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Evidence summaries

Restoration of Sinus Rhythm in Atrial Fibrillation

Rhythm control by repeated cardioversion in elderly patients does not improve survival or quality of life compared to rate control. Level of evidence: "A"

A systematic review 1 includied 5 studies with a total of 5 239 subjects with persistent atrial fibrillation (AF) or AF that was considered likely to be recurrent. There was no statistically significant difference in all-cause mortality between the rate and rhythm control groups (OR 0.87, 95% CI 0.74 to 1.02, P=0.09).

A meta-analysis 2 included 5 studies with a total of 5 239 subjects with AF. A rate-control strategy compared with a rhythm-control approach was associated with a significantly reduced risk of combined endpoint of all cause death and thromboembolic stroke (CEP, OR 0.84, 95% CI 0.73 to 0.98; NNT = 50), and with a trend towards a reduced risk of death (OR 0.87, 95% CI 0.74 to 1.02) and thromboembolic stroke (OR 0.80, 95% CI 0.6 to 1.07).

In a multi-centre trial 3 including 1 376 patients with atrial fibrillation, symptoms of congestive heart failure and left ventricular ejection fraction of 35% or less, rhythm control was compared to rate control. Of these patients, 182 (27%) in the rhythm control group died from cardiovascular causes, as compared with 175 (25%) in the rate-control group (HR 1.06, 95% CI 0.86 to 1.30).

RACE 4 and PIAF 5 studies found no difference in quality of life with rhythm control compared with rate control.

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    References

    • de Denus S, Sanoski CA, Carlsson J, Opolski G, Spinler SA. Rate vs rhythm control in patients with atrial fibrillation: a meta-analysis. Arch Intern Med 2005 Feb 14;165(3):258-62. [PubMed]
    • Testa L, Biondi-Zoccai GG, Dello Russo A, et al. Rate-control vs. rhythm-control in patients with atrial fibrillation: a meta-analysis. Eur Heart J 2005;26(19)2000-6. [PubMed]
    • Roy D, Talajic M, Nattel S, Wyse DG, Dorian P, Lee KL, Bourassa MG, Arnold JM, Buxton AE, Camm AJ, Connolly SJ, Dubuc M, Ducharme A, Guerra PG, Hohnloser SH, Lambert J, Le Heuzey JY, O'Hara G, Pedersen OD, Rouleau JL, Singh BN, Stevenson LW, Stevenson WG, Thibault B, Waldo AL, Atrial Fibrillation and Congestive Heart Failure Investigators. Rhythm control versus rate control for atrial fibrillation and heart failure. N Engl J Med 2008 Jun 19;358(25):2667-77. [PubMed]
    • Hagens VE, Ranchor AV, Van Sonderen E, Bosker HA, Kamp O, Tijssen JG, Kingma JH, Crijns HJ, Van Gelder IC, RACE Study Group. Effect of rate or rhythm control on quality of life in persistent atrial fibrillation. Results from the Rate Control Versus Electrical Cardioversion (RACE) Study. J Am Coll Cardiol 2004 Jan 21;43(2):241-7. [PubMed]
    • Hohnloser SH, Kuck KH, Lilienthal J. Rhythm or rate control in atrial fibrillation--Pharmacological Intervention in Atrial Fibrillation (PIAF): a randomised trial. Lancet 2000 Nov 25;356(9244):1789-94. [PubMed]

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