For patients who elect a rhythm-control approach, RCTs demonstrate the need for continued long-term anticoagulation in high-risk patients even if they are maintained in sinus rhythm.1,4,5 (High-risk patients are defined as those aged >65 years, or those <65 years with 1 or more stroke risk factors: diabetes, hypertension, heart failure, prior transient ischemic attack or stroke or systemic embolism, or echocardiographic evidence of a left atrium >50 mm, a shortening fraction <25%, or an ejection fraction <40%.)
Recommendation from others
The American Academy of Family Practice/American College of Physicians’ clinical guidelines support a rate-control strategy for most patients with atrial fibrillation and recommend atenolol, metoprolol, diltiazem, or verapamil as the first-choice drugs.8 Digoxin is recommended as a second-line agent. DC cardioversion and pharmacologic conversion for patients who desire a rhythm-control strategy are described as “appropriate options.”8
CLINICAL COMMENTARY:
Rate control best for atrial fibrillation
Clint Koenig, MD, MS
Fulton, Missouri
AFFIRMed at last, it’s rate-controlling and not rhythm-controlling drugs that get the evidence-based nod for most types of atrial fibrillation. While rate and rhythm control were equally efficacious in most patient-oriented outcomes, the antiarrhythmics sent more people to the hospital and, potentially, killed more people than the rate controlling medications. The antiarrhythmics, especially amiodarone,9 do have a place in maintaining sinus rhythm in select patients with atrial fibrillation; but that role is limited and may be best managed with the help and support of a cardiologist.
The atrial fibrillation evidence also suggests that we need to place beta-blocker and non-dihydropyridine calcium-channel blockers (ie, verapamil and diltiazem) as first-line choices for rate-control therapy. Digoxin still has a place in our medical armamentarium; but its role is as an adjunct or backup to the blockers for most patients.