Rate or rhythm control depends on patient

March 24, 2015

For patients with atrial fibrillation (AF), management may be both challenging and multimodal, and treatment with rate or rhythm control is all about quality of life and managing symptoms. Whether to opt for rate or rhythm control is based on patient specific factors, with patient preference a key factor shared by both treatment strategies.

For patients with atrial fibrillation (AF), management may be both challenging and multimodal, and treatment with rate or rhythm control is all about quality of life and managing symptoms. Whether to opt for rate or rhythm control is based on patient specific factors, with patient preference a key factor shared by both treatment strategies.

“In the absence of strong data, or strong symptoms, the choice between rate and rhythm control strategies is patient-preference sensitive, and affected by the patient’s contextual factors,” said Kristen K. Patton, MD, an electrophysiologist at the University of Washington, Seattle, WA, who spoke during a session entitled “Strategies for Rate and Rhythm Control,” at the ACC meeting.

“Likewise, the choice of which rate or rhythm control strategy is also dependent on patient factors and preferences,” she said.

Patient factors that favor rate control include asymptomatic AF, older age, persistent AF, very large left atrium or severe mitral regurgitation, and contraindications or interactions with antiarrhythmic drugs.

Patient factors that favor rhythm control include symptoms (particularly when attributable to AF and not rate control), younger age, paroxysmal, reasonably structurally normal heart, and heart failure with worsening AF.

For both strategies, a patient’s medical comorbidities and drug side effects, metabolism, and interactions need to be considered.

Evidence from eight randomized controlled trials and four meta-analyses, noted Patton, show that for many patients it doesn’t matter which strategy (rate or rhythm control) is chosen.

“For either strategy, many options for medical management are available,” Patton said, emphasizing that it often takes work to find the right regimen to fit an individual patient.

Overall, Patton stressed the need to consider patient preferences, medical comorbidities, and other medications when selecting which strategy to follow.

“Patient goals of care need to be understood, and patients need to understand that one cannot always achieve perfection or resolution in managing AF,” Patton emphasized, adding that aggressive management of risk factors (such as weight loss, exercise, treatment of sleep apnea, diabetes, hypertension, and smoking cessation) is needed to reduce AF recurrence.