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Will we be able to predict in which atrial fibrillation patients a rhythm control strategy will be successful?

Several randomized clinical trials have demonstrated that with regard to prognosis, rate control is not inferior to rhythm control in atrial fibrillation (AF).1 This has led to the development that restoration of sinus rhythm is no longer the treatment objective for every patient presenting with AF. Rhythm control remains therapy of choice, however, for symptomatic patients.2 Yet, when we interpret the results of the rate vs. rhythm control trials, we should keep in mind that rhythm control was never fully successful, meaning that these trials compared strategies instead of actual achieved rhythms. Restoration and maintenance of sinus rhythm indeed is challenging, even despite strong anti-arrhythmic drugs.3 We still do not know whether true restoration of sinus rhythm, preferably without the need for anti-arrhythmic drugs, improves survival in comparison to acceptance of AF. One way to overcome this conundrum is to investigate the results of new treatment options. On the other hand, we could try to improve the outcome of rhythm control therapy by aiming to differentiate those patients in whom rhythm control will be successful from those in whom it will not be effective.

Outcome of rhythm control depends on the severity of AF, in terms of electrical and structural remodelling. The extent of remodelling is influenced by the duration of AF in addition to clinical factors like age and underlying disease including hypertension, congestive heart failure, coronary artery disease, valvular disease, diabetes mellitus, and thyroid disease. Furthermore, less well-known risk factors for AF such as obesity, alcohol abuse, excessive sports practice, genetic factors, sleep apnoea, and inflammation may affect the severity of AF.4 The severity of atrial remodelling is … 

*Corresponding author. Tel: +31 50 3611327, Fax: +31 50 3614391, Email: i.c.van.gelder{at}thorax.umcg.nl