Rhythm vs Rate Control Strategy for Atrial Fibrillation: A Meta-Analysis of Randomized Controlled Trials

Stefanos Zafeiropoulos; Ioannis Doundoulakis; Alexandra Bekiaridou; Ioannis T Farmakis; Georgios E Papadopoulos; Kristie M Coleman; George Giannakoulas; Stavros Zanos; Dimitris Tsiachris; Firat Duru; Ardan Muammer Saguner; Stavros E Mountantonakis; Stavros Stavrakis

doi:10.1016/j.jacep.2024.03.006

Rhythm vs Rate Control Strategy for Atrial Fibrillation: A Meta-Analysis of Randomized Controlled Trials

JACC Clin Electrophysiol. 2024 Apr 15:S2405-500X(24)00187-7. doi: 10.1016/j.jacep.2024.03.006. Online ahead of print.

Affiliations

¹ Feinstein Institutes for Medical Research at Northwell Health, Manhasset, New York, USA; Department of Cardiology, University Hospital Zurich, Zürich, Switzerland.
² Hippokration Hospital, Athens, Greece.
³ Feinstein Institutes for Medical Research at Northwell Health, Manhasset, New York, USA.
⁴ Center for Thrombosis and Hemostasis, University Medical Center Mainz, Mainz, Germany.
⁵ Aristotle University of Thessaloniki, Thessaloniki, Greece.
⁶ Athens Heart Center, Athens Medical Center, Athens, Greece.
⁷ Hippokration Hospital, Athens, Greece; Athens Heart Center, Athens Medical Center, Athens, Greece.
⁸ Department of Cardiology, University Hospital Zurich, Zürich, Switzerland; Center for Translational and Experimental Cardiology (CTEC), University of Zürich, Zurich, Switzerland.
⁹ Department of Cardiology, Northwell Health, New York, New York, USA.
¹⁰ University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA. Electronic address: Stavros-stavrakis@ouhsc.edu.

PMID: 38727662
DOI: 10.1016/j.jacep.2024.03.006

Abstract

Background: Rhythm control, either with antiarrhythmic drugs or catheter ablation, and rate control strategies are the cornerstones of atrial fibrillation (AF) management. Despite the increasing role of rhythm control over the past few years, it remains inconclusive which strategy is superior in improving clinical outcomes.

Objectives: This study summarizes the total and time-varying evidence regarding the efficacy of rhythm- vs rate-control strategies in the management of AF.

Methods: We systematically perused the MEDLINE, CENTRAL (Cochrane Central Register of Controlled Trials), and Web of Science databases for randomized controlled trials from inception to November 2023. We included studies that compared the efficacy of rhythm control (ie, antiarrhythmic drugs classes Ia, Ic, or III, AF catheter ablation, and electrical cardioversion) and rate control (ie, beta-blocker, digitalis, or calcium antagonist) strategies among patients with nonvalvular AF. The primary outcome was cardiovascular (CV) death, whereas secondary outcomes included all-cause death, stroke, hospitalization for heart failure (HF), sinus rhythm at the end of the follow-up, and rhythm control-related adverse events. A cumulative meta-analysis to assess temporal trends and a meta-regression analysis using the percentage of ablation use was performed.

Results: We identified 18 studies with a total of 17,536 patients (mean age: 68.6 ± 9.7 years, 37.9% females) and a mean follow-up of 28.5 months. Of those, 31.9% had paroxysmal AF. A rhythm control strategy reduced CV death (HR: 0.78; 95% CI: 0.62-0.96), stroke (HR: 0.801; 95% CI: 0.643-0.998), and hospitalization for HF (HR: 0.80; 95% CI: 0.69-0.94) but not all-cause death (HR: 0.86; 95% CI: 0.73-1.02) compared with a rate control strategy. This benefit was driven by contemporary studies, whereas more ablation use within the rhythm control arm was associated with improved outcomes, except stroke.

Conclusions: In patients with AF, a contemporary rhythm control strategy leads to reduced CV mortality, HF events, and stroke compared with a rate control strategy.

Keywords: atrial fibrillation; catheter ablation; rate control; rhythm control.