Atrial Fibrillation (AF)

1. Introduction Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, affecting more than 5% of the worldwide population [1]. It is associated with a high risk of thromboembolic events, including stroke, which occurs in about 23% of AF patients, older than 80 years [2, 3]. Over the last decade, it accounted for about one third of hospital admissions for cardiac arrhythmias [4, 5] with an increasing prevalence in patients with cardiovascular problems, such as valvular heart disease, heart failure (HF), and coronary artery disease (CAD) [6, 7].
The pharmacological management of AF targets either rate control (maintaining the heart rate at normal levels, using pharmacological agents, such as beta-blockers, non-dihydropyridine
calcium-channel blocker, and cardiac glycosides) or rhythm control (restoration of sinus rhythm, using electrical cardioversion and/or antiarrhythmic agents, such as sodium channel blockers and potassium channel blockers) [8]. In the past few years, several randomized controlled trials (RCTs) have investigated whether rhythm control is superior to rate control with respect to mortality and cerebrovascular accidents [9–22].
Besides the controversial results of these trials, former meta-analyses showed conflicting results, suggesting that rate control is either similar or superior to rhythm control in terms of mortality and stroke rates [23, 24]. Moreover, recent trials have compared both strategies in different groups of AF patients, including younger and those with concomitant HF [9, 12]. Therefore, we conducted this systematic review and meta-analysis to update the evidence regarding the optimal control approach for AF.