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Rhythm vs Rate Control for Atrial Fibrillation – How It’s Done In Spain

March 5, 2019

Written by Clay Smith

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In this multicenter observational study in Spain, most hemodynamically stable patients with atrial fibrillation (a-fib) < 48 hours were managed with pharmacologic rhythm control rather than rate control.

Why does this matter?
In AFFIRM, there was no survival advantage to rhythm control over simple rate control for a-fib. Yet in many centers, such as in Canada, patients with new onset a-fib are routinely treated with rhythm control, that is, medically or electrically cardioverting to normal sinus rhythm (NSR). Though there may not be survival benefit with rhythm control, patients often have reduced symptoms in NSR, and the sooner the cardioversion, the more likely they are to stay in NSR. This was a cross-sectional look at the practice patterns at these centers in Spain.

Cómo se manejan los latidos irregularmente irregulares en España… (I hope this is correct.)
This was a multicenter observational study with prospective data collection on patients with recent onset (<48 hours), hemodynamically stable a-fib that enrolled 421 patients. The study was purely observational, with no intervention specified. Of these, 84% were treated with rhythm control, which was successful 84% of the time. They used pharmacologic cardioversion 77% of the time, most often amiodarone, then flecainide, followed by propafenone. Patients with rate control only were fairly evenly split between digoxin, beta blockers, and calcium channel blockers. Overall, 86% of patients were discharged. Symptom relief was much better in the rhythm control group. However, this was just the impression of the treating, unblinded doctor, as there was no validated a-fib symptom score to measure this. Another matter to consider with a rhythm control approach is anticoagulation. The 2014 AHA guideline on a-fib recommends anticoagulation in patients at high risk of stroke, even if onset is <48 hours. So, be sure to calculate a CHA2DS2-VASc score. The implication for my practice is that many of my patients with recent onset a-fib could be safely and quickly managed in the ED with either pharmacologic or DC cardioversion and often don’t need admission.

Benefits of rhythm control and rate control in recent-onset atrial fibrillation. The HERMES-AF study. Acad Emerg Med. 2019 Jan 31. doi: 10.1111/acem.13703. [Epub ahead of print]

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Reviewed by Thomas Davis

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