Relationships Between Sinus Rhythm, Treatment, and Survival in the Atrial Fibrillation Follow-Up Investigation of Rhythm Management (AFFIRM) Study Atrial fibrillation: the rate versus rhythm management controversy. A comparison of rate control and rhythm control in patients with recurrent persistent atrial fibrillation. An evaluation of the strategy of maintenance of sinus rhythm by antiarrhythmic drug therapy after ablation and pacing therapy in patients with paroxysmal atrial fibrillation. Comparison of rate and rhythm control in patients with atrial fibrillation and nonischemic heart failure. Long-term efficacy and safety of two different rhythm control strategies in elderly patients with symptomatic persistent atrial fibrillation. Rhythm Control Versus Rate Control and Clinical Outcomes in Patients With Atrial Fibrillation: Results From the ORBIT-AF Registry. Randomized trial of rate-control versus rhythm-control in persistent atrial fibrillation: the Strategies of Treatment of Atrial Fibrillation (STAF) study. Maintenance of sinus rhythm in patients with atrial fibrillation: an AFFIRM substudy of the first antiarrhythmic drug. Real-life observations of clinical outcomes with rhythm- and rate-control therapies for atrial fibrillation RECORDAF (Registry on Cardiac Rhythm Disorders Assessing the Control of Atrial Fibrillation). A comparison of rate control and rhythm control in patients with atrial fibrillation. Functional status in rate- versus rhythm-control strategies for atrial fibrillation: results of the Atrial Fibrillation Follow-Up Investigation of Rhythm Management (AFFIRM) Functional Status Substudy. Mending the rhythm does not improve prognosis in patients with persistent atrial fibrillation: a subanalysis of the RACE study. A randomized clinical trial of early invasive intervention for atrial fibrillation (EARLY-AF) - methods and rationale. Atrial fibrillation: an observational study with outpatients. Randomized Study Comparing Combined Pulmonary Vein–Left Atrial Junction Disconnection and Cavotricuspid Isthmus Ablation Versus Pulmonary Vein–Left Atrial Junction Disconnection Alone in Patients Presenting With Typical Atrial Flutter and Atrial Fibrillation Comparison of rate and rhythm control in hypertension patients with atrial fibrillation.
Background —The AFFIRM Study showed that treatment of patients with atrial fibrillation and a high risk for stroke or death with a rhythm-control strategy offered no survival advantage over a rate-control strategy in an intention-to-treat analysis . This article reports an “ on-treatment ” analysis of the relationship of survival to cardiac rhythm and treatment as they changed over time . Methods and Results —Modeling techniques were used to determine the relationships among survival , baseline clinical variables , and time-dependent variables . The following baseline variables were significantly associated with an increased risk of death : increasing age , coronary artery disease , congestive heart failure , diabetes , stroke or transient ischemic attack , smoking , left ventricular dysfunction , and mitral regurgitation . Among the time-dependent variables , the presence of sinus rhythm ( SR ) was associated with a lower risk of death , as was warfarin use . Antiarrhythmic drugs ( AADs ) were associated with increased mortality only after adjustment for the presence of SR . Consistent with the original intention-to-treat analysis , AADs were no longer associated with mortality when SR was removed from the model . Conclusions —Warfarin use improves survival . SR is either an important determinant of survival or a marker for other factors associated with survival that were not recorded , determined , or included in the survival model . Currently available AADs are not associated with improved survival , which suggests that any beneficial antiarrhythmic effects of AADs are offset by their adverse effects . If an effective method for maintaining SR with fewer adverse effects were available , it might be beneficial The fundamental management strategy for atrial fibrillation ( AF ) is still debated . There is no doubt that those patients at risk of thromboembolic events should be offered anticoagulant therapy . However , it is uncertain whether rhythm control ( restoration and maintenance of sinus rhythm ) or rate control ( adjustment to a physiological ventricular rate while allowing AF to continue ) is the preferred primary treatment option for the reduction of symptoms and major cardiovascular ( CV ) outcomes associated with AF . Several well conducted trials comparing the two strategies led to the conclusion that there was little to choose between them . However , guidelines leaned towards recommending rate control as the initial strategy , and reserved rhythm control for those who remained symptomatic . Recently this status quo is being increasingly challenged by the clear demonstration that left atrial catheter ablation is effective at suppressing AF resistant to traditional antiarrhythmic drugs , such as those that failed to demonstrate any superiority when compared with rate control . Also , recently introduced antiarrhythmic therapy may have superior efficacy with regard to reducing unexpected CV hospitalization , CV mortality and stroke . In addition , there is a growing perception that atrial remodelling should be best prevented by early rhythm control rather than delaying until rate control has proven unsatisfactory . For these reasons the results of large r and omised clinical trials , which recruit patients soon after the presentation of AF and compare ' aggressive ' modern rhythm control against the guideline approach of primary rate control , are eagerly awaited . In the meantime the pendulum of clinical opinion has begun to swing towards a rhythm control strategy BACKGROUND Maintenance of sinus rhythm is the main therapeutic goal in patients with atrial fibrillation . However , recurrences of atrial fibrillation and side effects of antiarrhythmic drugs offset the benefits of sinus rhythm . We hypothesized that ventricular rate control is not inferior to the maintenance of sinus rhythm for the treatment of atrial fibrillation . METHODS We r and omly assigned 522 patients who had persistent atrial fibrillation after a previous electrical cardioversion to receive treatment aim ed at rate control or rhythm control . Patients in the rate-control group received oral anticoagulant drugs and rate-slowing medication . Patients in the rhythm-control group underwent serial cardioversions and received antiarrhythmic drugs and oral anticoagulant drugs . The end point was a composite of death from cardiovascular causes , heart failure , thromboembolic complications , bleeding , implantation of a pacemaker , and severe adverse effects of drugs . RESULTS After a mean ( + /-SD ) of 2.3+/-0.6 years , 39 percent of the 266 patients in the rhythm-control group had sinus rhythm , as compared with 10 percent of the 256 patients in the rate-control group . The primary end point occurred in 44 patients ( 17.2 percent ) in the rate-control group and in 60 ( 22.6 percent ) in the rhythm-control group . The 90 percent ( two-sided ) upper boundary of the absolute difference in the primary end point was 0.4 percent ( the prespecified criterion for noninferiority was 10 percent or less ) . The distribution of the various components of the primary end point was similar in the rate-control and rhythm-control groups . CONCLUSIONS Rate control is not inferior to rhythm control for the prevention of death and morbidity from cardiovascular causes and may be appropriate therapy in patients with a recurrence of persistent atrial fibrillation after electrical cardioversion AIMS Permanent atrial fibrillation develops in many patients after ablation and pacing therapy .  We compared a strategy that initially allowed patients to remain in atrial fibrillation with a strategy that initially attempted to restore and maintain sinus rhythm . METHODS AND RESULTS In this multicentre r and omized controlled trial , 68 patients affected by severely symptomatic paroxysmal atrial fibrillation were assigned , after successful atrioventricular junction ablation and pacing treatment  , to antiarrhythmic drug therapy with amiodarone , propafenone , flecainide or sotalol and were compared with 69 patients assigned , after successful AV junction ablation and pacing treatment , to no antiarrhythmic drug therapy . The patients were followed-up for 12 to 24 months ( mean 16+/-4 ) . The drug arm patients had a 57 % reduction in the risk of developing permanent atrial fibrillation ( 21 % vs 37 % , P=0.02 ) . Evaluation after 12 months revealed similar quality of life scores and echocardiographic parameters in the two groups , but the drug arm patients had more episodes of heart failure and hospitalizations ( P=0.05 ) . The outcome was similar between the 40 patients who developed permanent atrial fibrillation and the 97 who did not . CONCLUSION Conventional antiarrhythmic therapy reduces the risk of development of permanent atrial fibrillation after ablation and pacing therapy . The present data do not support the concept that the development of permanent atrial fibrillation is related to an adverse outcome when a perfect control of heart rate is obtained by ablation and pacing Atrial fibrillation ( AF ) is a very common cardiac arrhythmia with an increased mortality in patients with heart failure . Whether the best therapeutic approach to these patients is to restore sinus rhythm or to adequately control the ventricular rate is still controversial . The aim of this study was to compare both strategies in patients with AF and nonischemic heart failure . One hundred and fifty-four patients with AF duration greater than 48 hours and nonischemic left ventricular dysfunction were r and omized either to a rhythm ( n = 84 ) or rate ( n = 74 ) control group . The composite end points of the study were embolism , death , and exercise capacity .  The average age of the patients was 61 + /- 10 years in the rhythm control group and 58 + /- 12 years in the rate control group ( P = NS ) . The average follow-up period was 35 + /- 21 months in the rhythm control group and 37 + /- 19 months in the rate control group ( P = NS ) . In the first year of the study , exercise capacity and left ventricular ejection fraction ( LVEF ) were improved in the rhythm control group compared to the exercise capacity and LVEF of the rate control group ( P < 0.0001 and P = 0.0005 , respectively ) . There were no statistically significant differences in the embolic event rate between the two groups ( P = NS ) . The mortality rate , especially for death due to pump failure , was significantly higher in the rate control group at the end of the study ( P < 0.0001 ) . Restoring and maintaining sinus rhythm had a beneficial effect on mortality and exercise capacity in patients with nonischemic heart failure and AF BACKGROUND We prospect ively compared the efficacy , safety , and quality of life ( QoL ) impact of catheter ablation versus antiarrhythmic drugs ( AAD ) in elderly patients with persistent atrial fibrillation ( AF ) . METHODS AND RESULTS Four hundred and twelve consecutive patients , aged ≥ 70 years , underwent ablation ( Group A , 153 patients ) or AAD ( Group B , 259 patients ) . Study endpoints : treatment failure ( any AF/AT lasting > 30 seconds ) and treatment-related adverse events ( acute when ≤1 month of procedure and long term when > 1 month ) . At a follow-up of 60 ± 17 months , 43 % and 46 % patients in Group B versus 58 % and 76 % in Group A were in sinus rhythm ( SR ) , respectively , after one ( P = 0.003 ) and 2 procedures ( P < 0.001 ) . Fifteen acute adverse events occurred ( 6.7 % in Group A vs 1 % in Group B , P < 0.001 ) , mainly periprocedural cerebral thromboembolism ( 3.3 % in Group A vs 0.7 % in Group B , P = 0.058 ) . Previous TIA/stroke result ed the only independent predictor of periprocedural cerebrovascular accidents ( OR 1.2 , 95%IC 1.1 - 1.3 ) . At follow-up , 74 long-term adverse events occurred ( 7.7 % in Group A vs 23.9 % in Group B , P < 0.001 ) with Group B patients more often experiencing  AAD-related  adverse events ( 12.7 % vs 2.6 % , P < 0.001 ) . Group A and absence of AF/AT recurrences significantly improved QoL scores ( P < 0.001 ) . CONCLUSIONS In elderly persistent AF patients  , catheter ablation is more effective in maintaining SR and in improving QoL  than AAD but is affected by a higher risk of embolic complications , particularly in patients with previous TIA/stroke . Over time , Group A patients more likely discontinued AAD with a reduction of long-term adverse events OBJECTIVES The study sought to evaluate clinical outcomes in clinical practice with rhythm control versus rate control strategy for management of atrial fibrillation ( AF ) . BACKGROUND R and omized trials have not demonstrated significant differences in stroke , heart failure , or mortality between rhythm and rate control strategies . The comparative outcomes in contemporary clinical practice are not well described . METHODS Patients managed with a rhythm control strategy targeting maintenance of sinus rhythm were retrospectively  compared with a strategy of rate control alone in a AF registry across various U.S. practice setting s. Unadjusted and adjusted ( inverse-propensity weighted ) outcomes were estimated . RESULTS The overall study population ( N = 6,988 ) had a median of 74 ( 65 to 81 ) years of age , 56 % were males , 77 % had first detected or paroxysmal AF , and 68 % had CHADS2 score ≥2 . In unadjusted analyses , rhythm control was associated with lower all-cause death , cardiovascular death , first stroke/non- central nervous system systemic embolization/transient ischemic attack , or first major bleeding event ( all p < 0.05 ) ; no difference in new onset heart failure ( p = 0.28 ) ; and more frequent cardiovascular hospitalizations ( p = 0.0006 ) . There was no difference in the incidence of pacemaker , defibrillator , or cardiac resynchronization device implantations ( p = 0.99 ) . In adjusted analyses , there were no statistical differences in clinical outcomes between rhythm control and rate control treated patients ( all p > 0.05 ) ; however , rhythm control was associated with more cardiovascular hospitalizations ( hazard ratio : 1.24 ; 95 % confidence interval : 1.10 to 1.39 ; p = 0.0003 ) . CONCLUSIONS Among patients with AF , rhythm control was not superior to rate control strategy for outcomes of stroke , heart failure , or mortality , but was associated with more cardiovascular hospitalizations OBJECTIVES This study was design ed to compare two treatment strategies in patients with atrial fibrillation(AF ) :  rhythm-control ( restoration and maintenance of sinus rhythm ) and rate-control ( pharmacologic or invasive rate-control and anticoagulation ) . BACKGROUND Atrial fibrillation is the most common arrhythmia . It is unclear whether a strategy of rhythm- or rate-control is better in terms of mortality , morbidity , and quality of life . METHODS The Strategies of Treatment of Atrial Fibrillation ( STAF ) multicenter pilot trial r and omized 200 patients ( 100 per group ) with persistent AF to rhythm- or rate-control .  The combined primary end point was a combination of death , cardiopulmonary resuscitation , cerebrovascular event , and systemic embolism . RESULTS After 19.6 + /- 8.9 months ( range 0 to 36 months ) there was no difference in the primary end point between rhythm-control ( 9/100 ; 5.54%/year ) and rate-control ( 10/100 ; 6.09%/year ; p = 0.99 ) . The percentage of patients in sinus rhythm in the rhythm-control group after up to four cardioversions during the follow-up period ( rate-control group ) was 23 % ( 0 % ) at 36 months . Eighteen primary end points occurred in atrial fibrillation ; only one occurred in sinus rhythm ( p = 0.049 ) . CONCLUSIONS The STAF pilot study showed no differences between the two treatment strategies in all end points except hospitalizations . These data suggest that there was no benefit in attempting rhythm-control in these patients with a high risk of arrhythmia recurrence . It remains unclear whether the results in the rhythm-control group would have been better if sinus rhythm had been maintained in a higher proportion of patients , as all but one end point occurred during AF OBJECTIVES This study evaluated the efficacy of antiarrhythmic drugs for the treatment of  atrial fibrillation ( AF ) .  BACKGROUND The most effective and safest antiarrhythmic drug for the treatment of AF is unknown . METHODS The Atrial Fibrillation Follow-up Investigation of Rhythm Management ( AFFIRM ) study compared two treatment strategies -- rate control and rhythm control -- in patients with AF and risk factors for stroke or death . This sub study , performed in patients r and omized to rhythm control , compared different antiarrhythmic drugs by r and omly assigning the first drug treatment to : 1 ) amiodarone , 2 ) sotalol , or 3 ) a class I drug . The primary end point was the proportion of patients alive , in sinus rhythm , with no additional cardioversions and still taking the assigned drug at one year . Comparisons were made between patients eligible for each of three drug pairs . RESULTS At one year , in 222 patients r and omized between amiodarone and class I agents , 62 % were successfully treated with amiodarone , compared with 23 % taking class I agents ( p < 0.001 ) . In 256 patients r and omized between amiodarone and sotalol , 60 % versus 38 % were successfully treated , respectively ( p = 0.002 ) . In 183 patients r and omized between sotalol and class I agents , 34 % versus 23 % were successfully treated , respectively ( p = 0.488 ) , although this portion of the sub study was stopped early when amiodarone was shown to be better than class I agents . Sinus rhythm was achieved in nearly 80 % of patients at one-year follow-up with serial therapy . Adverse effects were common . CONCLUSIONS Amiodarone was more effective at one year than either sotalol or class I agents for the strategy of maintenance of sinus rhythm without cardioversion OBJECTIVES RECORDAF is the first worldwide , prospect i ve , observational survey of management of atrial fibrillation ( AF ) in unselected , community-based patients . BACKGROUND Primary outcomes were therapeutic success and clinical outcomes associated with rhythm-control and rate-control strategies . METHODS Patients with recent-onset AF were included ( n = 5,604 ) . Treatment strategy ( rhythm control or rate control ) was noted at baseline . Follow-up was 12 months . Therapeutic success required that strategy was unchanged without clinical events . Further maintenance of sinus rhythm was required in the rhythm-control group , and heart rate ≤80 beats/min in the rate-control group . RESULTS Data from 5,171 patients were assessable . Therapeutic success was 54 % overall ( rhythm control 60 % vs. rate control 47 % ) , a result driven by control of AF : rhythm control , 81 % vs. rate control , 74 % . After adjustment for propensity score quintiles , the rhythm-control strategy was significantly related to superior therapeutic success ( odds ratio : 1.34 , 95 % confidence interval : 1.15 to 1.55 ; p = 0.0002 ) . Clinical events occurred in 18 % of patients . The arrhythmia management strategy was not predictive of clinical events . The type ( persistent ) , presence at baseline visit , and duration ( > 3 months ) of AF , together with age older than 75 years and the presence of heart failure , predicted progression to permanent AF . The choice of rhythm control reduced the likelihood of AF progression ( odds ratio : 0.20 , 95 % confidence interval : 0.17 to 0.25 ; p < 0.0001 ) . CONCLUSIONS Clinical outcomes in AF patients were driven mainly by hospitalizations for arrhythmia/proarrhythmia and other cardiovascular causes , but not by the choice of rate or rhythm strategy . Rhythm-control patients progressed less rapidly to permanent AF BACKGROUND There are two approaches to the treatment of atrial fibrillation : one is cardioversion and treatment with antiarrhythmic drugs to maintain sinus rhythm , and the other is the use of rate-controlling drugs , allowing atrial fibrillation to persist . In both approaches , the use of anticoagulant drugs is recommended . METHODS We conducted a r and omized , multicenter comparison of these two treatment strategies in patients with atrial fibrillation and a high risk of stroke or death . The primary end point was overall mortality . RESULTS A total of 4060 patients ( mean [ + /-SD ] age , 69.7+/-9.0 years ) were enrolled in the study ; 70.8 percent had a history of hypertension , and 38.2 percent had coronary artery disease . Of the 3311 patients with echocardiograms , the left atrium was enlarged in 64.7 percent and left ventricular function was depressed in 26.0 percent . There were 356 deaths among the patients assigned to rhythm-control therapy and 310 deaths among those assigned to rate-control therapy ( mortality at five years , 23.8 percent and 21.3 percent , respectively ; hazard ratio , 1.15 [ 95 percent confidence interval , 0.99 to 1.34 ] ; P=0.08 ) . More patients in the rhythm-control group than in the rate-control group were hospitalized , and there were more adverse drug effects in the rhythm-control group as well . In both groups , the majority of strokes occurred after warfarin had been stopped or when the international normalized ratio was subtherapeutic . CONCLUSIONS Management of atrial fibrillation with the rhythm-control strategy offers no survival advantage over the rate-control strategy , and there are potential advantages , such as a lower risk of adverse drug effects , with the rate-control strategy . Anticoagulation should be continued in this group of high-risk patients OBJECTIVES The Atrial Fibrillation Follow-up Investigation of Rhythm Management ( AFFIRM ) functional status sub study aim ed to test the hypothesis that functional status is similar in rate-control and rhythm-control strategies . BACKGROUND R and omized studies , including the AFFIRM study , have failed to demonstrate survival benefits between rate-control and rhythm-control strategies for atrial fibrillation ( AF ) . However , AF may cause functional capacity or cognitive impairment that might justify maintenance of sinus rhythm . METHODS Investigators of the AFFIRM study enrolled 4,060 patients with AF who required long-term therapy and who were 65 years of age or older or who had another risk factor for stroke or death . New York Heart Association functional class ( NYHA-FC ) and Canadian Cardiovascular Society Angina Classification were assessed at initial and each follow-up visit . From 22 r and omly chosen functional status sub study sites , 245 participants underwent  6-min walk tests and Mini-Mental State Examination ( MMSE ) at initial , two-month , and yearly visits . Patients were assigned r and omly to rate-controlling drugs , allowing AF to persist , or rhythm-controlling antiarrhythmic drugs , to maintain sinus rhythm . RESULTS The NYHA-FC worsened with time in both rate-control and rhythm-control groups , with no differences between groups . Presence of AF was associated with worse NYHA-FC ( p < 0.0001 ) . No differences were observed in Canadian Cardiovascular Society Angina Classification or MMSE scores . Six-minute walk distance improved over time in both study arms . On average , walk distance was 94 feet greater in the rhythm-control group ( adjusted p = 0.049 ) . CONCLUSIONS Modest improvement in 6-min walk distance was noted in the rhythm-control arm . Presence of AF was associated with worse NYHA-FC . No difference in cognitive function was detected AIMS To compare outcome of AF patients with effective rhythm control with patients treated with rate control .  METHODS AND RESULTS Out of the 266 AF patients r and omized to rhythm control in the RACE study , 49 patients turned to long-term sinus rhythm and were continuously treated with oral anticoagulation . The incidence of the primary endpoint in these patients was compared to that in 178 patients out of the initial 256 rate-control patients of RACE who were in AF and using oral anticoagulation continuously . Baseline characteristics of both groups were not different . After a mean follow-up of 2.3+/-0.6 years , the primary endpoint ( a composite of cardiovascular mortality , heart failure , thrombo-embolic complications ( TECs ) , bleeding , serious adverse effects of antiarrhythmic drugs and pacemaker implants ) was 22.4 % in the rhythm-control group vs. 15.2 % in the rate-control group . Multivariable regression analysis indicated coronary artery disease , heart failure , and digitalis as independent risk indicators of cardiovascular morbidity and mortality . Chronic sinus rhythm did not matter . CONCLUSION Among patients who remained on warfarin  , those who mostly were maintained in sinus rhythm under a rhythm-control strategy did not have a superior prognosis compared to those who remained in AF under a rate-control strategy BACKGROUND The ideal management of patients with newly diagnosed symptomatic atrial fibrillation ( AF ) remains unknown . Current practice guidelines recommend a trial of antiarrhythmic drugs ( AAD ) prior to considering an invasive ablation procedure . However , earlier ablation offers an opportunity to halt the progressive patho-anatomical changes associated with AF , as well as impart other important clinical benefits . OBJECTIVE The aim of this study is to determine the optimal initial management strategy for patients with newly diagnosed , symptomatic atrial fibrillation . METHODS / DESIGN The EARLY-AF study ( Clinical Trials.govNCT02825979 ) is a prospect i ve , open label , multicenter , r and omized trial with a blinded assessment of outcomes . A total of 298 patients will be r and omized in a 1:1 fashion to first-line AAD therapy , or first-line cryoballoon-based pulmonary vein isolation .  Patients with symptomatic treatment naïve AF will be included . Arrhythmia outcomes will be assessed by implantable cardiac monitor ( ICM ) . The primary outcome is time to first recurrence of AF , atrial flutter , or atrial tachycardia ( AF/AFL/AT ) between days 91 and 365 following AAD initiation or AF ablation . Secondary outcomes include arrhythmia burden , quality of life , and healthcare utilization . DISCUSSION The EARLY-AF study is a r and omized trial design ed to evaluate the optimal first management approach for patients with AF . We hypothesize that catheter ablation will be superior to drug therapy in prevention of AF recurrence BACKGROUND Atrial fibrillation ( AF ) is the most common sustained arrhythmia with serious clinical consequences in the absence of treatment . However , there are limited data on the treatment of these patients in Argentina . The objective was to describe the therapeutic management of patients with nonacute AF by Argentinean cardiologists and to determine the incidence of clinical events after 12 months follow-up . METHODS The Atrial Fibrillation study in Argentina ( FARAON ) was an observational , descriptive , prospect i ve , national , and multicentric study that included out patients with AF , followed for 12 months . The study included 38 sites in Argentina . Each research er included the first 10 patients who met the inclusion criteria of being over 21 and also being an AF carrier documented by electrocardiogram or Holter within 12 months prior to or at the time of enrollment . RESULTS A total of 373 patients were included , mean age 70 ± 11.5 years , 40 % women ; 65 % had AF rhythm at the time of inclusion , 57 % had permanent AF , and 56 % were asymptomatic . At the time of enrollment , 40 % of physicians opted for rhythm control strategy . β-blockers and amiodarone were the most used drugs . Patients with rhythm control drugs had higher success rate than those with frequency control drug therapy ( 80 % vs 57 % ) . CONCLUSION Cardiologists in Argentina receive patients with AF that are mostly permanent AF . More than half of the patients are asymptomatic . They opt primarily by controlling the pace . When choosing antiarrhythmic drugs , nearly half of them indicated amiodarone Background —Atrial flutter ( AFL ) and atrial fibrillation ( AF ) frequently coexist in the same patient . Recently it has been demonstrated that the triggers for both AF and AFL may originate in the pulmonary veins ( PVs ) . We hypothesized that in patients with both AF and typical AFL , pulmonary vein – left atrial junction ( PV-LAJ ) disconnection may eliminate both arrhythmias . Methods and Results —Consecutive patients with documented symptomatic AF and typical AFL were r and omly assigned to have PV-LAJ disconnection combined with cavotricuspid isthmus ( CTI ) ablation ( group 1 , n=49 ) or PV-LAJ disconnection alone ( group 2 , n=59 ) . Within the first 8 weeks after ablation , 32 of the group 2 patients had typical AFL documented , whereas none was seen in group 1 . Twenty of these 32 converted to sinus rhythm after initiating antiarrhythmic drugs ( AADs ) . Twelve were cardioverted , and AADs were started . After 8 weeks , all AADS were stopped , and only 3 patients continued to have recurrent sustained typical AFL that was eliminated by CTI ablation . Beyond 8 weeks of follow-up , 7 patients in group 1 and 6 patients in group 2 ( 14 % and 11 % , respectively ) continued to have AF . Ten of these 13 patients underwent a repeat PV-LAJ disconnection procedure and were cured . The remaining 3 remained in normal sinus rhythm while taking AADs . Conclusions —In patients with both AFL and AF , PV-LAJ disconnection alone may be sufficient to control both arrhythmias . CTI block reduced early postablation recurrence of arrhythmias , which in the majority of patients reflects a short-term clinical problem BACKGROUND Atrial fibrillation ( AF ) is a very common cardiac arrhythmia , and is associated with an increased mortality in patients with hypertension . Whether the best therapeutic approach for these patients is to restore sinus rhythm ( SR ) or to adequately control the ventricular rate is still controversial . The aim of this study is to compare both strategies in patients with hypertension . METHODS AND RESULTS Two hundred and twenty-one patients with hypertension and AF of duration > 48 h were r and omly assigned to either the rhythm ( n=155 ) or rate ( n=66 ) control group . Exercise capacity was improved in the rhythm control group in the 1st year of the study ( p<0.0001 ) . There were no statistically significant differences in the embolic event rate and the total mortality between the 2 groups at the end of the study ( p = NS ) . CONCLUSIONS Although restoring and maintaining SR had a beneficial effect on exercise capacity in patients with hypertension and AF , no significant difference was found in terms of the total mortality and the embolic event rates . Thus , rate control is an acceptable primary strategy in patients with AF and hypertension
As such , evidence was insufficient to recommend rhythm or rate control as the first-line therapy for AF in older adults .
Atrial fibrillation ( AF ) is highly prevalent in older adults and has been associated with increased morbidity and mortality .
To reduce this AF-related morbidity in older adults , antiarrhythmic drugs ( AADs ) are regularly used for rhythm control , assuming that increasing time in sinus rhythm reduces AF-related morbidity .
However , whether AADs can improve clinical outcomes in older adults remains unclear because of the increased risk for adverse drug events compared with rate control .
The aim of this study was to determine the impact of rhythm control versus rate control on clinical outcomes in older adults with AF .