Rhythm Versus Rate Control for Atrial Fibrillation: A Meta-analysis of Randomized Controlled Trials

Abdelrahman Ibrahim Abushouk,Loalo'A El-Sherif,Mennat-Allah Abdelsamed,Nehal Alaa Mohamed,Mohamed M Abdel-Daim,Mohamed Kamal Mohamed,Merhan Kamal Sayed,Aya Ashraf Ali,Ahmed Abdou Mohamed,Ahmed Abdelbaset Osman,Sameh M Shaheen

doi:10.13005/bpj/1413

Abdelrahman Ibrahim Abushouk, Loalo'A El-Sherif + Show 9 more

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https://doi.org/10.13005/bpj/1413

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Abstract

Atrial fibrillation (AF) is a common, sustained tachyarrhythmia, associated with an increased risk of mortality and thromboembolic events. We performed this meta-analysis to compare the clinical efficacy of rate and rhythm control strategies in patients with AF in a meta-analysis framework. A comprehensive search of PubMed, OVID, Cochrane-CENTRAL, EMBASE, Scopus, and Web of Science was conducted, using relevant keywords. Dichotomous data on mortality and other clinical events were extracted and pooled as risk ratios (RRs), with their 95% confidence-interval (CI), using RevMan software (version 5.3). Twelve studies (8451 patients) were pooled in the final analysis. The overall effect-estimate did not favor rate or rhythm control strategies in terms of all-cause mortality (RR= 1.13, 95% CI [0.88, 1.45]), stroke (RR= 0.97, 95% CI [0.79, 1.20]), thromboembolism (RR= 1.06, 95% CI [0.64, 1.76]), and major bleeding (RR= 1.10, 95% CI [0.90, 1.35]) rates. These findings were consistent in AF patients with concomitant heart failure (HF). The rate of rehospitalization was significantly higher (RR= 0.72, 95% CI [0.57, 0.92]) in the rhythm control group, compared to the rate control group. In younger patients (<65 years), rhythm control was superior to rate control in terms of lowering the risk of all-cause mortality (p=0.0003), HF (p=0.003) and major bleeding (p=0.02). In older AF patients and those with concomitant HF, both rate and rhythm control strategies have similar rates of mortality and major clinical outcomes; therefore, choosing an appropriate strategy should consider individual variations, such as patient preferences, comorbidities, and treatment cost.

Highlights

Atrial fibrillation (AF) is a common, sustained tachyarrhythmia, associated with an increased risk of mortality and thromboembolic events
We developed the search strategy for each database using the following terms: “Atrial fibrillation”, “Rate control”, “Beta blockers”, “Calcium channel blockers”, “Antiarrhythmic”, “Cardioversion”, and “Rhythm control” (Supplementary file 1)
All included studies had a low risk of selection, attrition, and reporting biases, except for the AFFIRM trial[20,21], as well as How to Treat Chronic Atrial Fibrillation study (CAFÉ) II (16) and RACE15,22 trials

Summary

Introduction

Atrial fibrillation (AF) is a common, sustained tachyarrhythmia, associated with an increased risk of mortality and thromboembolic events We performed this meta-analysis to compare the clinical efficacy of rate and rhythm control strategies in patients with AF in a meta-analysis framework. The overall effect-estimate did not favor rate or rhythm control strategies in terms of all-cause mortality (RR= 1.13, 95% CI [0.88, 1.45]), stroke (RR= 0.97, 95% CI [0.79, 1.20]), thromboembolism (RR= 1.06, 95% CI [0.64, 1.76]), and major bleeding (RR= 1.10, 95% CI [0.90, 1.35]) rates These findings were consistent in AF patients with concomitant heart failure (HF). Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, affecting more than 5% of the worldwide population[1] It is associated with a high risk of thromboembolic events, including stroke, which occurs in about 23% of AF patients, older than 80 years[2,3]. In the past few years, several randomized controlled trials (RCTs) have investigated whether rhythm control is superior to rate control with respect to mortality and cerebrovascular accidents[9–22]

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