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July 9, 2012

Rate vs Rhythm Control in Atrial Fibrillation: Can Observational Data Trump Randomized Trial Results?

Author Affiliations

Author Affiliations: Division of Cardiology, Section of Electrophysiology, University of California, San Francisco.

Arch Intern Med. 2012;172(13):983-984. doi:10.1001/archinternmed.2012.2332

Nearly 100 years have passed since a Dutch merchant first astonished Dr Karel Wenckebach with the ability to terminate episodes of atrial fibrillation (AF) through self-medication with quinine.1 Following this initial account of chemical cardioversion, maintenance of sinus rhythm gradually emerged as the preferred but unproven approach to the management of AF. In the past decade, several randomized trials examined the comparable efficacy of a rhythm vs rate control strategy in varied patient populations.2-4 The Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) trial enrolled over 4000 patients 66 years or older with at least 1 other risk factor for stroke,2 whereas the Rate Control vs Electrical Cardioversion (RACE) trial studied 522 patients with a history of recurrent AF after electrical cardioversion.3 Both investigations failed to demonstrate a mortality benefit with rhythm control. Amid speculation that heart failure patients may derive particular benefit from sinus rhythm, these strategies were subsequently compared among 1376 patients with symptomatic left ventricular systolic dysfunction in the Atrial Fibrillation and Congestive Heart Failure (AF-CHF) trial.4 Once again, no significant difference in cardiovascular death was found.

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