In a population‑based perspective, both paroxysmal and chronic atrial fibrillation bothers us more because of stroke risk than hemodynamic instability. AF confers a 3–5‑fold higher stroke risk and accounts for roughly 1 in 5 ischemic strokes overall.
Stroke‑related disability, recurrent events, and higher mortality make thromboembolic risk the dominant public‑health concern.

Hemodynamic instability does matter ,in ACS, pre‑existing systolic dysfunction or structural heart disease. At a community level, , stroke prevention (anticoagulation, risk stratification) outweighs rate‑rhythm control as the primary priority. This is exactly the reason, rate control was suffice to beat rhythm in major trials with a optimal anticoagulants.

*The pre-systolic 25% booster pump function acts more as a physiological reserve, effectively managing LV suction force in early stages (or even, intriguingly, it can function pre-systole) in otherwise healthy individuals.

We must also realise, rhythm control can paly a hide and seek game in many paroxysmal / persistent and most chronic AF , even with all these sophisticated ablation stuff including the Cryo and PFA. Also, we need to understand stroke in elderly , is not fully prevented even if SR is restored in piecemeals (of time) because the source of bolus can be elsewhere from ventricle, Aorta, carotids etc.

Final message

AF management require primarily a stroke prevention strategy rather than a hemodynamic stabilizing strategy in public health perspective. OAC can perfectly takes care of it in most. DOACS is also playing useful alternaterole. Contrary to the popular belief, many , LAA occlusion devices and ablation strategies do not necessarily negate the need for OAC in many elderly people.

Reference

1. Andrew Hill Atrial fibrillation and stroke: State-of-the-art and future directions Current Problems in Cardiology Volume 49, Issue 1, January 2024,