ANNALS OF EMERGENCY MEDICINE
MAY 2015
Systematic Review Snapshot TAKE-HOME MESSAGE
In patients with new-onset atrial fibrillation and symptom onset within 48 hours, rhythm control is preferred over rate control if the patient is younger than 65 years. For patients with congestive heart failure, valvular heart disease, hypertension, or permanent atrial fibrillation, rate control remains the favored strategy. DATA SOURCES The authors searched PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials from 1966 through 2011 for these Medical Subject Headings terms, limited to English: “atrial fibrillation,” “heart rate control,” and “rhythm control.” In addition, the references of included studies were manually searched. STUDY SELECTION Studies that enrolled adult patients with atrial fibrillation and randomized to rhythm control or rate control were included. Studies that used nonpharmacologic methods for rate control (eg, pacing, ablation) were excluded. DATA EXTRACTION AND SYNTHESIS The authors used Cochrane methodology to assess trials, and their systematic review was consistent with the Preferred Reported Items for Systematic Reviews and Meta-Analyses statement.1 Pooled treatment effects were estimated with a Mantel-Haenszel risk ratio to analyze the primary outcome of allcause mortality, with exploratory subanalysis for patients younger than 65 years.
540 Annals of Emergency Medicine
Is Rhythm Control Better Than Rate Control for New-Onset Atrial Fibrillation in the Emergency Department? EBEM Commentators
Rohith R. Malya, MD, MSc Department of Emergency Medicine University of Texas at Houston Houston, TX
Latha Ganti, MD, MS Department of Emergency Medicine University of Central Florida Gainesville, FL North Florida-South Georgia Veterans Affairs Medical Center Lake City, FL
Results ED-relevant atrial fibrillation trials. Study (n)
Design
Inclusion Criteria
Primary Outcome
Results
2
Multicenter PIAF, 2000 (252) RCT
18–75 y, persistent Symptomatic No difference between AF 7–360 days improvement at groups at any follow-up 3 wk, 3 mo, time 6 mo, and 1 y HOT CAFE,3 Multicenter 50–75 y, persistent Death and stroke No difference between 2004 (205) RCT AF 7–730 days, from all causes groups first symptomatic at 12 mo episode of AF Okcun,4 Single-center >18 y, persistent Embolic events and Rhythm control with fewer 2004 (154) RCT AF >48 h, death at 3 y deaths (15% vs 43%; nonischemic LV P.05) J-RHYTHM,5 Multicenter >18 y, paroxysmal Composite primary Rhythm-control arm with 2009 (827) RCT AF
MAY 2015
Systematic Review Snapshot TAKE-HOME MESSAGE
In patients with new-onset atrial fibrillation and symptom onset within 48 hours, rhythm control is preferred over rate control if the patient is younger than 65 years. For patients with congestive heart failure, valvular heart disease, hypertension, or permanent atrial fibrillation, rate control remains the favored strategy. DATA SOURCES The authors searched PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials from 1966 through 2011 for these Medical Subject Headings terms, limited to English: “atrial fibrillation,” “heart rate control,” and “rhythm control.” In addition, the references of included studies were manually searched. STUDY SELECTION Studies that enrolled adult patients with atrial fibrillation and randomized to rhythm control or rate control were included. Studies that used nonpharmacologic methods for rate control (eg, pacing, ablation) were excluded. DATA EXTRACTION AND SYNTHESIS The authors used Cochrane methodology to assess trials, and their systematic review was consistent with the Preferred Reported Items for Systematic Reviews and Meta-Analyses statement.1 Pooled treatment effects were estimated with a Mantel-Haenszel risk ratio to analyze the primary outcome of allcause mortality, with exploratory subanalysis for patients younger than 65 years.
540 Annals of Emergency Medicine
Is Rhythm Control Better Than Rate Control for New-Onset Atrial Fibrillation in the Emergency Department? EBEM Commentators
Rohith R. Malya, MD, MSc Department of Emergency Medicine University of Texas at Houston Houston, TX
Latha Ganti, MD, MS Department of Emergency Medicine University of Central Florida Gainesville, FL North Florida-South Georgia Veterans Affairs Medical Center Lake City, FL
Results ED-relevant atrial fibrillation trials. Study (n)
Design
Inclusion Criteria
Primary Outcome
Results
2
Multicenter PIAF, 2000 (252) RCT
18–75 y, persistent Symptomatic No difference between AF 7–360 days improvement at groups at any follow-up 3 wk, 3 mo, time 6 mo, and 1 y HOT CAFE,3 Multicenter 50–75 y, persistent Death and stroke No difference between 2004 (205) RCT AF 7–730 days, from all causes groups first symptomatic at 12 mo episode of AF Okcun,4 Single-center >18 y, persistent Embolic events and Rhythm control with fewer 2004 (154) RCT AF >48 h, death at 3 y deaths (15% vs 43%; nonischemic LV P.05) J-RHYTHM,5 Multicenter >18 y, paroxysmal Composite primary Rhythm-control arm with 2009 (827) RCT AF
