[Atrial fibrillation: rhythm or rate control?]

Abstract

For many years it has been considered that it was necessary, whenever possible, to cardiovert atrial fibrillation and to maintain the sinus rhythm with antiarrhythmic drugs. There are many theoretical advantages to this maintenance of the sinus rhythm. Nevertheless the choice of the drugs used to maintain rhythm is often difficult and the therapeutical index of these drugs may be poor. It is necessary to avoid class I antiarrhythmic drugs in patients with congestive heart failure and coronary artery disease. In these cases, only sotalol and amiodarone can be used. The safety index of these drugs being low, plain rate control with persistence of atrial fibrillation has been proposed as a treatment alternative. Several drugs may be used: calcium inhibitors, beta-blockers, digitalis. It is always necessary to associate anticoagulation: of course if rate control is chosen, but also if rhythm control is obtained, owing to the possible risk of relapse. Several trials of comparison between these 2 strategies have been recently performed. Available results show no clear superiority of a strategy above the other but there is a tendency towards a lower mortality in the rate control group.