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Rate Control Is Preferable to Rhythm Control in the Majority of Patients With Atrial Fibrillation

“…but to his surprise — the more he looked — the more Piglet wasn’t there.” — A.A. Milne, The House at Pooh Corner 

The management of patients with atrial fibrillation has been the subjects of intense investigation over the past 2 decades. In the 1980s and early 1990s, large clinical trials of anticoagulant therapy for stroke prevention were performed. These consistently demonstrated that atrial fibrillation confers a significant and ongoing stroke risk and that anticoagulant therapy significantly reduces this risk.1–10 Warfarin subsequently became a standard of therapy for patients with atrial fibrillation, whether paroxysmal, persistent, or permanent.

If patients with atrial fibrillation had a high stroke risk compared with those in sinus rhythm, then logic appeared to dictate that restoration and maintenance of sinus rhythm should reduce the likelihood of thromboembolism and hence obviate the need for long-term warfarin anticoagulation. Perhaps driven in part by this belief, new atrial antiarrhythmic drugs were introduced during this period, and there was an increasing use of such drugs among patients with atrial fibrillation.11 A decade after the trials of anticoagulation in atrial fibrillation, several international trials were implemented to determine whether heart rate control would result in a similar outcome to the outcome after a strategy of restoration and maintenance of sinus rhythm.12–15 Analysis of these trials demonstrated no benefit either in mortality or in a combined end point of mortality and morbidity. These results are generally interpreted as showing that either rate control or rhythm control is a suitable strategy in a patient with atrial fibrillation, and there has therefore been a rethinking of the appropriate way in which to treat a patient with atrial fibrillation when the options include control of either rate or rhythm. In the treatment of atrial fibrillation, as with most things in medicine, one …