When will the “Rate vs Rhythm” control debate in AF will end ?

May 15, 2024 by dr s venkatesan

We have more than solid evidence, that rate control is good enough or even better than rhythm control in the management of AF , for more than two decades. Studies that showed either equipoise or rate control was marginally superior in certain clinical parameters are.

1.AFFIRM (2002)

2.RACE

3.STAF(2003)

4.HOT-CAFE (2004)

Now, in 2020s with modalities like ablation, the choice is being pushed toward Pro-rhythm control. (Of course with evidence).Some of these studies are,

1.EAST-AFNET (2020)

2.CASTLE AF(2018)

3.RAFT AF (Again equivocal)

With emerging new technologies, scientists are trying whether more safer methods like cryoablation or pulse-filed ablation would beat the rate control with drugs. Still, rhythm control strategy is finding it tough to win over the apparently less scientific rate control strategy. (Why? The reason is discussed elsewhere )

“How can rhythm control be inferior or non-superior? Something is wrong. We can’t leave it like that. Let’s do a meta-analysis”

Even meta-analysis couldn’t help out rhythm control strategy.(Caldeira, Daniel et al. “Rate versus rhythm control in atrial fibrillation and clinical outcomes: updated systematic review and meta-analysis of randomized controlled trials.” Archives of cardiovascular diseases 105 4 (2012): 226-38 .)

Now, what shall we do? , Let us do another meta-analysis. A fresh one is released just a few days ago in 2024 . This mega meta-analysis with almost similar data, clearly vouchs for the superiority of early rhythm control with some form of ablation. It is gratifying that, with this study, we could sustain some confusion, in the management of this most common cardiac arrhythmia.

When will this fight for Rate vs Rhythm control in AF end?

Answer: It will not stop as long as an entity AF exists. Research, as the name implies, we need to search again, & again for truth. However, In the case of AF, I think, a different game is being played in the EP arena. It looks like, we are fighting with an established truth, not fighting for the truth.

Reference

1.Stefanos Zafeiropoulos, Ioannis Doundoulakis, Alexandra Bekiaridou et al Rhythm vs Rate Control Strategy for Atrial Fibrillation: A Meta-Analysis of Randomized Controlled Trials J Am Coll Cardiol EP. May 08, 2024. Epublished DOI: 10.1016/j.jacep.2024.03.006