Sana M. Al-Khatib, MD, MHS; Nancy M. Allen LaPointe, PharmD; Ranee Chatterjee, MD, MPH; Matthew J. Crowley, MD; Matthew E. Dupre, PhD; David F. Kong, MD; Renato D. Lopes, MD, PhD; Thomas J. Povsic, MD, PhD; Shveta S. Raju, MD; Bimal Shah, MD; Andrzej S. Kosinski, PhD; Amanda J. McBroom, PhD; Gillian D. Sanders, PhD
Disclaimer: The authors of this article are responsible for its contents. Statements in the article should not be construed as endorsements by AHRQ or the U.S. Department of Health and Human Services.
Grant Support: By AHRQ (contract 290-2007-10066-I).
Disclosures: Dr. Allen LaPointe reports grants from AHRQ during the conduct of the study and grants from Pfizer outside the submitted work. Dr. Kong reports grants from AHRQ during the conduct of the study. Dr. Lopes reports personal fees from Bayer, Boehringer Ingelheim, and Pfizer; grants and personal fees from Bristol-Myers Squibb; and grants from GlaxoSmithKline outside the submitted work. Dr. Shah reports personal fees from Bristol-Myers Squibb, Cardinal, Castlight, and Janssen Pharmaceutical and grants from Amgen, Amylin/BMS, and Lilly outside the submitted work. Dr. McBroom reports other funding from AHRQ during the conduct of the study. Dr. Sanders reports grants from AHRQ during the conduct of the study. Authors not named here have disclosed no conflicts of interest. Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M13-1467.
Requests for Single Reprints: Sana M. Al-Khatib, MD, MHS, Duke Clinical Research Institute, PO Box 17969, Durham, NC 27715; e-mail, firstname.lastname@example.org.
Current Author Addresses: Drs. Al-Khatib, Allen LaPointe, Dupre, Kong, Lopes, Shah, Kosinski, McBroom, and Sanders: Duke Clinical Research Institute, PO Box 17969, Durham, NC 27715.
Dr. Chatterjee: Sutton Station Internal Medicine, 5832 Fayetteville Road, Suite 113, Durham, NC 27713.
Dr. Crowley: Durham Veterans Affairs Medical Center, Health Services Research & Development (152), 508 Fulton Street, Durham, NC 27705.
Dr. Povsic: Duke University Medical Center, Bell Building, Room 348, Durham, NC 27710.
Dr. Raju: Gwinnett Clinic, 475 Philip Boulevard, Suite 100, Lawrenceville, GA 30046.
Author Contributions: Conception and design: S.M. Al-Khatib, N.M. Allen LaPointe, D.F. Kong, R.D. Lopes, S.S. Raju, B. Shah, A.J. McBroom, G.D. Sanders.
Analysis and interpretation of the data: S.M. Al-Khatib, N.M. Allen LaPointe, R. Chatterjee, M.J. Crowley, D.F. Kong, R.D. Lopes, T.J. Povsic, S.S. Raju, B. Shah, A.S. Kosinski, A.J. McBroom, G.D. Sanders.
Drafting of the article: S.M. Al-Khatib, N.M. Allen LaPointe, R. Chatterjee, M.J. Crowley, A.J. McBroom, G.D. Sanders.
Critical revision of the article for important intellectual content: N.M. Allen LaPointe, R. Chatterjee, M.J. Crowley, D.F. Kong, R.D. Lopes, T.J. Povsic, B. Shah, A.J. McBroom, G.D. Sanders.
Final approval of the article: N.M. Allen LaPointe, M.J. Crowley, R.D. Lopes, T.J. Povsic, B. Shah, G.D. Sanders.
Statistical expertise: D.F. Kong, A.S. Kosinski, G.D. Sanders.
Obtaining of funding: G.D. Sanders.
Administrative, technical, or logistic support: M.E. Dupre, A.J. McBroom, G.D. Sanders.
Collection and assembly of data: S.M. Al-Khatib, N.M. Allen LaPointe, R. Chatterjee, M.J. Crowley, M.E. Dupre, R.D. Lopes, B. Shah, A.J. McBroom, G.D. Sanders.
Al-Khatib SM, Allen LaPointe NM, Chatterjee R, Crowley MJ, Dupre ME, Kong DF, et al. Rate- and Rhythm-Control Therapies in Patients With Atrial Fibrillation: A Systematic Review. Ann Intern Med. 2014;160:760-773. doi: 10.7326/M13-1467
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Published: Ann Intern Med. 2014;160(11):760-773.
The comparative effectiveness of treatments for atrial fibrillation (AF) is uncertain.
To evaluate the comparative effectiveness of rate- and rhythm-control therapies.
English-language studies in PubMed, EMBASE, and the Cochrane Database of Systematic Reviews between January 2000 and November 2013.
Two reviewers independently screened citations to identify comparative studies that assessed rate- or rhythm-control therapies in patients with AF.
Reviewers extracted data on study design, participant characteristics, interventions, outcomes, applicability, and quality.
200 articles (162 studies) involving 28 836 patients were included. When pharmacologic rate- and rhythm-control strategies were compared, strength of evidence (SOE) was moderate supporting comparable efficacy with regard to all-cause mortality (odds ratio [OR], 1.34 [95% CI, 0.89 to 2.02]), cardiac mortality (OR, 0.96 [CI, 0.77 to 1.20]), and stroke (OR, 0.99 [CI, 0.76 to 1.30]) in older patients with mild AF symptoms. Few studies compared rate-control therapies and included outcomes of interest, which limited conclusions. For the effect of rhythm-control therapies in reducing AF recurrence, SOE was high favoring pulmonary vein isolation versus antiarrhythmic medications (OR, 5.87 [CI, 3.18 to 10.85]) and the surgical maze procedure (including pulmonary vein isolation) done during other cardiac surgery versus other cardiac surgery alone (OR, 7.94 [CI, 3.63 to 17.36]).
Studies were heterogeneous in interventions, populations, settings, and outcomes.
Pharmacologic rate- and rhythm-control strategies have comparable efficacy across outcomes in primarily older patients with mild AF symptoms. Pulmonary vein isolation is better than antiarrhythmic medications at reducing recurrences of AF in younger patients with paroxysmal AF and mild structural heart disease. Future research should address uncertainties related to subgroups of interest and the effect of different therapies on long-term clinical outcomes.
Agency for Healthcare Research and Quality.
Summary of evidence search and selection.
AAD = antiarrhythmic drug; CRT = cardiac resynchronization therapy; RCT = randomized, controlled trial.
* Some studies were relevant to more than 1 topic.
Meta-analysis forest plots.
AAD = antiarrhythmic drug; PVI = pulmonary vein isolation. A. All-cause mortality for rate- vs. rhythm-control strategies. B. Cardiovascular mortality for rate- vs. rhythm-control strategies. C. Stroke for rate- vs. rhythm-control strategies. D. Restoration of sinus rhythm for monophasic vs. biphasic waveforms. E. Maintenance of sinus rhythm for PVI vs. AAD therapy.
Table 1. Summary of SOE and Effect Estimates for Rate- Versus Rhythm-Control Strategies
Table 2. Summary of SOE and Effect Estimates for Medications Used for Ventricular Rate Control
Table 3. Summary of SOE and Effect Estimates for Electrical Cardioversion and Antiarrhythmic Medications for Rhythm Control
Appendix Table. Summary of SOE and Effect Estimates for Procedural Rhythm-Control Therapies
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