Pharmacologic rate versus rhythm-control strategies in atrial fibrillation: an updated comprehensive review and meta-analysis
Abstract
BACKGROUND: In patients with atrial fibrillation (AF), ventricular rate control with medications has been found to be noninferior in preventing clinical events, compared to a strategy converting patients to sinus rhythm and maintaining it with medications. Guidelines have accepted rate control as an acceptable therapeutic option. Most of the prior studies excluded patients without significant left ventricular dysfunction, or permanent AF. METHODS: The authors searched the PubMed, CENTRAL, and EMBASE databases for randomized controlled trials from 1966 to 2011. Trials included were direct head-to-head comparisons of rate- and rhythm-control strategy using pharmacological means. The primary outcome assessed was risk of all-cause mortality. We also assessed other pooled clinical endpoints using a random effects model (Mantel-Haenszel) between rate and rhythm-control strategies. RESULTS: Ten studies (total N = 7,867) met inclusion/exclusion criteria. In-hospital mortality was not different between groups (P = 0.31). The rates of stroke, systemic embolism, worsening heart failure, myocardial infarction, and bleeding were also similar. However, rates of rehospitalization were much lower with a rate-control strategy (P = 0.007). An exploratory analysis in patients younger than 65 years revealed a rhythm-control strategy was superior to rate control in the prevention of all-cause mortality (P = 0.0007). CONCLUSIONS: This systematic review suggests no difference in clinical outcomes with a rate or rhythm-control strategy with AF. However, rehospitalization rates appear to be lower with pharmacological rate control for all ages, while finding support for rhythm control in younger patients.
Integrity signals
Registry
Cites
Statistics
Claims the paper makes
Claims other papers make about this one
Each is checked against this paper’s own text: does it say what the citing paper says it does?
All trials that have compared rhythm control to rate control (with appropriate anticoagulation) therapy have resulted in neutral outcomes.
“Although many clinicians believe that maintaining sinus rhythm can improve outcomes in AF patients, 588 all trials that have compared rhythm control to rate control (with appropriate anticoagulation) therapy have resulted in neutral outcomes.41,578,579,582,[589][590][591][592][593]”
From 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS (2016) · cites this paper as [578]
Cites
1 retracted
Pharmacological cardioversion for atrial fibrillation and flutter
Cordina, J., & Mead, G. E. (2005) · Cochrane Database of Systematic Reviews · doi:10.1002/14651858.cd003713.pub2 · Cited by 35 · see citing works
RetractedLiberati, A., Altman, D. G., Tetzlaff, J., Mulrow, C., Gøtzsche, P. C., Ioannidis, J. P. A., Clarke, M., Devereaux, P. J., Kleijnen, J., & Moher, D. (2009) · PLoS Medicine · doi:10.1371/journal.pmed.1000100 · Cited by 28,164 · see citing works
A comparison of rate control and rhythm control in patients with atrial fibrillation
(2002) · New England Journal of Medicine · doi:10.1056/nejmoa021328 · Cited by 4,405 · see citing works
Ivabradine and outcomes in chronic heart failure (SHIFT): a randomised placebo-controlled study
Swedberg, K., Komajda, M., Böhm, M., Borer, J. S., Ford, I., Dubost-Brama, A., Lerebours, G., & Tavazzi, L. (2010) · The Lancet · doi:10.1016/s0140-6736(10)61198-1 · Cited by 2,563 · see citing works
Wang, T. J., Larson, M. G., Levy, D., Vasan, R. S., Leip, E. P., Wolf, P. A., D’Agostino, R. B., Murabito, J. M., Kannel, W. B., & Benjamin, E. J. (2003) · Circulation · doi:10.1161/01.cir.0000072767.89944.6e · Cited by 1,970 · see citing works
Rhythm control versus rate control for atrial fibrillation and heart failure
Roy, D., Talajic, M., Nattel, S., Wyse, D. G., Dorian, P., Lee, K. L., Bourassa, M. G., Arnold, J. M. O., Buxton, A. E., Camm, A. J., et al. (2008) · New England Journal of Medicine · doi:10.1056/nejmoa0708789 · Cited by 1,585 · see citing works
Hohnloser, S. H., Kück, K., & Lilienthal, J. (2000) · The Lancet · doi:10.1016/s0140-6736(00)03230-x · Cited by 1,132 · see citing works
Randomized trial of rate-control versus rhythm-control in persistent atrial fibrillation
CARLSSON, J., Miketíc, S., Windeler, J., Cuneo, A., Haun, S., Micus, S., Walter, S., & Tebbe, U. (2003) · Journal of the American College of Cardiology · doi:10.1016/s0735-1097(03)00332-2 · Cited by 938 · see citing works
Fuster, V., Rydén, L. E., Cannom, D. S., Crijns, H. J., Curtis, A. B., Ellenbogen, K. A., Halperin, J. L., Kay, G. N., Le Huezey, J.-Y., Lowe, J. E., et al. (2011) · Circulation · doi:10.1161/cir.0b013e318214876d · Cited by 859 · see citing works
Rate Control vs Rhythm Control in Patients With Nonvalvular Persistent Atrial Fibrillation
Opolski, G., Torbicki, A., KOSIOR, D. A., Szulc, M., Wożakowska−Kapłon, B., Kołodziej, P., & Achremczyk, P. (2004) · CHEST Journal · doi:10.1378/chest.126.2.476 · Cited by 473 · see citing works
Rate vs Rhythm Control in Patients With Atrial Fibrillation: A Meta-analysis
de Denus, S. (2005) · Archives of Internal Medicine · doi:10.1001/archinte.165.3.258 · Cited by 239 · see citing works
Sherman, D. G. (2005) · Archives of Internal Medicine · doi:10.1001/archinte.165.10.1185 · Cited by 232 · see citing works
Optimal Treatment Strategy for Patients With Paroxysmal Atrial Fibrillation J-RHYTHM Study
Ogawa, S., Yamashita, T., Yamazaki, T., Aizawa, Y., Atarashi, H., Inoue, H., Ohe, T., Ohtsu, H., Okumura, K., Katoh, T., et al. (2009) · Circulation Journal · doi:10.1253/circj.cj-08-0608 · Cited by 205 · see citing works
Camm, A. J., BREITHARDT, G. E., Crijns, H. J. G. M., Dorian, P., Kowey, P. R., Heuzey, J. L., Merioua, I., Pedrazzini, L., Prystowsky, E. N., Schwartz, P. J., et al. (2011) · Journal of the American College of Cardiology · doi:10.1016/j.jacc.2011.03.034 · Cited by 177 · see citing works
Joglar, J. A., Acusta, A., Shusterman, N. H., Ramaswamy, K., Kowal, R. C., Barbera, S. J., Hamdan, M. H., & Page, R. L. (2001) · American Heart Journal · doi:10.1067/mhj.2001.117318 · Cited by 126 · see citing works
Rate-control vs. rhythm-control in patients with atrial fibrillation: a meta-analysis
Testa, L., Biondi‐Zoccai, G., Russo, A. D., Bellocci, F., Andreotti, F., & Crea, F. (2005) · European Heart Journal · doi:10.1093/eurheartj/ehi306 · Cited by 125 · see citing works
Andersen, L. V., Vestergaard, P., Deichgræber, P., Lindholt, J. S., Mortensen, L. S., & Frost, L. (2008) · Heart · doi:10.1136/hrt.2007.135657 · Cited by 82 · see citing works
Jøns, C., Jacobsen, U. G., Joergensen, R. M., Olsen, N. T., Dixen, U., Johannessen, A. C., Huikuri, H. V., Messier, M., McNitt, S. A., & Thomsen, P. E. B. (2010) · Heart Rhythm · doi:10.1016/j.hrthm.2010.09.090 · Cited by 76 · see citing works
Crandall, M. A., Horne, B. D., DAY, J. D., Anderson, J. L., Muhlestein, J. B., Crandall, B. G., Weiss, J. P., OSBORNE, J. S., LAPPE, D. L., & Bunch, T. J. (2009) · Pacing and Clinical Electrophysiology · doi:10.1111/j.1540-8159.2009.02427.x · Cited by 74 · see citing works
Control of Heart Rate Versus Rhythm in Rheumatic Atrial Fibrillation: A Randomized Study
Vora, A. M., Karnad, D. R., Goyal, V., Naik, A. M., Gupta, A. K., Lokhandwala, Y. Y., Kulkarni, H. L., & Singh, B. N. (2004) · Journal of Cardiovascular Pharmacology and Therapeutics · doi:10.1177/107424840400900201 · Cited by 48 · see citing works
Rienstra, M., van Veldhuisen, D. J., Crijns, H. J. G. M., Gelder, I. C. V., & for the RACE investigators (2007) · European Heart Journal · doi:10.1093/eurheartj/ehl436 · Cited by 46 · see citing works
Rate versus Rhythm Control in Patients with Atrial Fibrillation
Crijns, H. J. G. M. (2005) · Drugs · doi:10.2165/00003495-200565120-00004 · Cited by 37 · see citing works
Caldeira, D., David, C., & Sampaio, C. (2011) · European Journal of Internal Medicine · doi:10.1016/j.ejim.2011.05.001 · Cited by 35 · see citing works
Ökçün, B., Yiğit, Z., Özkan, A. A., & Küçükoğlu, S. (2004) · Japanese Heart Journal · doi:10.1536/jhj.45.591 · Cited by 33 · see citing works
Kong, M. H., Shaw, L. K., O’Connor, C. J., Califf, R. M., Blazing, M. A., & Al‐Khatib, S. M. (2010) · Annals of Noninvasive Electrocardiology · doi:10.1111/j.1542-474x.2010.00365.x · Cited by 29 · see citing works
The cost comparison of rhythm and rate control strategies in persistent atrial fibrillation
Pietrasik, A., KOSIOR, D. A., Niewada, M., Opolski, G., Łatek, M. M., & Kamiński, B. (2006) · International Journal of Cardiology · doi:10.1016/j.ijcard.2006.03.085 · Cited by 19 · see citing works
Rhythm control agents and adverse events in patients with atrial fibrillation
Taylor, C. J., Hodgkinson, J., & Hobbs, R. F. (2010) · International Journal of Clinical Practice · doi:10.1111/j.1742-1241.2010.02426.x · Cited by 17 · see citing works
Chen, S., Dong, Y., Fan, J., & Yin, Y. (2011) · International Journal of Cardiology · doi:10.1016/j.ijcard.2011.09.009 · Cited by 16 · see citing works
Comparison of Rate and Rhythm Control in Hypertension Patients With Atrial Fibrillation
Yıldız, A., Yiğit, Z., Okcun, B., Başkurt, M., Ortak, K., Kaya, A., & Küçükoğlu, S. (2008) · Circulation Journal · doi:10.1253/circj.72.705 · Cited by 16 · see citing works
Ivabradine for treatment of stable angina pectoris
de Silva, R., & Fox, K. (2009) · Nature Reviews Cardiology · doi:10.1038/nrcardio.2009.47 · Cited by 11 · see citing works
Chinushi, M., & Iijima, K. (2011) · Circulation Journal · doi:10.1253/circj.cj-11-0080 · Cited by 7 · see citing works
Flagged first, then by citations
Cited by
Sorted by citations
2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS
Kirchhof, P., Benussi, S., Kotecha, D., Ahlsson, A., Atar, D., Casadei, B., Castella, M., Diener, H.-C., Heidbuchel, H., Hendriks, J., et al. (2016) · European Heart Journal · doi:10.1093/eurheartj/ehw210 · Cited by 6,418 · see citing works
2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS
Kirchhof, P., Benussi, S., Kotecha, D., Ahlsson, A., Atar, D., Casadei, B., Castella, M., Diener, H.-C., Heidbuchel, H., Hendriks, J., et al. (2016) · European Journal of Cardio-Thoracic Surgery · doi:10.1093/ejcts/ezw313 · Cited by 1,403 · see citing works
- Authors
- CHATTERJEE, S., SARDAR, P., LICHSTEIN, E., MUKHERJEE, D., & AIKAT, S.
- Affiliations
- Brown University (US)
- Metropolitan Hospital Center (US)
- Maimonides Medical Center (US)
- Texas Tech University Health Sciences Center (US)
- University of Kentucky (US)
- Corresponding author
- CHATTERJEE, SAURAV
- Venue
- Pacing and Clinical Electrophysiology
- Publisher
- Wiley
- Published
- 2012-09-14
- Volume
- 36
- Issue
- 1
- Pages
- 122-133
- ISSN
- 0147-8389 (ISSN-L)
- 1540-8159
- OpenAlex
- W1717660429
- Cited by
- 113
- References
- 31
- Citations by year
- 2026: 2 · 2025: 5 · 2024: 5 · 2023: 8 · 2022: 7 · 2021: 11 · 2020: 5 · 2019: 16 · 2018: 16 · 2017: 14 · 2016: 8 · 2015: 6 · 2014: 7 · 2013: 2
- FWCI
- 0.78
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Pacing and Clinical Electrophysiology (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Atrial Fibrillation Management and Outcomes
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiac pacing and defibrillation studies
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiac Arrhythmias and Treatments
- Keywords
- atrial fibrillation, rate control, rhythm control, sinus rhythm maintenance, all-cause mortality, hospital readmission, stroke and systemic embolism, heart failure, hemorrhage, myocardial infarction, age differences in treatment outcomes
- MeSH terms
- Adrenergic beta-Antagonists, Anti-Arrhythmia Agents, Atrial Fibrillation, Humans, Prevalence, Randomized Controlled Trials as Topic, Treatment Outcome, Defibrillators, Implantable, Evidence-Based Medicine
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
Statistics and arithmetic are recomputed, not judged.
Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.
What counts as a claim ›How we measure confidence ›How we check this ›
Are you an author, or do you see a problem with this page? Request a review
