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November 9, 2005

Making Sense of the MazeWhich Patients With Atrial Fibrillation Will Benefit?

JAMA. 2005;294(18):2357-2359. doi:10.1001/jama.294.18.2357

Atrial fibrillation imposes heavy burdens on both patients and clinical practice. Approximately 2.3 million individuals in the United States have atrial fibrillation and the advancing age of the population,1,2 along with the increasing prevalence of obesity,3 is likely to further expand this number. Recent clinical trials have provided valuable information regarding management strategies of rate control with anticoagulation as opposed to the maintenance of sinus rhythm, primarily by the use of antiarrhythmic drugs. In general, not only has maintenance of sinus rhythm proven no better than rate control,4 but the AFFIRM trial actually demonstrated a benefit of rate control over rhythm control in terms of overall mortality among patients with coronary artery disease and hypertension.5 Nonetheless certain patients most likely to benefit from coordinated atrioventricular contraction were underrepresented in these trials, including patients with severe symptoms, hypertrophic cardiomyopathy, severe heart failure, valvular heart disease, and those undergoing cardiac surgical procedures. Some evidence suggests that the impact of one treatment strategy over another may vary among patient categories.6 In these patient subsets, there is considerable and growing interest in restoration and maintenance of sinus rhythm using pharmacologic therapies and either surgical or catheter-based nonpharmacologic approaches.

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