Rate versus rhythm control in atrial fibrillation and clinical outcomes: Updated systematic review and meta-analysis of randomized controlled trials

Summary Atrial fibrillation is the most frequently occurring sustained cardiac arrhythmia and is associated with a significantly increased risk of thromboembolic events and death. We sought to compare the clinical efficacy of rate and rhythm control strategies in patients with non-postoperative atrial fibrillation. We searched the PubMed database and the Cochrane Central Register of Controlled Trials for randomized controlled trials comparing rate versus rhythm control in patients with atrial fibrillation. Studies were retrieved and we analysed major clinical outcomes. Risk ratios (RRs) and 95% confidence intervals were calculated assuming random effects due to the clinical heterogeneity of the study populations. Eight randomized controlled trials were identified, with a total of 7499 patients with atrial fibrillation. There were no significant differences in the effects of rate and rhythm control on any outcome: all-cause mortality (RR: 0.95; CI: 0.86–1.05), cardiovascular mortality (RR: 0.99; CI: 0.87–1.13), arrhythmic/sudden death (RR: 1.12; CI: 0.91–1.38), ischaemic stroke (RR: 0.89; CI: 0.52–1.53), systemic embolism (RR: 0.89; CI: 0.69–1.14) and major bleeding (RR: 1.10; CI: 0.89–1.36). Updated data pooled from a large population of patients with atrial fibrillation suggests that rate and rhythm control strategies have similar effects on major clinical outcomes. Other factors, including individual preferences, comorbidities, drug tolerance and cost issues, should be considered when choosing the approach for these patients.