Persistent atrial fibrillation: rate control or rhythm control

Boos, Christopher J.

doi:10.1136/bmj.326.7404.1411

Cited by 16 publications

(7 citation statements)

References 10 publications

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“…In recent years, several randomised trials 10 18-22 have compared heterogeneous groups of patients, and the data are consistent and strong enough to promote rate control as the initial strategy for the vast majority of patients with persistent AF. 23 Firstly, with current antiarrhythmic drugs a rhythm control approach does not lead to improved symptom control or QOL or a reduction in clinical events in the short to medium term. In the longer term, mortality may increase.…”

Section: Discussionmentioning

confidence: 99%

Comparison of rate control and rhythm control in patients with atrial fibrillation after percutaneous mitral balloon valvotomy: a randomised controlled study

2006

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Objective: To compare rate control and rhythm control strategies in patients with atrial fibrillation (AF) after percutaneous mitral balloon valvotomy (PMV). Methods: 183 patients with AF after successful PMV, with AF duration ( 12 months and post-PMV left atrial (LA) size ( 45 mm, were studied in a prospective, randomised trial. The primary end point was improvement in AF-related symptoms. Secondary study end points were 6 min walk tests, quality of life (QOL), normalisation of LA size, number of hospital admissions and duration of hospital stay. Results: Over one year, 2% patients in the rate control group had sinus rhythm, as compared with 96% of patients in the rhythm control group (p , 0.001). A greater proportion of patients reported improvement in symptoms in the rhythm control group than in the rate control group (p , 0.0001 at every visit time). Walking distance in a 6 min walk test, QOL and LA size normalisation were better in the rhythm control group than in the rate control group. The strategy of rhythm control was associated with similar numbers of hospital admissions but with longer duration of hospital admissions. Drug-related side effect did not differ between the rate control and rhythm control groups. During the follow-up period, no patients in either group had embolic or transitory ischaemic neurological events. Conclusions: In patients with AF after PMV, AF duration ( 12 months and post-PMV LA size ( 45 mm, sinus rhythm was easy and safe to achieve and maintain. Moreover, patients benefited from restoration and maintenance of sinus rhythm in terms of improved AF-related symptoms, 6 min walk tests and QOL, and of LA size normalisation. Rhythm control should therefore be considered as the preferred initial therapy for this group of patients. The optimal strategy to treat AF after PMV should be individualised. M ost patients with rheumatic mitral valvular stenosis and atrial fibrillation (AF) remain in AF rhythm after percutaneous mitral balloon valvotomy (PMV).1-3 AF can adversely affect haemodynamic function. The absence of atrial systole (atrial kick) and a rapid ventricular rate with relative shortening of diastole can increase left atrial (LA) pressure, worsen pulmonary venous congestion and compromise cardiac output. Moreover, stasis of blood in the LA appendage predisposes to development of thrombi and embolic complications.4 AF also generates significant healthcare costs. 5Sinus rhythm is difficult to achieve and maintain in patients with rheumatic mitral valvular stenosis and AF but would be more easily achieved with reduction of LA pressure after successful PMV. 6 In our previous study, we found that longer AF history, smaller mitral valve area and higher LA pressure after PMV are the key factors of AF recurrence.1 Sinus rhythm can be maintained in a higher proportion of patients with AF duration ( 12 months and post-PMV LA size ( 45 mm than of those with AF duration . 12 months and post-PMV LA size . 45 mm.

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Section: Discussionmentioning

confidence: 99%

Comparison of rate control and rhythm control in patients with atrial fibrillation after percutaneous mitral balloon valvotomy: a randomised controlled study

2006

Heart

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“…10 11 The implications of these studies are that even greater numbers of patients (including the elderly) should be treated with long term oral anticoagulation. 12 This raises the critical issue regarding the risk:benefit ratio of this treatment in general clinical practice. We therefore aimed at assessing the reliability, efficacy, and associated risks of computer aided long term oral anticoagulation for NRAF over a five year period in a district general hospital.…”

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confidence: 99%

Warfarin for non-rheumatic atrial fibrillation: five year experience in a district general hospital

Yousef

Tandy²,

Tudor³

et al. 2004

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Objectives: To assess the long term efficacy of and risks associated with computer aided oral anticoagulation for non-rheumatic atrial fibrillation (NRAF) in a district hospital setting. Design: Retrospective, age stratified, event driven clinical database analysis. Setting: District general hospital. Participants: 739 patients receiving warfarin for NRAF between 1996 and 2001. Patients were selected from an anticoagulation database through appropriate filter settings. Main outcome measures: Anticoagulation control (international normalised ratio (INR)) and hospitalisations for bleeding complications, thromboembolic events, and stroke. Results: Over 1484 patient-years, computer assisted anticoagulation was uncontrolled in 38.3% of patients (INR , 2.0 or . 3.0). No significant differences in INR control were observed with respect to patient age (, 65, 65-75, and . 75 years), although to achieve adequate control of anticoagulation, the frequency of testing increased significantly with age. Annual risks of bleeding complications, thromboembolism, and stroke were 0.76%, 0.35%, and 0.84%, respectively. No significant differences in these events were observed between the three age groups studied. Patients who had thromboembolic events and haemorrhagic complications were significantly more likely to have been under-anticoagulated (INR , 2.0) and over-anticoagulated (INR . 3.0), respectively, at the time of their clinical event.Conclusions: Computerised long term oral anticoagulation for NRAF in a community setting of elderly and diverse patients is safe and effective. Anticoagulation control, bleeding events, thromboembolic episodes, and stroke rates are directly comparable with those reported in major clinical trials. The authors therefore support the strategy of rate control with long term oral anticoagulation for NRAF in general clinical practice.

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“…1 Amiodarone has emerged as the most effective agent at preventing relapse of AF post-DEC, with up to 69% of patients remaining in sinus rhythm at one year. 2 However, as many as 25% of amiodarone treated patients are forced to discontinue treatment because of side effects of the drug.…”

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confidence: 99%

A short course of oral amiodarone improves sinus rhythm maintenance post-cardioversion for atrial fibrillation

Boos

2004

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Persistent atrial fibrillation: rate control or rhythm control

Abstract: Rate control is not inferior to rhythm control

Cited by 16 publications

References 10 publications

Comparison of rate control and rhythm control in patients with atrial fibrillation after percutaneous mitral balloon valvotomy: a randomised controlled study

Comparison of rate control and rhythm control in patients with atrial fibrillation after percutaneous mitral balloon valvotomy: a randomised controlled study

Warfarin for non-rheumatic atrial fibrillation: five year experience in a district general hospital

A short course of oral amiodarone improves sinus rhythm maintenance post-cardioversion for atrial fibrillation

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