Treating Atrial Fibrillation - The Bottom Line

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If you have atrial fibrillation, how do you decide between the two basic approaches to treating your arrhythmia (that is, restoring and maintaining a normal rhythm or controlling the heart rate)?

There are a number of factors that you and your doctor will have to consider in making this decision.

When Is The Rhythm Control Approach Appropriate?

On its face, the rhythm control approach - restoring and maintaining a normal heart rhythm - would seem to be the right approach for just about anyone.

After all, who wants to stay in atrial fibrillation? The problem, of course, is that the treatments available to achieve rhythm control in atrial fibrillation tend to be of only modest effectiveness, and expose patients to some substantial risks.

So doctors most often reserve the rhythm control strategy for their patients who seem to have the best chance of success with it, or who are least likely to tolerate persistent atrial fibrillation even when the heart rate is controlled.

Such patients would include the following categories -

  • Those whose atrial fibrillation appears to be related to a transient event, a reversible cause, or an underlying medical problem that can be better controlled. These might include: hyperthyroidism; pericarditis; pulmonary embolus, pneumonia or other acute lung problem; recent surgical procedure; alcohol ingestion (“holiday heart”); poorly controlled heart failure; or untreated sleep apnea. Once the treatment of these underlying causes for atrial fibrillation has been optimized, the patient has a much better chance of staying in a normal heart rhythm.
  • People who have relatively “stiff” ventricles that tend to make atrial fibrillation poorly tolerated, even when adequate rate control is achieved. Such conditions include hypertrophic cardiomyopathy, hypertensive heart disease, diastolic dysfunction, or aortic stenosis.
  • Patients in whom the rate control method has been tried, and has failed to control symptoms adequately.
  • Athletes and others whose occupations require them to perform at peak cardiovascular function.
  • People who want to use a rhythm control approach once they have been fully informed as to its potential limitations.

When Is The Rate Control Approach Appropriate?

Because of the difficulties and the risks associated with the rhythm control approach to atrial fibrillation, most experts consider the rate control method to be the “default” approach for the majority of patients with this arrhythmia.

Not only is the rate control approach safer and far more effective than the rhythm control approach, but also it is effective in eliminating the symptoms of atrial fibrillation in the majority of people who have this arrhythmia. Since the whole point in treating atrial fibrillation is to get rid of the symptoms, the rate control approach is commonly quite effective in achieving the treatment goal.

Furthermore, while in the past it was assumed that if you could make the atrial fibrillation go away the risk of stroke would greatly diminish, clinical studies have failed to demonstrate this outcome.

So, even if a rhythm control strategy is employed and it appears to be successful, patients still need to be treated with anticoagulant drugs. Thus, a major potential advantage of the rhythm control approach has failed (at least until now) to materialize.

Is Maintaining a Normal Rhythm Inherently Better than Rate Control?

While it seems intuitively obvious that a rhythm control strategy would give better outcomes than a rate control strategy in atrial fibrillation, clinical studies have failed to demonstrate that this is the case. Instead, randomized clinical trials comparing rhythm control to rate control in patients with atrial fibrillation have shown a trend toward worse clinical outcomes (including a higher incidence of death, heart failure, stroke and bleeding) with the rhythm-control approach. Most experts attribute these worse outcomes to the side effects of antiarrhythmic drugs, but this is unclear.

Bottom line:

For now, experts agree that the "default" approach for most patients atrial fibrillation (especially after one or perhaps two attempts to maintain a normal rhythm have failed) is the rate-control approach. However, this decision always needs to be jointly made between the doctor and the patient, with all the pros and cons of each approach being taken into careful account.


American College of Cardiology Foundation, American Heart Association, European Society of Cardiology, et al. Management of patients with atrial fibrillation (compilation of 2006 ACCF/AHA/ESC and 2011 ACCF/AHA/HRS recommendations): a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines. Circulation 2013; 127:1916.

Wyse DG, Waldo AL, et al. A comparison of rate control and rhythm control in patients with atrial fibrillation. N Eng J Med 2002;347(23):1825.

Van Gelder IC, Hagens VE, et al. A comparison of rate control and rhythm control in patients with recurrent persistent atrial fibrillation. N Eng J Med 2002;347(23):1834.

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