Drug Therapy for the Management of Atrial Fibrillation: An Update

Andrew RJ Mitchell


Br J Cardiol. 2003;10(5) 

In This Article

Rate or Rhythm Control?

One of the long-standing uncertainties in AF management has been whether to achieve rate control or rhythm control in patients with persistent AF. The two approaches were compared in the Pharmacological Intervention in Atrial Fibrillation (PIAF) trial, a randomised trial in 252 patients with AF of seven to 360 days' duration.[7] The trial showed that both strategies resulted in similar symptom scores during long-term follow-up but exercise tolerance was improved with rhythm control (at the expense of more frequent hospital admissions).

The Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) trial randomised 4,060 elderly patients to medical therapy to either restore atrial rhythm or to control ventricular rate.[8] At an average of 3.5 years of follow-up, 60% in the rhythm arm were in sinus rhythm and adequate rate control was achieved in 80% of rate-control patients. The primary end point (total mortality) was unchanged between the two treatment groups, although there was a trend towards more stroke in the rhythm control group. Warfarin use at study end was 85–90% in the rate group and 70% in the rhythm group.

The Rate Control vs. Electrical Cardioversion for Persistent Atrial Fibrillation (RACE) trial was presented in the same journal.[9] The investigators compared the strategies of rate control with medical therapy and repeat electrical cardioversion. Over a three-year follow-up period there was no difference in mortality between the 256 patients randomised to rate control and the 266 patients randomised to rhythm control. There were, however, more thrombo-embolic complications in the rhythm group suggesting that anticoagulation therapy may need to be continued for longer in patients with persistent AF.


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