Rhythm Versus Rate Control for Atrial Fibrillation: A Meta-analysis of Randomized Controlled Trials

Abstract

Atrial fibrillation (AF) is a common, sustained tachyarrhythmia, associated with an increased risk of mortality and thromboembolic events. We performed this meta-analysis to compare the clinical efficacy of rate and rhythm control strategies in patients with AF in a meta-analysis framework. A comprehensive search of PubMed, OVID, Cochrane-CENTRAL, EMBASE, Scopus, and Web of Science was conducted, using relevant keywords. Dichotomous data on mortality and other clinical events were extracted and pooled as risk ratios (RRs), with their 95% confidence-interval (CI), using RevMan software (version 5.3). Twelve studies (8451 patients) were pooled in the final analysis. The overall effect-estimate did not favor rate or rhythm control strategies in terms of all-cause mortality (RR= 1.13, 95% CI [0.88, 1.45]), stroke (RR= 0.97, 95% CI [0.79, 1.20]), thromboembolism (RR= 1.06, 95% CI [0.64, 1.76]), and major bleeding (RR= 1.10, 95% CI [0.90, 1.35]) rates. These findings were consistent in AF patients with concomitant heart failure (HF). The rate of rehospitalization was significantly higher (RR= 0.72, 95% CI [0.57, 0.92]) in the rhythm control group, compared to the rate control group. In younger patients ( <65 years), rhythm control was superior to rate control in terms of lowering the risk of all-cause mortality (p="0.0003)," hf (p="0.003)" and major bleeding (p="0.02)." in older af patients and those with concomitant hf, both rate and rhythm control strategies have similar rates of mortality and major clinical outcomes; therefore, choosing an appropriate strategy should consider individual variations, such as patient preferences, comorbidities, and treatment cost.

Introduction

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, affecting more than 5% of the worldwide population.¹ It is associated with a high risk of thromboembolic events, including stroke, which occurs in about 23% of AF patients, older than 80 years.^2,3 Over the last decade, it accounted for about one third of hospital admissions for cardiac arrhythmias^4,5 with an increasing prevalence in patients with cardiovascular problems, such as valvular heart disease, heart failure (HF), and coronary artery disease (CAD).^6,7

The pharmacological management of AF targets either rate control (maintaining the heart rate at normal levels, using pharmacological agents, such as beta-blockers, non-dihydropyridine calcium-channel blocker, and cardiac glycosides) or rhythm control (restoration of sinus rhythm, using electrical cardioversion and/or antiarrhythmic agents, such as sodium channel blockers and potassium channel blockers) (8). In the past few years, several randomized controlled trials (RCTs) have investigated whether rhythm control is superior to rate control with respect to mortality and cerebrovascular accidents.^9-22

Besides the controversial results of these trials, former meta-analyses showed conflicting results, suggesting that rate control is either similar or superior to rhythm control in terms of mortality and stroke rates.^23,24 Moreover, recent trials have compared both strategies in different groups of AF patients, including younger and those with concomitant HF.^9,12 Therefore, we conducted this systematic review and meta-analysis to update the evidence regarding the optimal control approach for AF.

Methods

This study was conducted following the guidelines of the Cochrane handbook of systematic reviews of interventions and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement.^25,26 All steps have been prespecified in a published protocol on PROSPERO register of systematic reviews (CRD42016049648).

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