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Rate Control for Atrial Fibrillation: Can We Relax?
In a randomized trial, patients whose heart rates were strictly controlled fared no better than those treated more leniently — at least in the short term.
In many patients with relatively few symptoms, atrial fibrillation (AF) can be managed with heart rate control alone, without rhythm correction. Traditionally, the target in such cases has been the rate that would be expected in a similar patient in sinus rhythm. However, a retrospective analysis of data from two trials of rate versus rhythm control showed no clinical benefit from such strict control. In the current prospective Dutch trial, investigators randomized 614 patients with AF suitable for management with rate control alone to either strict control (<80 beats/minute at rest and <110 beats/minute during moderate exercise) or lenient control (<110 beats/minute at rest).
At the end of the dose-titration phase of the trial, the mean resting heart rate was markedly different in the strict- and lenient-control groups (76 vs. 93 beats/minute), but by 1 year, the difference had narrowed (75 vs. 86 beats/minute). At 3 years, the composite rate of death, hospitalization for heart failure, stroke, embolization, bleeding, and life-threatening arrhythmia did not differ significantly between the groups.
Comment: This study is the third to show no outcome improvement in patients with atrial fibrillation treated with strict versus lenient rate control. However, these were relatively short-term trials, and remodeling associated with rapid heart rates might not become evident for many more years. Furthermore, even the patients in the lenient-control group achieved reasonably low heart rates. Nonetheless, as an editorialist reminds us, adverse drug effects may outweigh what we believe to be the benefits of strict rate control. It is, indeed, "better to treat the patient and not the electrocardiogram."
Published in Journal Watch Cardiology March 15, 2010
Citation(s):
Van Gelder IC et al. Lenient versus strict rate control in patients with atrial fibrillation. N Engl J Med 2010 Mar 15; [e-pub ahead of print]. (http://dx.doi.org/10.1056/NEJMoa1001337)
Dorian P. Rate control in atrial fibrillation. N Engl J Med 2010 Mar 15; [e-pub ahead of print]. (http://dx.doi.org/10.1056/NEJMe1002301)
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- A very significant Study
Dr. Kewal Krishen Thassu, Bhopal, 18 Mar 2010 4:18 PM EST
I fully agree with dr. Mark Links remark that we have to treat the patients and not the electrocardiogram.the study... [more] - Atrial Fibrillation
John W Gallo, retired.., 12 Apr 2010 12:48 PM EST
It's been 17 years now since my first AF attack and I now realize it is all related to sleep... [more]
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