Rate versus Rhythm Control in Patients with Atrial Fibrillation
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REVIEW ARTICLE
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Rate versus Rhythm Control in Patients with Atrial Fibrillation What the Trials Really Say Harry J.G.M. Crijns Department of Cardiology, University Hospital Maastricht, Maastricht, The Netherlands
Contents Abstract . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1651 1. Rate versus Rhythm: Rationale . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1653 2. Rate-versus-Rhythm Trials: The Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1654 2.1 PIAF (Pharmacological Intervention in Atrial Fibrillation) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1654 2.2 STAF (Strategies of Treatment of Atrial Fibrillation) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1654 2.3 RACE (RAte Control versus Electrical conversion) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1654 2.4 HOT-CAFE (How to Treat Chronic Atrial Fibrillation) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1655 2.5 AFFIRM (Atrial Fibrillation Follow-up of Rhythm Management) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1655 3. Study Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1655 4. Where We Stand Today . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1658 4.1 How Does Achieved Heart Rate Relate to Clinical Outcomes? . . . . . . . . . . . . . . . . . . . . . . . . . . 1658 4.2 Would Successful Maintenance of Normal Sinus Rhythm (NSR) Improve Atrial Function and Clinical Outcomes? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1659 4.3 Would Successful Maintenance of NSR Improve Quality of Life? . . . . . . . . . . . . . . . . . . . . . . . . . 1660 4.4 Do Current Antiarrhythmic Drugs Limit the Ability to Achieve the Potential Benefits of NSR? 1661 4.5 Should Anticoagulant Practices be Changed in Light of these Studies? . . . . . . . . . . . . . . . . . . 1663 5. Future Directions for Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1663 6. Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1664
Abstract
Despite new insights into the pathophysiological triggers of atrial fibrillation (AF) and the development of novel ablative techniques and antiarrhythmic drugs, the management of this chronic rhythm disturbance remains problematic. At present, there are two funda
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