To Be or Not To Be in Normal Sinus Rhythm: What Do We Really Know?

The high prevalence of atrial fibrillation and the shortcomings of currently available therapies fuel continued discussion of best clinical practice. The recent publication of the Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) trial (1), the largest randomized trial of management strategies for atrial fibrillation, seemed to resolve a major issue: Rate control and the use of anticoagulation are equivalent to restoring and maintaining normal sinus rhythm by using contemporary antiarrhythmic drugs.

In this issue, Marshall and colleagues (2) provide additional analyses of the AFFIRM database—a comparison of the cost-effectiveness of rate control versus rhythm control of atrial fibrillation. The study is important because it compared randomized data on the efficacy and resource use of the 2 strategies over a mean of 3.5 years. The duration of follow-up was sufficiently long to include substantial changes in management within each group. Rhythm-control costs were approximately $5000 more per person than rate-control costs, and mean survival was reduced. These conclusions were robust; dominance of rate control over rhythm control persisted regardless of the costing scenario used in the analysis. This is the first report from AFFIRM data to show an advantage of one treatment strategy, namely rate control. The higher cost for rhythm control confirms our intuition that this strategy often requires hospitalization for antiarrhythmic drug loading, cardioversion, or acute rate control for recurrent rapid atrial fibrillation.

This editorial considers important qualifications of the AFFIRM study design and addresses 3 key questions: First, does a rhythm control strategy have any role in the treatment of atrial fibrillation in the AFFIRM sample or others? Second, does normal sinus rhythm provide substantial benefits for patients with atrial fibrillation in general, and, if so, why didn't AFFIRM demonstrate improved outcome in the rhythm control group? Third, what is a reasonable treatment approach for patients …