A Contemporary Look at Classic Trials in Atrial Fibrillation: What Do They Really Show and How Might They Apply to Future Therapies?

Abstract

Atrial fibrillation (AF) is a common cardiac arrhythmia associated with significant morbidity, decreased exercise tolerance, and impairment of quality of life (QOL). Primary treatment objectives are either to restore and/or maintain sinus rhythm or to achieve satisfactory rate control. There are 5 landmark randomized trials comparing rhythm and rate control strategies that have reported equivalence in overall survival, and data from several trials suggest that the appropriate use of either approach leads to improvement in QOL. Study limitations (eg, trial design, analytic methodology, patient selection criteria, and lack of specificity of therapeutic intervention), however, have made the applicability of findings to a general AF patient population difficult. Although the optimal strategy remains unclear, an important first step in AF management is the proper identification and stratification of patients who require therapy. Given the currently available pharmacologic agents and procedures, as-needed therapy may be a reasonable approach in patients with intermittent AF, whereas the pursuit of sinus rhythm may be warranted in the balance of patients who remain symptomatic despite rate control therapy. The overarching treatment goal should be to provide individualized care based on patient characteristics at presentation, with appropriate consideration given to potential treatment-related adverse effects. Importantly, as the armamentarium of AF management strategies is broadened, the risk/efficacy balance must continue to be evaluated on a patient-specific basis.