Health

New guidelines for treating atrial fibrillation focus on rate over rhythm

A revised approach to the common heart condition triggers debate on how much emphasis to place on establishing normal rhythm.

By Susan J. Landers — Posted Jan. 12, 2004

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Washington -- Focus treatment on a patient's heart rate rather than heart rhythm in controlling atrial fibrillation, according to new guidelines released Dec. 16 by the American Academy of Family Physicians and the American College of Physicians.

"The generally accepted practice has been to do everything we can to get patients back into sinus rhythm and to try to keep them there," said Michael LeFevre, MD, MSPH, co-chair of the Joint AAFP-ACP Panel on Atrial Fibrillation.

However, the latest research shows that the preferred approach for most of these patients should be to focus on control of heart rate rather than attempting to restore sinus rhythm, said Dr. LeFevre.

"Controlling rhythm was not better than controlling rate in reducing complications and death, and the side effects of medications to keep patients in normal rhythm may be greater than their benefits," he said.

Atrial fibrillation, the most common heart arrhythmia, is found in about 2 million people. Standard treatments have attempted to convert the heart to normal rhythm, either with medications, often used long term, or by electricity. While it's rarely fatal, if uncontrolled, atrial fibrillation can cause strokes when blood clots formed in the atria travel to the brain.

The new guidelines, which were published in the Dec. 16, 2003, Annals of Internal Medicine, also recommend the use of warfarin to help prevent strokes. A strategy of using blood thinners has been recommended in the past, though all would caution against using such medications in patients who have an increased risk of bleeding.

Quality of life issues

The guidelines received a cautious review from Valentin Fuster, MD, PhD, who chaired a committee that wrote guidelines on atrial fibrillation two years ago. He urged that, while the emphasis in treatment should probably favor rate control, physicians should not be too quick to abandon rhythm control as a treatment goal.

Abnormal heart rhythm can have a large impact on a patient's quality of life, said Dr. Fuster, who directs the Zena and Michael A. Wiener Cardiovascular Institute and the Marie-Josee and Henry R. Kravis Center for Cardiovascular Health at Mount Sinai Hospital in New York City. "To say that [rate control] is the preferred strategy and that only people with severe quality of life impairments should be returned to normal rhythm is going to an extreme that is not part of the reality of patients we see today."

The new guidelines come in the wake of studies published last year that compared rate control and rhythm control in patients with atrial fibrillation, said Dr. LeFevre. Those studies found that rhythm-control strategies, for the most part, provided no improvement in patient survival over rate control and carried a higher risk of adverse drug effects. The guidelines do note that certain subgroups of patients with atrial fibrillation, such as younger patients with healthy hearts, were not well represented in the trials.

"I see a positive aspect [to the new guidelines]," said Dr. Fuster. "Based on the studies, the maintenance of the rate is an important strategy to take into account. The negative is that the studies on which they are based are ones in which a large number of people who had impaired quality of life did not enter the studies."

The earlier guidelines developed by Dr. Fuster and colleagues for the American Heart Assn., the American College of Cardiology and the European Society of Cardiology, placed greater emphasis on tailoring treatment to each patient's age, lifestyle, overall health and any other coexisting forms of heart disease.

They are to be updated soon, said Dr. Fuster.

He anticipates they will continue to include rhythm control as an important treatment goal and rate control for patients whose good quality of life makes rhythm control pharmacological strategies a poor choice.

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ADDITIONAL INFORMATION

Move to the beat

The American College of Physicians and the American Academy of Family Physicians developed new guidelines for controlling newly detected atrial fibrillation. Among their recommendations:

  • For most patients, slowing heart rates with medications, such as atenolol, metoprolol, diltiazem or verapamil, is the most appropriate treatment.
  • Patients should receive blood thinners to prevent stroke unless they have a condition that would make anticoagulation dangerous.
  • Patients who choose conversion to normal heart rhythm instead of rate control because of symptoms can select electrical or medical cardioversion.

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External links

Agency for Healthcare Research and Quality's evidence report on the management of new onset atrial fibrillation (link)

American Heart Assn.'s recommendations on atrial fibrillation (link)

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