If you have atrial fibrillation, how do you decide between the two basic approaches to treating your arrhythmia (that is, restoring and maintaining a normal rhythm or controlling the heart rate)? Usually, this question is best answered by first considering which pattern of atrial fibrillation you have.
Patients with atrial fibrillation generally fall into one of two broad categories: those with occasional episodes of atrial fibrillation (paroxysmal atrial fibrillation) and those with chronic or persistent atrial fibrillation.
If You Have Paroxysmal Atrial Fibrillation:
Description of this condition: People with intermittent or paroxysmal atrial fibrillation spend most of their time in a normal heart rhythm. But they have occasional episodes - lasting minutes to hours - in which they are in atrial fibrillation. The symptoms they experience with these episodes can be relatively mild or relatively severe, and the frequency of episodes varies tremendously from person to person. Some may have episodes that occur many months apart; others may have episodes almost every day.Treatment: In general, the preferred approach to therapy if you are in this group is the rhythm-control approach - that is, to maintain a normal heart rhythm. You should avoid foods and substances that are known to trigger atrial fibrillation in some people, such as caffeine and other stimulants, tobacco and alcohol. Alcohol is a particularly important trigger in those where even a single drink can cause atrial fibrillation (the so-called holiday heart syndrome).
When you have an episode of atrial fibrillation, you can wait up to six hours to see if it stops on its own. If it does not, get medical attention. Your doctors need to make sure you are back in a normal rhythm within 12 to 24 hours (don't let them take the "wait-and-see" gambit too far), because blood clots begin to form in the atria. If you do not convert to a normal rhythm on your own, insist they cardiovert you before 24 hours have passed.
Especially if your episodes are quite troublesome - either because of the symptoms they cause or because of their frequency - then you and your doctor need to take a strategy to reduce or eliminate these episodes.
People with paroxysmal atrial fibrillation - just like people with the more chronic forms of atrial fibrillation - must discuss the need for stroke prevention with their doctors.
If You Have Chronic or Persistent Atrial Fibrillation:
Description of this condition: People with chronic atrial fibrillation have been in this arrhythmia for a period of weeks or months. In essence, atrial fibrillation has become their "new-normal" heart rhythm.People who still have periods of normal heart rhythm, but who frequently have recurrent episodes of atrial fibrillation that persist for a full day or longer (and that often persist until a cardioversion is performed) are said to have persistent atrial fibrillation. The condition of persistent atrial fibrillation is usually quite temporary and virtually always ends in chronic atrial fibrillation.
Treatment: Most doctors will try restoring and maintaining a normal heart rhythm at least once or twice in patients with chronic or persistent atrial fibrillation. A trial of cardioversion followed by watching and waiting is often tried first. If the atrial fibrillation recurs, then another cardioversion may be performed, this time along with a trial of an antiarrhythmic drug. If the drug fails, then it is time to consider more drug trials (that is, continuing with the rhythm-control approach) or switching to the rate-control approach to treatment.
In patients with chronic or persistent atrial fibrillation, the odds of success with the rhythm-control approach is relatively low, and the vast majority of these people end up following the rate-control method, and do quite well with it.
Virtually all people with chronic or persistent atrial fibrillation should be on chronic anti-coagulation therapy to reduce the risk of stroke.
Is Maintaining a Normal Rhythm Better than Rate Control?
For most people with chronic or persistent atrial fibrillation, there is no evidence that aggressively pursuing the rhythm-control approach yields better clinical outcomes than using a rate-control approach. In fact, two large, randomized, controlled clinical trials comparing rhythm control to rate control in patients with atrial fibrillation have now been completed. Both studies showed a trend toward worse clinical outcomes (including a higher incidence of death, heart failure, stroke and bleeding) with the rhythm-control approach. Most experts attribute these worse outcomes to the side effects of antiarrhythmic drugs, but this is unclear.
Bottom line: For now, the "default" approach for most patients with chronic or persistent atrial fibrillation (after one or perhaps two attempts to maintain a normal rhythm have failed) is the rate-control approach.Sources:
Wyse DG, Waldo AL, et al. A comparison of rate control and rhythm control in patients with atrial fibrillation. N Eng J Med 2002;347(23):1825.
Van Gelder IC, Hagens VE, et al. A comparison of rate control and rhythm control in patients with recurrent persistent atrial fibrillation. N Eng J Med 2002;347(23):1834.
