Addressing the Controversy of Rate-versus-Rhythm Control in Atrial Fibrillation

Atrial fibrillation is the most common sustained cardiac arrhythmia and significantly increases patient risk of stroke, cardiomyopathy, and mortality. Rate versus rhythm control as the best treatment strategy remains an issue of considerable, ongoing debate. A multitude of clinical trials have compared the 2 strategies and have not shown any benefit of one approach over the other. However, the trials were conducted in specific subgroups of patients and demonstrated low success rates with antiarrhythmic drug (AAD) therapy and a high incidence of adverse AAD effects. Sub-analyses of the trials have confirmed that successful rhythm control with sinus rhythm restoration is associated with a significant reduction in patient mortality. More recently, radiofrequency ablation (RFA) has emerged as a relatively effective procedure for maintaining sinus rhythm compared with use of AADs. Prospective randomized studies have shown good treatment results after the use of RFA, with acceptable risk. Given the limitation of pharmacologic rate versus rhythm control studies, and the promise of RFA, rhythm control should again be reconsidered as the best approach for managing many subgroups of patients with atrial fibrillation