When should rhythm control be chosen over rate control in a patient with atrial fibrillation?

When to Choose Rhythm Control Over Rate Control in Atrial Fibrillation

Rate control with chronic anticoagulation is the recommended strategy for the majority of patients with atrial fibrillation, but rhythm control should be chosen for younger patients with symptomatic paroxysmal AF, those with significant symptoms (EHRA score >2) despite adequate rate control, patients with AF-induced hemodynamic instability or heart failure, and those without structural heart disease who remain highly symptomatic. 1, 2, 3

Evidence Base: Rate Control is Non-Inferior for Most Patients

Multiple large randomized controlled trials (AFFIRM, RACE, PIAF, STAF, HOT CAFÉ) consistently demonstrate that rhythm control does not reduce mortality or stroke compared to rate control with anticoagulation. 1

• The AFFIRM trial (4,060 patients, mean age 69.7 years) found no difference in all-cause mortality between rhythm control (26.7%) and rate control (25.9%) after 3.5 years of follow-up. 1
• The RACE trial (522 patients) demonstrated rate control was non-inferior to rhythm control for preventing cardiovascular death and morbidity over 2.3 years. 1
• Rhythm control patients consistently experienced more hospitalizations and adverse drug events across all trials. 1
• A 2024 meta-analysis of 17,536 patients showed contemporary rhythm control strategies (particularly with increased ablation use) reduced cardiovascular death (HR 0.78), stroke (HR 0.80), and heart failure hospitalization (HR 0.80), but this benefit was driven by modern studies using more catheter ablation rather than antiarrhythmic drugs alone. 4

Specific Clinical Scenarios Favoring Rhythm Control

Hemodynamic Instability or Acute Heart Failure

• Early cardioversion is necessary when AF causes hypotension or worsening heart failure, making restoration of sinus rhythm both a short-term and long-term therapeutic goal. 1
• Electrical cardioversion is recommended for acute rhythm control in hemodynamically unstable patients. 2

Symptomatic Patients Despite Rate Control

• Patients with significant symptoms (EHRA score >2) despite adequate rate control should receive rhythm control strategies. 2, 3
• If rate control offers inadequate symptomatic relief, restoration of sinus rhythm becomes the clear long-term goal. 1
• Rhythm control is appropriate when based on patient symptoms, exercise tolerance, and patient preference. 1

Younger Patients with Paroxysmal AF

• For younger individuals, especially those with paroxysmal lone AF without structural heart disease, rhythm control is preferred as first-line therapy. 1
• Catheter ablation is recommended as a first-line therapy option for patients with paroxysmal AF (Class IIa recommendation). 2
• Younger patients with healthy hearts were not well represented in the major rate vs. rhythm control trials, so the evidence supporting rate control in this population is limited. 1

AF with Reversible Causes

• When the initiating pathophysiology of AF is reversible (thyrotoxicosis, post-cardiac surgery), rhythm control is preferred and no long-term therapy may be necessary after the underlying condition resolves. 1

AF with Slow Ventricular Response

• Rhythm control is the preferred initial approach for younger individuals with paroxysmal AF and slow ventricular response, as restoration of sinus rhythm eliminates both the bradycardia problem and the need for rate-controlling medications. 5

Specific Clinical Scenarios Favoring Rate Control

Elderly Patients with Persistent AF

• Rate control is reasonable initial therapy in older patients with persistent AF who have hypertension or heart disease. 1
• The AFFIRM trial showed a trend toward increased mortality with rhythm control in patients older than 65 years, those with coronary heart disease, and those without congestive heart failure. 1
• The RACE trial found a trend for increased mortality in the rhythm-control group in patients with hypertension and in women. 1

Asymptomatic or Minimally Symptomatic Patients

• Elderly patients with mild symptoms (EHRA score 1) should receive rate control with chronic anticoagulation as the preferred strategy. 3
• Amelioration of symptoms by rate control in older patients steers away from attempts to restore sinus rhythm. 1

Patients with Multiple Comorbidities

• Patients with persistent or permanent atrial fibrillation, left atrial dilation, multiple cardiovascular comorbidities, or uncontrolled hypertension are more suitable for rate control. 3

Failed Rhythm Control Attempts

• Only 40% of patients in rhythm-control groups maintained sinus rhythm at 1 year despite aggressive management, suggesting many patients cannot maintain sinus rhythm long-term. 1
• When rhythm control fails to improve symptoms or causes unwanted adverse effects (frequent cardioversions, sinus node disease requiring pacemaker, proarrhythmia), it should be abandoned in favor of rate control. 6

Critical Anticoagulation Consideration

Anticoagulation should be based on stroke risk assessment (CHA₂DS₂-VASc score) regardless of whether rhythm or rate control strategy is chosen. 2, 3

• Most strokes in rhythm control patients occurred after discontinuation of anticoagulation or at subtherapeutic INR levels. 1
• Clinically silent recurrences of AF in asymptomatic patients treated with antiarrhythmic drugs may be responsible for thromboembolic events after withdrawal of anticoagulation. 1
• All primary endpoints in the STAF trial occurred in patients in atrial fibrillation, even in the rhythm-control group, suggesting anticoagulation should continue indefinitely regardless of strategy. 1

Common Pitfalls to Avoid

• Do not discontinue anticoagulation in rhythm control patients based solely on apparent maintenance of sinus rhythm, as silent AF recurrences are common and most strokes occur after stopping anticoagulation. 1
• Do not use Class I antiarrhythmic agents (flecainide, propafenone) in patients with structural heart disease, coronary artery disease, or significant LV hypertrophy due to increased proarrhythmic risk. 2
• Do not assume rhythm control improves quality of life, as the AFFIRM, RACE, PIAF, and STAF studies found no differences in quality of life between strategies. 1
• Avoid rhythm control in patients with factors predicting failure: longer AF duration, older age, atrial dilatation, poor functional class or heart failure, and hypertension all predict failure to maintain sinus rhythm. 6