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Rate versus rhythm control for AF after cardiac surgery : which is better

Rate versus rhythm control for AF after cardiac surgery : which is better

Post operative atrial  fibrillation is very common happening in  more than 50% of patients undergoing cardiac surgery and are at increased risk of complications including death repeat hospitalization researches wanted to establish which of the two methods of control of atrial fibrillation i.e. rate control or rhythm control is better and is associated with reduced complications

Post-op AF occurred in 695 of 2109 patients (33.0%) enrolled preoperatively. From these, 523 were randomly assigned to either rhythm control with amiodarone and/or direct current cardioversion, or rate control with a beta-blocker, calcium channel blocker, or digoxin (target heart rate <100 bpm at rest). Patients were anticoagulated if they remained in AF or had recurrent AF 48 hours after randomization.

The primary endpoint was the total number of days of hospitalization within 60 days after randomization did not differ between groups (median 5.1 days and 5.0 days for rate and rhythm control, respectively (p=0.76). There were also no significant differences between strategies in terms of readmissions (p=0.99), deaths (p=0.64) or overall serious adverse events (p=0.61), including thromboembolic and bleeding events.

Those assigned to rhythm control had faster resolution of their AF. Nevertheless, at 60 days, 94.2% of the rate-control group and 98.3% of the rhythm-control group were free from AF.

The researches concluded that in this study there was no clear advantage for rate or rhythm control in terms of shortening hospital stay or reducing complications rates. “More than 90% of the time, the atrial fibrillation is going to be gone by 60 days no matter what we do,” the established strategy of rate control in hemodynamically stable patients with post-op AF is reasonable in that it avoids the toxicity associated with amiodarone. However, is was associated with slower resolution of AF and, therefore, a greater need for anticoagulation. Physician and patient preferences should dictate the approach used.

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Source: with inputs from Dr. Prem Aggarwal

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