Towards better management of chronic atrial fibrillation.

Important lessons should be drawn from two recently published randomised clinical trials comparing rhythm control and rate control strategies directed at the management of chronic atrial fibrillation in representative patient populations. In the larger Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) trial, 4060 patients were followed up for an average of 3.5 years, the rhythm control group did not fare better than those assigned to rate control. Respective rates for death, the composite end-point (death, disabling stroke, anoxic encephalopathy, major bleed, or cardiac arrest), and numbers hospitalised were 18% versus 15%, 22% versus 21%, and 68% versus 60%; the latter difference being statistically significant (P<0.001). Similarly, in the European trial with only 522 patients followed up for an average of 2.3 years, the composite end-point (cardiovascular death, heart failure, thromboembolism, bleeding, pacemaker implantation, or severe drug adverse effect) ensued in 23% and 17% of the patients assigned to the corresponding groups. Moreover, in both trials most patients who had thromboembolic complications, anticoagulation therapy had ceased or was ‘sub-therapeutic’. In summary, these trials provide compelling evidence pointing to the clinical and financial burdens imposed by current rhythm control interventions. Thus, if symptoms are not an issue in the course of rate control, the primary focus of management should be redirected to better implementation of long-term anticoagulation, the only strategy of proven benefit.