Quality of Life in Atrial Fibrillation: Rhythm or Rate Control

Accessible online at: www.karger.com/hed The management of atrial fibrillation may be based either on rate control or rhythm control. Four recent randomized clinical trials have been undertaken to compare the benefits and risks of the two approaches [1–4], and none of the studies reported any advantage for the rhythm control strategy. On the basis of these data, numerous editorials [5, 6] have concluded that rate control can be considered the primary approach for the majority of patients with atrial fibrillation. This may be the pragmatic approach in clinical practice in the elderly mildly symptomatic patient with persistent atrial fibrillation. However, more data are needed on groups of patients and therapies underrepresented in these trials. Only a minority had extensive structural heart disease, and highly symptomatic patients were not enrolled. Furthermore, only three studies have compared quality of life (QoL), and only one study has used more than one QoL instrument. In the studies by Hohnloser et al. [1] and Van Gelder et al. [2], QoL was assessed by a single generic instrument, and differences in important disease-specific dimensions (atrial-fibrillation-related symptoms) may have been overlooked. In all studies, QoL was significantly impaired compared to a general population of similar age [1–3]. Improvements in QoL were noted in both treatment strategies [1, 3], whereas only minor changes were observed in the study by Hagens et al. [7]. There were no significant differences between the two treatment strategies in any of the studies. It is noteworthy that in these mildly symptomatic patients, who seemingly had a small burden of cardiac disease, QoL was impaired even after pharmacological treatment. These results can be readily compared with nonpharmacologic treatment strategies where patients burdened by severe symptoms caused by atrial fibrillation report enhanced QoL [8], and in some cases even normative levels are reached after nonpharmacologic intervention [9]. Comparing the rate versus rhythm control approach, the impact of the pharmacological treatment strategies on QoL is in other words suboptimal and it may be argued that a greater use of nonpharmacologic therapies might have produced more favorable results with respect to the rhythm control strategy. The negative impact of atrial fibrillation on QoL should be evaluated in the context of other known hemodynamic and structural effects that have been described as a consequence of atrial fibrillation, i.e. loss of the atrial contribution to ventricular filling, irregularity in ventricular response leading to hemodynamic impairment and the risk of tachycardia-mediated cardiomyopathy. From this perspective, the rate control approach appears as a temporary strategy in the elderly mildly symptomatic patient with persistent atrial fibrillation. The ultimate goal for all patients with atrial fibrillation is still the maintenance of sinus rhythm, and the results from the above-mentioned four studies underlines the need for better treatment strategies, pharmacological as well as nonpharmacological. References