Rate- and Rhythm-Control Therapies in Patients With Atrial Fibrillation: A Systematic Review.

Ann Intern Med. 2014;160(11):760-773.

Background: The comparative effectiveness of treatments for atrial fibrillation (AF) is uncertain.
Study Selection: Two reviewers independently screened citations to identify comparative studies that assessed rate- or rhythm-control therapies in patients with AF.

Data Synthesis: 200 articles (162 studies) involving 28 836 patients were included.

When pharmacologic rate- and rhythm-control strategies were compared, strength of evidence (SOE) was moderate supporting comparable efficacy with regard to all-cause mortality (odds ratio [OR], 1.34 [95% CI, 0.89 to 2.02]), cardiac mortality (OR, 0.96 [CI, 0.77 to 1.20]), and stroke (OR, 0.99 [CI, 0.76 to 1.30]) in older patients with mild AF symptoms.
Few studies compared rate-control therapies and included outcomes of interest, which limited conclusions.

For the effect of rhythm-control therapies in reducing AF recurrence, SOE was high favoring pulmonary vein isolation versus antiarrhythmic medications (OR, 5.87 [CI, 3.18 to 10.85]) and the surgical maze procedure (including pulmonary vein isolation) done during other cardiac surgery versus other cardiac surgery alone (OR, 7.94 [CI, 3.63 to 17.36]).

Conclusion:

Pharmacologic rate- and rhythm-control strategies have comparable efficacy across outcomes in primarily older patients with mild AF symptoms.
Pulmonary vein isolation is better than antiarrhythmic medications at reducing recurrences of AF in younger patients with paroxysmal AF and mild structural heart disease.

CONTEXT.
Atrial fibrillation (AF) is a major public health problem in the United States. More than 2.3 million Americans are estimated to have AF . The known association between AF and substantial mortality, morbidity, and health care costs compounds the effect of this condition.
Not only is the risk for death in patients with AF twice that of patients without it, but AF can result in myocardial ischemia and infarction, exacerbate heart failure (HF), and cause tachycardia-induced cardiomyopathy if the ventricular rate is not well-controlled .

The most dreaded complication of AF is thromboembolism, especially stroke . In some patients, AF or therapies to manage this condition can severely depreciate quality of life Furthermore, the management of AF and its complications is responsible for nearly $16 billion in additional costs to the U.S. health care system per year

Despite the substantial public health effect of AF, uncertainties around its management remain.

PRACTICE POINT- SUMMARY BY G.MOHAN.

In General practice , Diagnosis before complications arise is crucial.
Management in the older patient, is quite adequate with Pharmacologic Rate/ Rhythm control,are Effective for outcomes.
In the younger patient, Interventional procedure , seems better than medical therapy, for reducing recurrences.