Rate-Control vs Rhythm-Control for Atrial Fibrillation: A Controversy Reluctant to Die in the Era of Dronedarone?
DOI:
https://doi.org/10.12970/2311-052X.2013.01.01.1Keywords:
Atrial fibrillation, antiarrhythmic drugs, dronedarone, AFFIRM, ATHENAAbstract
Although restoring atrial fibrillation to sinus rhythm seems beneficial in patients with non-permanent AF, clinical trials have not observed any convincing benefit of a rhythm-control strategy compared with a rate-control strategy. This may be related with the adverse effects associated with antiarrhythmic drugs that may offset any beneficial effect of this approach.
Dronedarone has been recently approved for the treatment of patients with paroxysmal or persistent atrial fibrillation and is the only antiarrhythmic agent that has shown a benefit in the reduction of the incidence of hospitalization due to cardiovascular events or death compared with placebo.
As AFFIRM is the most relevant clinical trial that has suggested that rhythm and rate control rates strategies are similar, and ATHENA the most important study analyzing the effects of dronedarone in patients with atrial fibrillation, the results of both studies have been compared.
References
Wyse DG, Waldo AL, DiMarco JP, Domanski MJ, Rosenberg Y, Schron EB, et al. A comparison of rate control and rhythm control in patients with atrial fibrillation. N Engl J Med 2002; 347: 1825-33. http://dx.doi.org/10.1056/NEJMoa021328
Corley SD, Epstein AE, DiMarco JP, Domanski MJ, Geller N, Greene HL, et al. Relationships between sinus rhythm, treatment, and survival in the Atrial Fibrillation Follow-Up Investigation of Rhythm Management (AFFIRM) Study. Circulation 2004; 109: 1509-13. http://dx.doi.org/10.1161/01.CIR.0000121736.16643.11
Hohnloser SH, Crijns HJ, van Eickels M, Gaudin C, Page RL, Torp-Pedersen C, Connolly SJ. Effect of dronedarone on cardiovascular events in atrial fibrillation. N Engl J Med 2009; 360: 668-78. http://dx.doi.org/10.1056/NEJMoa0803778
Connolly SJ, Camm AJ, Halperin JL, Joyner C, Alings M, Amerena J, et al. Dronedarone in high-risk permanent atrial fibrillation. N Engl J Med 2011; 365: 2268-76. http://dx.doi.org/10.1056/NEJMoa1109867
Køber L, Torp-Pedersen C, McMurray JJ, Gøtzsche O, Lévy S, Crijns H, et al. Dronedarone Study Group. Increased mortality after dronedarona therapy for severe heart failure. N Engl J Med 2008; 358: 2678-87. http://dx.doi.org/10.1056/NEJMoa0800456
Multaq®. Summary of product characteristics.Available at: http://www.ema.europa.eu/docs/es_GB/document_library/EP AR_-_Product_Information/human/001043/WC500044534. pdf
Rosman J, Hoffmeister P, Reynolds M, Peralta A. Possible proarrhythmia with dronedarone. J Cardiovasc Electrophysiol 2013; 24: 103-104. http://dx.doi.org/10.1111/j.1540-8167.2012.02353.x
