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

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.