posted on 2020-05-07, 10:02authored byStephan Willems, Christian Meyer, Joseph de Bono, Axel Brandes, Lars Eckardt, Arif Elvan, Isabelle van Gelder, Andreas Goette, Michele Gulizia, Laurent Haegeli, Hein Heidbuchel, Karl Georg Haeusler, Josef Kautzner, Lluis Mont, G Andre Ng, Lukasz Szumowski, Sakis Themistoclakis, Karl Wegscheider, Paulus Kirchhof
Recent innovations have the potential to improve rhythm control therapy in patients with atrial fibrillation (AF). Controlled trials provide new evidence on the effectiveness and safety of rhythm control therapy, particularly in patients with AF and heart failure. This review summarizes evidence supporting the use of rhythm control therapy in patients with AF for different outcomes, discusses implications for indications, and highlights remaining clinical gaps in evidence. Rhythm control therapy improves symptoms and quality of life in patients with symptomatic AF and can be safely delivered in elderly patients with comorbidities (mean age 70 years, 3-7% complications at 1 year). Atrial fibrillation ablation maintains sinus rhythm more effectively than antiarrhythmic drug therapy, but recurrent AF remains common, highlighting the need for better patient selection (precision medicine). Antiarrhythmic drugs remain effective after AF ablation, underpinning the synergistic mechanisms of action of AF ablation and antiarrhythmic drugs. Atrial fibrillation ablation appears to improve left ventricular function in a subset of patients with AF and heart failure. Data on the prognostic effect of rhythm control therapy are heterogeneous without a clear signal for either benefit or harm. Rhythm control therapy has acceptable safety and improves quality of life in patients with symptomatic AF, including in elderly populations with stroke risk factors. There is a clinical need to better stratify patients for rhythm control therapy. Further studies are needed to determine whether rhythm control therapy, and particularly AF ablation, improves left ventricular function and reduces AF-related complications.
Funding
This work was partially supported by European Union [grant agreement No 633196 (CATCH ME), European Union BigData@Heart (grant agreement EU IMI 116074)], British Heart Foundation (PG/17/30/32961, FS/13/43/30324; and AA/18/2/34218), German Centre for Cardiovascular Research supported by the German Ministry of Education and Research (DZHK, via grants to AFNET and to the DZHK site Hamburg), and Leducq Foundation.
History
Citation
European Heart Journal, 2019, Vol. 40, Issue 46
Author affiliation
Leicester Biomedical Research Centre
Version
VoR (Version of Record)
Published in
European Heart Journal
Volume
40
Issue
46
Pagination
3793 - + (10)
Publisher
Oxford University Press (OUP) for European Society of Cardiology