Practical Lessons from the New Atrial Fibrillation Guidelines

Atrial fibrillation is the most common arrhythmia in the country, and its prevalence is increasing as the U.S. population ages.¹ Frequently associated with hypertension and/or coronary artery disease (CAD), atrial fibrillation results in serious morbidity, mortality, hospitalization and emergency room visits.

Since 2000, five clinical trials have been published regarding the question of whether the use of long-term prophylactic therapy with antiarrhythmic drugs to maintain sinus rhythm (rhythm control) in patients with atrial fibrillation results in a better outcome than a strategy aimed at controlling heart rate and anticoagulation appropriate to the atrial fibrillation guidelines (rate control).^2-6 In all five trials, there was no improvement in clinical outcome (stroke, death, heart failure, hospitalization) in patients comparing the two strategies.

It is useful to focus on the Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) trial since it is three-times the size of the other four trials combined.² AFFIRM studied 4,060 patients to assess the benefits of prophylactic antiarrhythmic therapy, and patients were randomized to either a rate control or rhythm control strategy. Despite the fact that patients in the rhythm control group stayed in sinus rhythm nearly twice as often as the rate control group (62.6% vs. 34.6%), there was no difference in mortality, heart failure or stroke between the two strategies. Although it is still recommended to restore sinus rhythm during a first or second episode of atrial fibrillation, physicians are left with the conundrum of whether to adopt a rate or rhythm control strategy. This review will focus on selected aspects of the updated atrial fibrillation guidelines and the clinical trials impacting these alternatives.⁷