Rate Control In Patients Research Articles

Efficacy of amiodarone in patients with atrial fibrillation with and without left ventricular dysfunction: a pooled analysis of AFFIRM and AF-CHF trials.

Despite amiodarone's established safety profile in the setting of heart failure, it is unknown whether its impact on cardiovascular outcomes in patients with atrial fibrillation is modulated by left ventricular function. A pooled analysis of 3,307 patients (age 68.0 ± 0.2 years; 31.1% female) enrolled in AFFIRM and AF-CHF trials was conducted to assess the effect of rhythm control with amiodarone on cardiovascular outcomes, according to left ventricular systolic function. In amiodarone-treated patients (N = 1,107), freedom from recurrent atrial fibrillation was 84% and 45% at 1 and 5 years, respectively, with no differences according to left ventricular function (P = 0.8754). Similarly, the adjusted proportion of time spent in atrial fibrillation (15.0 ± 1.8%) did not vary according to ventricular function (P = 0.6094). Over 40.0 ± 0.3 months of follow-up, 1,963 (59.4%) patients required at least one hospitalization, 1,401 (42.6%) of whom had cardiovascular-related hospitalizations. Adjusted all-cause and cardiovascular hospitalization rates were similar with amiodarone versus rate control in all patients and in subgroups with and without severe left ventricular dysfunction. A total of 729 (22.0%) patients died, 498 (15.1%) from cardiovascular causes. Adjusted all-cause and cardiovascular mortality rates were similar with amiodarone versus rate control overall and in subgroups with and without severe left ventricular dysfunction. Amiodarone's efficacy in maintaining sinus rhythm and reducing the burden of atrial fibrillation is similar in the presence or absence of severe left ventricular dysfunction. Rhythm control with amiodarone is associated with comparable hospitalization and mortality rates to rate control in patients with and without left ventricular dysfunction.

GW25-e1679 Rhythm verse rate control in patients with atrial fibrillation and heart failure: An updated meta-analysis of randomized controlled trials

Several clinical studies showed inconsistent results of rhythm control in patients with heart failure (HF) and atrial fibrillation (AF). We hypothesized that rhythm control had a better outcome than rate control in these patients. PUBMED, EMBASE and the Cochrane Library were searched for randomized

Are beta-blockers more effective for rate control than calcium channel blockers in patients with atrial fibrillation?

Evidence-Based Answer It is unclear if beta-blockers are better than calcium channel blockers for outpatient rate control in patients with atrial fibrillation. Guideline recommendations state either option is acceptable (SOR: B, evidencebased guideline).

Heart Rate Control in Patients with Heart Failure and Left Ventricular Systolic Dysfunction, a Tertiary Center Experience

Heart Rate Control in Patients with Heart Failure and Left Ventricular Systolic Dysfunction, a Tertiary Center Experience

The effect of strict rate control on B-type natriuretic peptide values and echocardiographic parameters in chronic atrial fibrillation.

There have been conflicting results about the role of strict rate control on cardiovascular outcomes in patients with chronic atrial fibrillation (AF). To date, large clinical studies have not shown a net clinical benefit derived from the current trend to specify the target ventricular rate according to the patient's own clinical and laboratory characteristics. Although the existing literature shows no superiority of strict rate control in clinical end points, it is difficult to assess the pure rate effect without commonly coexisting medication side effects which can also influence clinical end points. To determine the effects of strict rate control in patients with chronic AF, regarding objective parameters such as echocardiographic data and B-type natriuretic peptide (BNP) values. 38 patients with chronic AF for whom strict rate control had been planned were enrolled in the study. Patients' echocardiographic parameters, BNP values and 24 h Holter electrocardiography findings showing the average heart rate (HR), were studied at baseline and then monthly, until the end of the 3rd month. Patients' negative dromotropic therapy was adjusted to achieve a target resting HR of below 80 bpm. Laboratory and echocardiographic parameters at baseline and at the end of the study were compared in the whole study group. The whole study group was subclassified according to the average resting HRs achieved, (group 1 with strict rate control < 80 bpm; n = 25, and group 2 without strict rate control; n = 13). In group 1, the average HR declined from 101 ± 16.3 bpm to 77 ± 5.2 bpm. In group 2, the average HR was 96.6 ± 6.8 bpm at baseline and there was no significant change at the end of the study (94.2 ± 5.9 bpm). In group 1, there were significant decreases in BNP, left ventricular volumes, left atrial and right atrial areas at the end of the study. In group 2, BNP values were significantly higher at the end of the study despite similar ventricular and atrial dimensions according to the baseline. Diastolic functions were assessed roughly by septal E/e', but no significant change was observed in either group. Strict rate control in patients with chronic AF yielded a significant decrease in BNP values as well as a reduction in volumes of cardiac chambers.

PW074 Clinical and hemodynamic effect of heart rate control in patients with severe aortic stenosis

PW074 Clinical and hemodynamic effect of heart rate control in patients with severe aortic stenosis

Is electrocardiography sufficient for supraventricular tachycardia treatment? A case report

In Wolff-Parkinson-White Syndrome (WPW), presence of accessory conduits causes various signs and clinical conditions in patients. WPW syndrome is presently defined as a congenital defect involving the occurrence of abnormal conductive tissue between the atria and the ventricles in relation to supraventricular tachycardia (SVT). SVT is observed in this group of patients. WPW syndrome at high rates can be mixed with SVT. Calcium channel blockers (diltiazem, verapamil) that are one of the most preferred medicines for rate control in patients with SVT may lead to fatal risks in individuals with WPW syndrome. In our presentation, we studied, in parallel to the literature, the case of a patient who presents the WPW syndrome but who is followed as a SVT without performing the electrophysiological tests in parallel to the literature. J. Exp. Clin. Med., 2013; 30:357-359

Outcomes in Atrial Fibrillation Patients With and Without Left Ventricular Hypertrophy When Treated With a Lenient Rate-Control or Rhythm-Control Strategy

Although left ventricular (LV) hypertrophy has been proposed as a factor predisposing to atrial fibrillation (AF), its relevance to prognosis and selection of therapeutic strategies is unclear. We identified 2,105 patients with echocardiographic data on LV mass enrolled in the Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) trial. LV hypertrophy was defined as increased LV mass, stratified by American Society of Echocardiography criteria. The primary end point was all-cause mortality, secondary end point was as per AFFIRM trial definition, and tertiary end point was cardiovascular hospitalizations. We compared "strict" versus "lenient" rate control in patients with increased LV mass, and studied association of heart failure (HF) with preserved and decreased systolic function in patients with increased LV mass. Over 6 years, 332 deaths (15.7%) were reported. Adjusted hazard ratio (HR) of severely increased LV mass for all-cause mortality was 1.34 (95% confidence interval [CI] 1.01 to 1.79, p=0.045) for the overall population and 1.61 (95% CI 1.09 to 2.37, p=0.016) for the rhythm-control arm. Increased LV mass was a predictor of cardiovascular hospitalizations in the lenient rate-control group (HR 1.72, 95% CI 1.05 to 2.82, p=0.03) but not in the strict rate-control group. Severely increased LV mass was predictive of cardiovascular hospitalizations in patients with HF with preserved (HR 1.8, 95% CI 1.0 to 3.2, p=0.03) and decreased LV systolic function (HR 2.4, 95% CI 1.1 to 5.2, p=0.02). Thus, LV hypertrophy is a significant independent predictor of mortality in patients with AF, especially those managed with rhythm control. In patients with LV hypertrophy, strict rate control may be associated with better outcomes than lenient rate control. LV hypertrophy portends higher cardiovascular morbidity in patients with AF and HF.

Short-term ECG recordings for heart rate assessment in patients with chronic atrial fibrillation.

IntroductionThere is no consensus on the length of ECG tracing that should be recorded to represent adequate rate control in patients with atrial fibrillation (AFib). The purpose of the study was to examine whether heart rate measurements based on short-term ECGs recorded at different periods of the day may correspond to the mean heart rate and rate irregularity analyzed from standard 24-hour Holter monitoring.Material and methodsThe study enrolled 50 consecutive patients with chronic AFib who underwent 24-hour Holter monitoring. Mean heart rate (mHR) and the coefficient of irregularity (CI) were assessed from 5- and 60-minute intervals of Holter recordings in different periods of the day.ResultsThe highest correlation in mean heart rate interval within 24 h was found during a 6-hour sample and in the periods 11.00 AM–12.00 PM, 12 PM–1.00 PM, and 1.00 PM–2.00 PM. With respect to irregularity, only the CI measurements based on a 6-hour interval (7.00 AM–1.00 AM) show a correlation > 0.08 compared to data from the 24-hour recording.ConclusionsOnly long-term (6-hour) recordings provide a high correlation within 24 h in mean heart rate interval and coefficient of irregularity. It seems that the mean heart rate interval in 1-hour periods between 11 AM and 2 PM might be predictive for 24-hour data. Short time recordings of the coefficient of irregularity of heart rate in AFib patients at this moment are not useful in clinical practice for long-term prognosis of ventricular irregularity.

Lenient vs. strict rate control in patients with atrial fibrillation and heart failure: a post‐hoc analysis of the RACE II study

It is unknown whether lenient rate control is an acceptable strategy in patients with AF and heart failure. We evaluated differences in outcome in patients with AF and heart failure treated with lenient or strict rate control. This post-hoc analysis of the RACE II trial included patients with an LVEF ≤ 40% at baseline or a previous hospitalization for heart failure or signs and symptoms of heart failure. Primary outcome was a composite of cardiovascular morbidity and mortality. Secondary endpoints were AF-related symptoms and quality of life. Two hundred and eighty-seven (46.7%) of the 614 patients had heart failure. Patients with heart failure had significantly higher NT-proBNP plasma levels, a lower LVEF, and more often used ACE inhibitors, ARBs, and diuretics. At 3 years follow-up, the primary outcome occurred more frequently in patients with heart failure (16.7% vs. 11.5%, P = 0.04). In heart failure patients, the estimated cumulative incidence of the primary outcome was 15.0% (n = 20) in the lenient and 18.2% (n = 26) in the strict group (P = 0.53). No differences were found in any of the primary outcome components, in either heart failure hospitalizations [8 (6.1%) vs. 9 (6.8%) patients in the lenient vs. strict group, respectively], symptoms, or quality of life. In patients with AF and heart failure with a predominantly preserved EF, the stringency of rate control seems to have no effect on cardiovascular morbidity and mortality, symptoms, and quality of life.

Atrial fibrillation in heart failure: catheter and surgical interventional therapies

Atrial fibrillation and heart failure commonly coexist in the same patient. Each may adversely affect the other. Atrial fibrillation leads to heart failure exacerbation, left ventricular function deterioration and an increase in thrombo-embolic risk. Therapeutic options targeting atrial fibrillation in heart failure patients include pharmacological and non-pharmacological means. Pharmacological therapy is directed at either rate control using nodal blocking agents or rhythm control using anti-arrhythmic agents, of which the options are limited in patients with heart failure. The landmark AF-CHF trial did not show any benefit of rhythm control strategy as opposed to rate control in patients with heart failure and atrial fibrillation. However, patients in this trial as well as in others used mostly amiodarone for rhythm control. This might have negated any positive effects of achieving normal sinus rhythm. Non-pharmacological therapy both for rate and rhythm control is appealing. This includes AV node ablation for rate control, catheter ablation of atrial fibrillation and surgical therapy of atrial fibrillation. This review will address non-pharmacologic treatment of AF in heart failure patients.

A bioenergetic assessment of mitral regurgitation: A new tool to assess severity?

Mitral regurgitation is frequently classified as mild, moderate or severe based on echocardiography. Patients with mild mitral regurgitation are usually managed medically. We hypothesise that mild mitral regurgitation as assessed volumetrically can in fact be severe when analysed from a bioenergetics point of view. The conservation of energy predicts that any regurgitant volume will require the heart to provide more work energy to support the circulation. Mitral regurgitation involves the left ventricle imparting potential energy, via blood pressure, and kinetic energy, via regurgitant velocity, to the regurgitant blood volume. This implies that regurgitant volume, regurgitant velocity, systolic blood pressure, heart rate, regurgitant orifice area and cardiac output are all important factors. We present limited data to demonstrate our hypothesis. A bioenergetic analysis of mitral regurgitation, may identify patients whose mitral regurgitation, assessed via echocardiography as mild, is actually clinically significant. In addition we identify the importance of blood pressure and heart rate control in patients with mitral regurgitation. The concept that a bit of mitral regurgitation in patients with poor left ventricles is a good thing, as it helps offload the left ventricle is from an engineering point fundamentally flawed.

The Role of Ablation of the Atrioventricular Junction in Patients with Heart Failure and Atrial Fibrillation

Ablation of the atrioventricular junction (AVJ) is a technically easy procedure that is safe and has a high success rate as an intervention for effective ventricular rate control in patients in symptomatic atrial fibrillation. AVJ ablation has been reported to improve quality of life, left ventricular ejection fraction, and exercise duration in these patients and minimize the incidence of inappropriate shocks. Because right ventricular pacing after AVJ ablation may result in decrease in left ventricular function and worsening of heart failure symptoms, there is increasing evidence to support the effectiveness of cardiac resynchronization therapy in atrial fibrillation populations.

Outcomes after rhythm versus rate control in patients with atrial fibrillation: the international prospective GARFIELD registry

Purpose: To determine whether rhythm control confers clinical benefits over rate control in patients with newly diagnosed atrial fibrillation (AF). Methods: Adults (≥18 y) with newly diagnosed non-valvular AF and ≥1 stroke risk factor were enrolled (540 sites, 19 countries). Cox proportional hazards model was used to determine the effects of rhythm vs rate control at 1 year, adjusted for antithrombotic treatments and components of CHA2DS2-VASc score. Results: Of the 10,614 adults enrolled, baseline and follow-up data were available in 9258 and 8839 patients, respectively. Patients in the rate control group were older, had higher risk scores and were more likely to have antithrombotic treatments initiated at AF diagnosis (Table 1). Rhythm control was associated with a significantly lower risk of death (absolute rates 1.6% vs 2.7%; adjusted HR 0.73, 95% CI 0.53–0.98; p=0.039) and a numerically lower risk of stroke/systemic embolism (0.9% vs 1.3%; HR 0.68, 95% CI 0.45–1.04; p=0.075). There were no differences in acute coronary syndrome, major bleeding or intracranial haemorrhage. View this table: Baseline characteristics Conclusions: Among patients with newly diagnosed non-valvular AF and ≥1 stroke risk factor, rhythm control seems to be associated with clinical benefits over rate control. However, the two groups differed in many respects, and we may not have been able to adjust for residual confounding. The results must therefore be interpreted with caution.

Atrial Fibrillation and Congestive Heart Failure: A Cost Analysis of Rhythm-Control vs Rate-Control Strategies

BackgroundAtrial fibrillation (AF) is common in patients with heart failure. Rhythm- and rate-control strategies are associated with similar efficacy outcomes. We compared the economic impact of the 2 treatment strategies in patients with AF and heart failure from the province of Québec, Canada. MethodsIn a substudy of the Atrial Fibrillation and Congestive Heart Failure trial, health care expenditures of patients from Québec randomized to rhythm and rate-control treatment strategies were compared from a single-payer perspective using a cost-minimization approach. In-trial resource utilization and unit costs were estimated from Québec Health Insurance Board databases supplemented by disease-specific costs from the Ontario Case Costing Initiative. ResultsIn all, 304 patients were included, aged 68 ± 9 years; 86% male; ejection fraction, 26% ± 6%. Baseline characteristics were similar in rhythm-control (n = 149) and rate-control (n = 155) groups. Arrhythmia-related costs accounted for 45% of total expenditures. Rate-control patients had fewer cardiac procedures (146 vs 238, P < 0.001), driven by fewer cardioversions, and lower costs related to antiarrhythmic drugs (CAD$48 per patient [95% confidence interval {CI}, $21-$96] vs $1319 per patient [95% CI, $1124-$1522]). However, these differences were offset by higher expenditures due to hospitalizations for noncardiovascular diagnoses, implantable cardiac arrhythmia devices, and noncardiovascular drugs in the rate-control group. The total cost per patient was not significantly different between rhythm-control ($72,764 [95% CI, $61,575-$85,145]) and rate-control ($78,767 [95% CI, $67,101-$92,139]) strategies. ConclusionIn the study population, the therapeutic strategy used to manage AF in patients with severe heart failure appears to have little influence on the overall financial burden, which remains substantial.

One‑year follow‑up of the Polish subset of the RecordAF registry of patients with newly diagnosed atrial fibrillation

Data on real-life management of atrial fibrillation (AF) in Poland is limited. To present data on 1-year follow-up of patients from Poland included in a worldwide registry on patients with AF (RecordAF). Patients with recent onset AF were included (n=303). Treatment strategy (rhythm or rate control) was noted at baseline. Therapeutic success (control of AF, with no incidence of cardiovascular events and no switch between the strategies) was assessed after one year. Data from 289 patients were assessable. A rhythm control strategy was noted in 70% of patients. Rhythm control patients received anti-thrombotic therapy less frequently than rate control patients (90.4% vs. 97.6%) but more often received class I (19.8% vs. 4.8%) and class III (20.8% vs. 4.8%) antiarrhythmic drugs (p<0.05 for all comparisons). Therapeutic success was noted in 71.5% of rhythm control patients vs. 29.1% of rate control patients (p<0.0001), a result driven by control of AF (89.3% in the rhythm control group vs. 56.1% in the rate control group, p<0.0001). The rate of cardiovascular events was similar in both groups (20.6% of all patients). Progression to permanent AF occurred in 5.9% of rhythm control patients vs. 73.2% of rate control patients (p<0.001). Most of the patients received thromboembolic prevention and the majority was assigned to rhythm control. Despite infrequent use of anti-arrhythmic drugs, a rhythm control strategy was associated with better AF control and slower progression but not with lower rate of cardiovascular events in patients with recent-onset AF in Poland.

Rate control efficacy in permanent atrial fibrillation: successful and failed strict rate control against a background of lenient rate control: data from the rate control efficacy in permanent atrial fibrillation study

Rate control is often the therapy of choice for permanent atrial fibrillation. The RACE II study was the first to evaluate the relative efficacy of strict rate control (resting heart rate < 80 bpm and during moderate exercise <110 bpm) versus lenient rate control (resting heart rate <110 bpm) in patients with permanent AF. The study demonstrated that lenient rate control was not only easier to achieve but was non-inferior to strict rate control in reducing symptoms, improving the quality of life, exercise tolerance and survival. However, an important limitation was the marked discrepancy in the number of patients achieving target heart rate (THR), in the two groups. While only 67% achieved THR in the strict rate control group, almost all (98%) achieved THR in the lenient rate control group. Since this could have influenced the outcome in favor of lenient rate control, the present post hoc analysis evaluated differences in outcomes in patients with successful strict (n = 203), failed strict (n = 98), and lenient rate control (n = 307). Patients in the strict rate control group who failed to achieve one of the heart rate criteria were classified as failed strict while the remaining patients were classified as successful strict rate control. Nearly 80% of patients in the failed strict group had resting heart rate >80 bpm at the end of dose-adjustment phase. Reasons for failure to achieve strict rate control included drug-related adverse events in 25% and inability to achieve THR with drugs in another 20% patients. Clinical characteristics and echocardiographic parameters (including left atrial and left ventricular dimensions and baseline EF) were similar amongst the three groups. Mean dosages of rate control drugs (beta blockers, verapamil and digoxin) as well as use of drug combination was significantly higher in successful strict and failed rate control as compared to lenient rate control groups. The number of additional hospital visits at 1 and 2 years of follow up were significantly more common in the successful strict and failed strict compared with the lenient group while there was no difference in additional visits between the successful strict and failed strict groups. The primary outcome (composite of death from cardiovascular causes, hospitalization for heart failure, and stroke, systemic embolism, bleeding, and life-threatening arrhythmic events), all-cause mortality and quality of life scores were not significantly different amongst patients with strict, failed strict or lenient rate control. Separate analysis of patients with EF <40% also revealed no differences in the primary outcome. Whether use of more aggressive measures to achieve strict rate control or longer follow up would reveal any outcome differences remains to be studied further. The study confirms that it is often difficult to achieve strict heart rate control in patients with AF with currently available anti-arrhythmic drugs. Not only do these patients require higher dosages of drugs and drug combinations, but the number of additional hospital visits is also more. Despite achieving pre-specified target heart rate, there was no difference in outcome between successful and failed strict rate control. Therefore a strategy of lenient rate control may continue to be the preferred strategy in patients with permanent AF. However in patients with intolerable rate related symptoms or onset of tachycardiomyopathy, lower heart rate targets may be reasonable.

Management of Patients With Atrial Fibrillation (Compilation of 2006 ACCF/AHA/ESC and 2011 ACCF/AHA/HRS Recommendations)

This document is a compilation of the current American College of Cardiology Foundation/American Heart Association (ACCF/AHA) practice guideline recommendations for atrial fibrillation (AF) from the “ACC/AHA/ESC 2006 Guidelines for the Management of Patients With Atrial Fibrillation),”* the “2011 ACCF/AHA/HRS Focused Update on the Management of Patients With Atrial Fibrillation (Updating the 2006 Guideline)”† and the “2011 ACCF/AHA/HRS Focused Update on the Management of Patients With Atrial Fibrillation (Update on Dabigatran).”‡ Updated and new recommendations from 2011 are noted and outdated recommendations have been removed. No new evidence was reviewed, and no recommendations included herein are original to this document. The ACCF/AHA Task Force on Practice Guidelines chooses to republish the recommendations in this format to provide the complete set of practice guideline recommendations in a single resource. ### 1.1. Pharmacological and Nonpharmacological Therapeutic Options #### 1.1.1. Rate Control During AF Class I 1. Measurement of the heart rate at rest and control of the rate using …

Safety and Efficiency of Calcium Channel Blockers Versus Beta‐blockers for Rate Control in Patients With Atrial Fibrillation and No Acute Underlying Medical Illness

Many patients with atrial fibrillation (AF) are not candidates for rhythm control and may require rate control, typically with beta-blocking (BB) or calcium channel blocking (CCB) agents. Although these patients appear to have a low 30-day rate of stroke or death, it is unclear if one class of agent is safer or more effective. The objective was to determine whether BBs or CCBs would have a lower hospital admission rate and to measure 30-day safety outcomes including stroke, death, and emergency department (ED) revisits. This retrospective cohort study used a database from two urban EDs to identify consecutive patients with ED discharge diagnoses of AF from April 1, 2006, to March 31, 2010. Comorbidities, rhythms, management, and immediate outcomes were obtained by manual chart review, and patients with acute underlying medical conditions were excluded by predefined criteria. Patients managed only with rate control agents were eligible for review, and patients receiving BB agents were compared to those receiving CCB agents. The primary outcome was the proportion of patients requiring hospital admission; secondary outcomes included the ED length of stay (LOS), the proportion of patients having adverse events, the proportion of patients returning within 7 or 30 days, and the number of patients having a stroke or dying within 30 days. A total of 259 consecutive patients were enrolled, with 100 receiving CCBs and 159 receiving BBs. Baseline demographics and comorbidities were similar. Twenty-seven percent of BB patients were admitted, and 31.0% of CCB patients were admitted (difference = 4.0%, 95% confidence interval [CI] = -7.7% to 16.1%), and there were no significant differences in ED LOS, adverse events, or 7- or 30-day ED revisits. One patient who received metoprolol had a stroke, and one patient who received diltiazem died within 30 days. In this cohort of ED patients with AF and no acute underlying medical illness who underwent rate control only, patients receiving CCBs had similar hospital admission rates to those receiving BBs, while both classes of medications appeared equally safe at 30 days. Both CCBs and BBs are acceptable options for rate control.

Rate versus rhythm control for management of atrial fibrillation in clinical practice: Results from the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation (ORBIT-AF) registry

All patients with atrial fibrillation (AF) require optimization of their ventricular rate. Factors leading to use of additional rhythm control in clinical practice have not been thoroughly defined. The ORBIT-AF registry enrolled patients with AF from a broad range of practice settings and collected data on rate versus rhythm control, as indicated by the treating physician. Multivariable logistic regression analysis was performed to identify factors associated with each strategy. Of 10,061 patients enrolled, 6,859 (68%) were managed with rate only control versus 3,202 (32%) with rhythm control. Patients managed with rate control were significantly older and more likely to have hypertension, heart failure, prior stroke, and gastrointestinal bleeds. They also had fewer AF-related symptoms (41% with no symptoms vs 31% for rhythm control). Systemic anticoagulation was prescribed for 5,448 (79%) rate-control patients versus 2,219 (69%) rhythm-control patients (P < .0001). After multivariable adjustment, patients with higher symptom scores (severe symptoms vs. none, OR 1.62, 95% CI 1.41-1.87) and those referred to electrophysiologists (OR 1.64, 95% CI 1.45-1.85) were more likely to be managed with a rhythm control strategy. In this outpatient registry of US clinical practice, the majority of patients with AF were managed with rate control alone. Patients with more symptoms and who were treated by an electrophysiologist were more likely to receive rhythm-control therapies. A significant proportion of AF patients, regardless of treatment strategy, were not treated with anticoagulation for thromboembolism prophylaxis.