With regard to rhythm therapy versus rate control for long-term management of recurrent atrial fibrillation (AF), the ICSI Technology Assessment Committee finds:
There is no observed survival advantage to strategies aimed at restoring sinus rhythm over strategies to control rate in older patients with relatively asymptomatic atrial fibrillation based on the limited data available from studies which have compared these strategies (Conclusion Grade II).
Strategies aimed at restoring sinus rhythm were associated with a higher incidence of hospitalization and adverse drug effects.
A strategy of rate control is an acceptable treatment option for older patients with recurrent or persistent atrial fibrillation who are asymptomatic or minimally symptomatic. The studies suggest that a rate control strategy should be reconsidered in patients in whom initial attempts at restoration of sinus rhythm have been ineffective or associated with side effects particularly if restoration of sinus rhythm did not result in significant symptomatic improvement.
Patients with atrial fibrillation with risk factors for thromboembolism should be considered for the warfarin anticoagulation. Early discontinuation of anticoagulation and subtherapeutic anticoagulation are factors associated with thromboembolic events.
Current randomized trials comparing rhythm therapy to rate control have included older patients with relatively asymptomatic, recurrent AF. Conclusions cannot be generalized to patients outside of these groups such as patients with symptomatic atrial fibrillation, first detected episodes of atrial fibrillation, or younger patients with atrial fibrillation.