The choice of treatment depends on whether the goal is to control the frequency of ventricular contractions while maintaining atrial fibrillation (AF) or maintaining sinus rhythm. These two strategies are called “rate control” and “rhythm control” (rhythm control), respectively. In general, frequency control is easier than rhythm control.
Atrial fibrillation (AF) results in a loss of mechanical atrial systole before ventricular contraction and often inadequately high heart rate. This leads to a decrease in cardiac output. Therefore, one would expect that the patient’s condition would be better while maintaining normal sinus rhythm than while maintaining persistent or paroxysmal AF.
Nevertheless, several large studies have revealed that in terms of mortality, hospitalization rate and quality of life, the rhythm control strategy is no better than the strategy aimed at controlling heart rate. Patients who participated in these studies were predominantly elderly, and many of them suffered from cardiovascular disease.
Therefore, the results obtained cannot be applied without fail to all patients with atrial fibrillation (AF). For example, young people with paroxysmal idiopathic AF often have more pronounced symptoms, and maintaining sinus rhythm in them is more appropriate.
Although studies have shown that treatment strategies aimed at maintaining sinus rhythm are not better than the “frequency control” strategy, it is important to note that a stable preservation of the normal heart rhythm was not achieved in many patients from the “rhythm control” group. Therefore, it is highly likely that maintaining a normal rhythm still leads to a therapeutic outcome.
This assumption is confirmed by the results of both long-standing and recent studies that indicate that maintaining sinus rhythm improves the quality of life and tolerance to physical exertion. If a safe and relatively cheap way to maintain sinus rhythm is found, the “frequency control” strategy can, of course, be abandoned.
Some patients with atrial fibrillation (AF), despite effective heart rate control, experience very uncomfortable symptoms and feel much better with normal sinus rhythm. Others, including those who did not experience symptoms prior to treatment, feel quite well when pursuing a “frequency control” strategy. Thus, the treatment must be selected individually.
Often the strategy of “rhythm control” ends in failure, which makes it necessary to use the strategy of “frequency control”. However, in patients with severe clinical symptoms, an “aggressive” approach to maintaining sinus rhythm is justified.