Elsevier

The Lancet

Volume 388, Issue 10046, 20–26 August 2016, Pages 829-840
The Lancet

Series
Rhythm control in atrial fibrillation

https://doi.org/10.1016/S0140-6736(16)31277-6Get rights and content

Summary

Many patients with atrial fibrillation have substantial symptoms despite ventricular rate control and require restoration of sinus rhythm to improve their quality of life. Acute restoration (ie, cardioversion) and maintenance of sinus rhythm in patients with atrial fibrillation are referred to as rhythm control. The decision to pursue rhythm control is based on symptoms, the type of atrial fibrillation (paroxysmal, persistent, or long-standing persistent), patient comorbidities, general health status, and anticoagulation status. Many patients have recurrent atrial fibrillation and require further intervention to maintain long term sinus rhythm. Antiarrhythmic drug therapy is generally recommended as a first-line therapy and drug selection is on the basis of the presence or absence of structural heart disease or heart failure, electrocardiographical variables, renal function, and other comorbidities. In patients who continue to have recurrent atrial fibrillation despite medical therapy, catheter ablation has been shown to substantially reduce recurrent atrial fibrillation, decrease symptoms, and improve quality of life, although recurrence is common despite continued advancement in ablation techniques.

Section snippets

Reasons to choose a rhythm control strategy

Atrial fibrillation affects 33 million individuals worldwide,1 and increases risk of stroke, heart failure, and death, and also impairs quality of life. Accordingly, the goals of care in atrial fibrillation include the prevention of stroke, control of the ventricular rate, and minimisation of symptoms to improve quality of life.2, 3, 4 Although some patients' symptoms are relieved with ventricular rate control alone, many require restoration and maintenance of sinus rhythm—referred to as rhythm

Acute rhythm management for atrial fibrillation

The acute evaluation and management of patients presenting with atrial fibrillation is mainly focused on the improvement of cardiac haemodynamics and the provision of protection against thromboembolic events, such as stroke and systemic embolism. Both inappropriately tachycardic ventricular rates and irregularity of the cardiac rhythm can lead to symptoms or haemodynamic impairment, particularly in patients with abnormal ventricular filling (eg, diastolic function). The severity of atrial

Antiarrhythmic drugs to maintain sinus rhythm

When atrial fibrillation recurs and impairs quality of life, rhythm control is needed to restore and maintain sinus rhythm. There is no evidence that antiarrhythmic drug treatment improves survival and neither rate nor rhythm control strategies have been shown to be superior to one another. Thus, the focus of rhythm control with antiarrhythmic treatment is on symptom control and improvement of quality of life. Oral drug treatment is considered first-line therapy for long-term outpatient rhythm

Indications and patient selection

After the discovery of ectopic impulses that initiate atrial fibrillation,42, 43 catheter ablation was developed to isolate and eliminate ectopic triggers of atrial fibrillation or modify the susceptible atrial substrate. There have been many improvements in the safety and efficiency of catheter ablation for atrial fibrillation management in the last decade.44 In terms of maintenance of sinus rhythm, catheter ablation is more effective than antiarrhythmic drug therapy in selected patients with

Heart failure

When rhythm and rate control strategies are compared in patients with atrial fibrillation and heart failure with reduced ejection fraction, neither strategy has been found to lead to superior outcomes.86 Efforts to restore and maintain sinus rhythm are particularly challenging in patients with heart failure.86 However, patients with heart failure who have less atrial fibrillation suffer less severe functional impairment and restoration of sinus rhythm after catheter ablation leads to improved

Conclusion

Rhythm control therapy to maintain sinus rhythm is an important component of arrhythmia management in patients with atrial fibrillation. Although neither ventricular rate nor rhythm control has been established as superior, rhythm control is an important strategy to improve symptoms, functional status, and quality of life in patients with atrial fibrillation. Antiarrhythmic drug therapy remains a first-line treatment for maintenance of sinus rhythm. Catheter ablation leads to improved outcomes

Search strategy and selection criteria

We searched MEDLINE, PubMed, and major conference proceedings with the search terms “atrial fibrillation”, “rhythm control”, “cardioversion”, “antiarrhythmic”, and “catheter ablation”. We also searched proccedings from the American Heart Association Scientific Sessions, American College of Cardiology, European Society of Cardiology, Heart Rhythm Society, and Cardiostim Scientific Sessions. Finally, guideline documents about management of atrial fibrillation across major cardiovascular societies

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