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Lluís Mont, ‘Fight for sinus rhythm, or surrender?’…, European Heart Journal, Volume 35, Issue 22, 7 June 2014, Pages 1427–1429, https://doi.org/10.1093/eurheartj/ehu099
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This editorial refers to ‘The young patient with asymptomatic atrial fibrillation: what is the evidence to leave the arrhythmia untreated?’‡, by K. Wasmer et al., on page 1439 and‘Early management of atrial fibrillation to prevent cardiovascular complications’†, by S. Natell et al., on page 1448
Since the publication of the AFFIRM trial,1 arrhythmology has been wrestling with the dilemma of ‘rate vs. rhythm control’ of atrial fibrillation (AF), with subtle variations on the theme. I suspect that some of our non-arrhythmologist colleagues may even experience some degree of ‘fatigue’ when the debate resurfaces. Two review papers now confront the dilemma from apparently different angles, but, in the end, they analyse similar facts and reach similar conclusions. Nattel et al.2 devote their attention to early rhythm control of AF as a potential strategy to prevent progression and decrease cardiovascular complications. On the other hand, Wasner et al.3 discuss whether to fight for sinus rhythm in asymptomatic young patients. These reviews share the hypothesis that previous studies advocating rhythm control have failed to demonstrate any definitive benefit over rate control in the AF population, because their trials included patients at a late stage of the disease. They suggest that pursuing sinus rhythm at an early stage of the disease and with better therapeutic tools may improve AF control and decrease morbidity and mortality. The new hypothesis that early treatment would result in better results is plausible, but not yet demonstrated in large trials. Therefore, after reading both reviews, we may conclude that we are more or less where we were before. In actual clinical practice, however, it is clear that many physicians recommend antiarrhythmic drugs or ablation in middle-aged patients with few co-morbidities. Therefore, the present reviews provide good tools to rethink the question and generate hypotheses that may lead us to the new evidence required.
