52 in 52: Rate vs. Rhythm for A fib

    NextPrevious

    52 in 52: Rate vs. Rhythm for A fib

    Article Citation:

    Wyse DG, Waldo AL, DiMarco JP, Domanski MJ, et al; Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) Investigators. A comparison of rate control and rhythm control in patients with atrial fibrillation. N Engl J Med. 2002 Dec 5;347(23):1825-33. PMID: 12466506

    Resident Reviewer: Courtney Cassella

    What we already know about the topic

    There are two approaches to atrial fibrillation, rhythm control or rate control. The benefits of rhythm control were possibly fewer symptoms, better quality of life, better exercise tolerance, lower risk of stroke, eventual discontinuation of anticoagulation, and better survival. However, rhythm control can be difficult to achieve and often at the expense of serious adverse effects from antiarrhythmic drugs. Rate control is a simpler strategy with less toxic drugs although anticoagulation plays a more important role in this strategy.

    Why this study is important

    This study compares long-term treatment of atrial fibrillation. By comparing rhythm versus rate control the study aimed to answer if one treatment strategy was superior in regards to outcomes for mortality, ischemic stroke, or hemorrhage.

    Brief overview of the study

    A total of 4060 patients over the age of 65 years who had risk factors for stroke or death were enrolled in this study. The rhythm-control strategy group allowed the treating physician to pick antiarrhythmic drugs to maintain sinus rhythm. The rate control group used beta-blockers, calcium-channel blockers, digoxin, or a combination of drugs for a goal heart rate less than 80 bpm at rest and less than 110 bpm during a 6-min walk test. Mortality was higher in the rhythm-control group but was not statistically significant. There was no difference in the composite endpoint of death, disabling stroke, disabling anoxic encephalopathy, major bleeding, or cardiac arrest.

    Limitations

    Limitations in this study include patients were only eligible if age was greater than 65 years or those with risk factors for stroke making generalizability to younger patients difficult. Furthermore, given the perceived benefits of rhythm control, if patients were thought to have more frequent or severe symptoms investigators may not have enrolled them in the study. Lastly the follow-up was 5 years and given atrial fibrillation patients often need therapy for longer treatment benefit in one group or the other could be masked.

    Take home points

    • Rate control is non-inferior to rhythm control in the long term treatment of atrial fibrillation
    • Rate control may be superior to rhythm control given the adverse drug effects of rhythm control agents
    • Welcome! This is the website for the Mount Sinai Emergency Ultrasound Division. It serves as an information resource for residents, fellows, medical students and others seeking information about point-of-care ultrasound. There is a lot ofRead more

    • renal handling of water

      If you were on a tea & toast diet, how much water would you need to drink before you develop hyponatremia? I haven’t seen anyone work out the numbers before so here are my calculations. AndRead more

    • acute acidemia physiology

      As alluded to in the first post, don’t be fooled by a “normal” potassium in the setting of DKA because osmotic diuresis and H+/K+ exchange means that total body potassium is actually LOW. You all knowRead more

    • renal handling of potassium

      the first symptom of hyperkalemia is death Earlier post covered temporizing measures to counter hyperkalemia — namely, intracellular shift, increasing cardiac myocyte threshold potential. Give furosemide if the patient still urinates and consider dialysis, but then askRead more

    • bicarbonate revisited

      Previous post reviewed the safety of balanced crystalloids in hyper K. But what was up with serum bicarbonate decreasing with saline administration? This post introduces a new way of looking at the anion gap to possiblyRead more

    • hyperkalemia and balanced crystalloids

      Is it safe to give LR or plasmalyte to a hyperkalemic patient (these balanced crystalloids have 4-5 mEq/L K as opposed to 0 mEq/L K in normal saline)? Postponing the discussion of renal handling of potassium toRead more

    • hyperkalemia physiology

      You’ll likely encounter hyperkalemia on your next Resus / Cardiac shift, and you’ll instinctively treat it. But take a moment to review the fascinating physiology behind the “cocktail”! First, consider how K+ is buffered byRead more

    • Slow down your tachycardia (but not really)

      You’re sitting in resus bemoaning the departure of your most beloved attending when suddenly a patient wheels in without warning. The patient looks relatively stable but the triage RN tells you her heart rate wasRead more

    • Otitis externa: use the ear wick!

      Acute otitis externa (AOE) is a common complaint seen in pediatric as well as adult emergency departments. AOE is typically not accompanied by acute otitis media, although concurrent cases are possible. Also called “swimmer’s ear”Read more

    NextPrevious