors affecting the choice of treatment approach in atrial fibrillation. The EHRA score developed by the European Heart Rhythm Association is recommended for assessing the severity of symptoms (table T2).

EHRA score for the classification of AF-related symptoms

EHRA class	Criteria
EHRA 1	No symptoms
EHRA 2	Mild symptoms; normal daily activity not affected
EHRA 3	Severe symptoms; normal daily activity affected
EHRA 4	Disabling symptoms; normal daily activity discontinued

Sources: Atrial fibrillation. Current Care Guideline, Duodecim 2021 and Kirchhof P, Auricchio A, Bax J ym. Outcome parameters for trials in atrial fibrillation: recommendations from a consensus conference organized by the German Atrial Fibrillation Competence NETwork and the European Heart Rhythm Association. Europace 2007;9(11):1006-23. [PubMed]

Factors supporting rate control Restoration of Sinus Rhythm in Atrial Fibrillation

In elderly patients (> 65 years) with mild symptoms (EHRA 1-2), it is possible to abandon attempt at cardioversion and concentrate on rate control and anticoagulation, particularly in the presence of presdiposing diseases, e.g. heart failure, coronary heart disease, hypertension or diabetes.
- In these patients, rate control and rhythm control will have an equal effect on the patient's prognosis and, on average, their quality of life will not show great variation.
Other factors supporting rate control:
- symptoms improve with rate controlling medication
- rapid recurrence of AF after cardioversion (within < 1-2 months) despite prophylactic medication
- echocardiogram shows enlarged left atrium (transverse diameter> 5 cm)
- the duration of AF > 6-12 months
- a physically inactive patient.

Factors supporting rhythm control

The restoration of sinus rhythm should be attempted, almost without exception in all cases, of first occurrence of symptomatic AF.
- In symptomless patients, the restoration of sinus rhythm may at discretion be abandoned already at the diagnostic phase.
Rhythm control is the treatment approach of choice, despite the presence of co-existing diseases, if
- the patient has severe symptoms (EHRA 3-4) or haemodynamic complications despite maximal rate controlling medication
- there is a good response to antiarrhythmic prophylactic medication
- the left atrium is of normal size
- the duration of AF is < 6 months
- the patient is young and physically active
- the patient is suitable for catheter ablation treatment.

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