Abstract
Recent innovations have the potential to improve rhythm control therapy in patients with atrial fibrillation (AF). Controlled trials provide new evidence on the effectiveness and safety of rhythm control therapy, particularly in patients with AF and heart failure. This review summarizes evidence supporting the use of rhythm control therapy in patients with AF for different outcomes, discusses implications for indications, and highlights remaining clinical gaps in evidence. Rhythm control therapy improves symptoms and quality of life in patients with symptomatic AF and can be safely delivered in elderly patients with comorbidities (mean age 70 years, 3–7% complications at 1 year). Atrial fibrillation ablation maintains sinus rhythm more effectively than antiarrhythmic drug therapy, but recurrent AF remains common, highlighting the need for better patient selection (precision medicine). Antiarrhythmic drugs remain effective after AF ablation, underpinning the synergistic mechanisms of action of AF ablation and antiarrhythmic drugs. Atrial fibrillation ablation appears to improve left ventricular function in a subset of patients with AF and heart failure. Data on the prognostic effect of rhythm control therapy are heterogeneous without a clear signal for either benefit or harm. Rhythm control therapy has acceptable safety and improves quality of life in patients with symptomatic AF, including in elderly populations with stroke risk factors. There is a clinical need to better stratify patients for rhythm control therapy. Further studies are needed to determine whether rhythm control therapy, and particularly AF ablation, improves left ventricular function and reduces AF-related complications.
Highlights
The prevalence of atrial fibrillation (AF) and its associated mortality and morbidity are expected to double or triple within the two to three decades, driven by population ageing and increased incidence of AF.[1,2] Even on optimal anticoagulation and rate control therapy, patients with AF are at high risk of cardiovascular death, sudden death and death due to heart failure.[3,4] Rhythm control therapy using antiarrhythmic drugs, cardioversion, and AF ablation, is clinically used to improve AF-related symptoms.[5]
The smaller CASTLE-AF (Catheter Ablation vs. Standard Conventional Therapy in Patients with Left Ventricular Dysfunction and Atrial Fibrillation) suggests that AF ablation could improve outcomes in patients with AF and severe heart failure compared to drug therapy, combining rate control therapy and antiarrhythmic drug therapy.[10]
Over a median follow-up of 48.5 months, the primary endpoint occurred in 8.0% of patients randomized to AF ablation, and in 9.2% of patients randomized to antiarrhythmic drug therapy [hazard ratio (HR) 0.86, 95% CI 0.65–1.15; P = 0.30]
Summary
The prevalence of atrial fibrillation (AF) and its associated mortality and morbidity are expected to double or triple within the two to three decades, driven by population ageing and increased incidence of AF.[1,2] Even on optimal anticoagulation and rate control therapy, patients with AF are at high risk of cardiovascular death, sudden death and death due to heart failure.[3,4] Rhythm control therapy using antiarrhythmic drugs, cardioversion, and AF ablation, is clinically used to improve AF-related symptoms.[5] Currently, there is no established indication for rhythm control therapy apart from improvement of AF-related symptoms.[6,7,8] The CABANA (Catheter Ablation vs Anti-arrhythmic Drug Therapy for Atrial Fibrillation) trial recently provided new confirmation on the safety of AF ablation in contemporary AF patients at risk of stroke.[9] The smaller CASTLE-AF (Catheter Ablation vs Standard Conventional Therapy in Patients with Left Ventricular Dysfunction and Atrial Fibrillation) suggests that AF ablation could improve outcomes in patients with AF and severe heart failure compared to drug therapy, combining rate control therapy and antiarrhythmic drug therapy.[10] Here, we review the available evidence supporting the use of rhythm control therapy in patients with AF, discuss potential implications for indications, and highlight clinical evidence gaps
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