Optimal Rhythm Control Strategy in Patients With Atrial Fibrillation

Abstract

For almost 20 years, data regarding the effect of rhythm control therapy for atrial fibrillation (AF) on cardiovascular prognosis in comparison with rate control therapy has not been conclusive. The safety of rhythm control and anticoagulation therapy has generally improved. Recently, it was revealed that a rhythm-control strategy reduced the risk of adverse cardiovascular events than usual rate control in patients with recent AF (diagnosed within 1 year). Within 1 year after the AF diagnosis, early initiation of rhythm control led to more favorable cardiovascular outcomes than rate control. Early rhythm control reduced the risks of stroke and heart failure-related admission than rate control. Moreover, rhythm control was associated with lower dementia risk than rate control. Finally, early rhythm control treatment was also effective in patients with asymptomatic AF but less effective in older adults. Therefore, in patients with AF, rhythm control should be considered at earlier stages, regardless of symptom.

Keywords: Atrial fibrillation; Cardiovascular outcome; Cognitive outcome; Early treatment; Rhythm control.

Figure 1. Weighted cumulative incidence curves for individual components of the primary composite outcome in (A) early and (B) late atrial fibrillation treatments. Figure courtesy of Kim et al.

AF = atrial fibrillation; CI = confidence interval; HR = hazard ratio.

Figure 2. Benefit-to-harm ratios of rhythm control compared with rate control according treatment timing. The ratios >1 indicate positive net benefit. Figure courtesy of Kim et al.

AF = atrial fibrillation; CI = confidence interval.

Figure 3. Relation between treatment timing and risk of clinical outcomes for rhythm control or rate control in (A) overall period and (B) within 1 year after the first diagnosis of AF. Figure courtesy of Kim et al.

The x-axis shows the timing of treatment initiation since the first diagnosis of AF; the y-axis, HRs associated with rhythm control compared with rate control. The black horizontal lines indicate HR=1, which corresponds to an equal risk of outcomes in patients treated with rhythm and rate control. Dashed black lines show the 95% CI. AF = atrial fibrillation; CI = confidence interval; HR = hazard ratio.

Figure 4. Relation between treatment timing and risk of ischemic stroke (A), hospitalization owing to heart failure (B), acute myocardial infarction (C), and cardiovascular death (D) for rhythm control or rate control. Figure courtesy of Kim et al.

The x-axis shows the timing of treatment initiation since the first diagnosis of atrial fibrillation; the y axis, HRs associated with rhythm control compared with rate control. The skyblue horizontal dotted lines indicate HR=1, which corresponds to an equal risk of outcomes in patients treated with rhythm and rate control. Dashed black lines show the 95% CI. CI = confidence interval; HR = hazard ratio.

Figure 5. Relationship between age at treatment initiation and the risk of the primary composite outcome in early rhythm control and rate control groups. Figure courtesy of Kim et al.

The x-axis shows the age at treatment initiation and the y-axis shows HRs associated with rhythm control when compared with rate control. The purple horizontal line indicates HR=1, which corresponds to an equal risk of outcomes in patients treated with rhythm control and rate control. The dashed black lines indicate the 95% CI. CI = confidence interval; HR = hazard ratio.

Figure 6. Weighted cumulative incidence curves for the primary composite outcome in patients aged <75 years (A) and ≥75 years (B) who were recently (within 1 year) diagnosed with atrial fibrillation. Figure courtesy of Kim et al.

CI = confidence interval; HR = hazard ratio.

Figure 7. Weighted cumulative incidence curves for all-cause dementia in (A) overall and (B) after censoring stroke. Figure courtesy of Kim et al.

CI = confidence interval; sHR = subdistribution hazard ratio.

Figure 8. Relation between age at treatment initiation and risk of dementia for rhythm control or rate control. Figure courtesy of Kim et al.

The x-axis shows the age at the time of treatment initiation; the y-axis, HR associated with rhythm control compared with rate control. The purple horizontal line indicates HR=1, which corresponds to an equal risk of outcomes in patients treated with rhythm and rate control. Dashed black lines show the 95% CI. CI = confidence interval; HR = hazard ratio.