Rate-control vs. rhythm-control in patients with atrial fibrillation: a meta-analysis

Aims To systematically assess the risk/benefit ratio of a rate-control strategy vs. a rhythm-control strategy in patients with first or recurrent atrial fibrillation (AF). Methods and results We searched Medline, CENTRAL, and other sources up to September 2004 for randomized trials. Individual and pooled random-effect odd ratios (OR) and 95% confidence intervals (CI) [OR (95% CI)] were calculated for the combined endpoint of all cause death and thromboembolic stroke (CEP), major bleeds (intra and extracranial), and systemic embolism. Number needed to treat (NNT) to avoid one CEP and heterogeneity were also assessed. Five studies enrolling 5239 patients with AF compared rate-control vs. rhythm-control. Average follow-up ranged from 1 to 3.5 years. A rate-control strategy compared with a rhythm-control approach was associated with a significantly reduced risk of CEP [OR 0.84 (0.73, 0.98), P=0.02], and with a trend towards a reduced risk of death [OR 0.87 (0.74, 1.02), P=0.09] and thromboembolic stroke [OR 0.80 (0.6, 1.07), P=0.14]. NNT to save one CEP was 50. There was no significant difference in the risk of major bleeds [OR 1.14 (0.9, 1.45), P=0.28] and systemic embolism [OR 0.93 (0.43, 2.02), P=0.90]. No significant heterogeneity was found in any of the analyses (P>0.1). Conclusion This meta-analysis of 5239 patients with AF indicates that an initial rate-control strategy compared with a rhythm-control one is associated with a better prognosis, thus representing the standard treatment against which to test new therapeutic approaches.