Rate or rythym

[Tomred]

Hi everyone and good day to all, which is most important , rate or rythym control in af.

[mjames1]

The old answer used to be "take your choice", but newer studies suggest rhythm control to be superior.

Jim

"It has long been debated whether rhythm control vs. rate control strategies have differing effects on mortality and morbidity for atrial fibrillation (AF). Recently, several randomized controlled studies (RCTs) and observational trials described that an early rhythm management method was linked to a lower likelihood of negative clinical outcomes in individuals with AF. We wanted to see if an early rhythm management method may help patients with AF."

Front Cardiovasc Med. 2023; 10: 978637. Published online 2023 Feb 6. doi: 10.3389/fcvm.2023.978637

PMCID: PMC9939510PMID: 36815025

[Paulbounce]

Hi Tom.

As much as I respect Jims reply rate control is the most important to me. The lower your HR the longer you live. Even a difference of 10 beats per minute can make a difference of a few years to your life scan.

Paul

[mjames1 in reply to Paulbounce]

Paulbounce: rate control is the most important to me. The lower your HR the longer you live.

When you control rhythm, for all practical purposes, you control rate. But not the other way around.

Unless your resting heart rate is over 100, I have never heard of any benefit of lowering it with medication's.

On the other hand, a normal rhythm is more efficient than an irregular rhythm, and that seems why studies suggest better outcomes with rhythm control.

Jim

[Tomred in reply to mjames1]

thank you mjames

[Paulbounce in reply to mjames1]

I can't link to medical journals due to new forum rules. However the choice between rate or rhythm control is different for us all. It depends on your underlying heart conditiontons and general heath.

For me rate control is king.

Paul

[Singwell in reply to Paulbounce]

We're all different aren't we? It's rhythm for me without doubt. I felt do much better when I switched from BBs to Flecainide. Currently off all that. Fingers crossed it lasts.

[beach_bum in reply to Singwell]

Did your AFIB go away?

[Singwell in reply to beach_bum]

Currently not visiting. Fingers crossed 🤞 post ablation number 2

[Tomred in reply to Paulbounce]

thank you Paul

[mav7]

The target for rate control for afib patients is <80 (avg rate) if using medications. Not always attainable.

As mjames states, rhythm control is the preferred therapy. My cardiologist stated this on last visit. However, some are ineligible for rhythm control due to various reasons including valve issues. I am on Metoprolol and Sotalol did not work for me maybe because of moderate aortic stenosis. Overall, like Paul I am satisfied with rate control.

Regular echocardiograms are vital to monitor the heart.

 Tomred Lot of studies/info on the ‘net. Sry we can’t post links.

[pusillanimous in reply to mav7]

How frequent should echocardiograms be done - I have an annual one - is that sufficient? - although the Cardiologist always says 'see you in a year' after each visit.

[Singwell in reply to pusillanimous]

I'd say that's a good rate. I had 3 years between the 2 I've had - maybe because of the pandemic.

[pusillanimous in reply to Singwell]

I live in South Africa and belong to a Medical Aid Society which provides private treatment, maybe the criteria is different.

[mav7 in reply to pusillanimous]

Annuals are good and probably the highest standard. Depending on individual, every 2 yrs seems to be the norm .

[Tomred in reply to mav7]

Thank you mav7

[DKBX]

Perhaps it’s a ‘both-and’ answer rather than an ‘either-or’ (depending on how the patient responds)?

[Tomred in reply to DKBX]

thank you DKBX

[Ppiman]

I have found two recent studies that have used "meta-analyses" which have come down in favour of rhythm control, thus reversing the previous general outcome that there is little to choose between the two forms of treatment of AF. These studies both show that rhythm control can lead lead to somewhat better "all cause mortality" and a few other important health parameters compared with rate control. There are many studies that show the opposite, but these are newer and seem to be very well conducted studies, but they are meta-studies that rely on secondary data rather than primary studies that look at live data.

Also, and perhaps much more importantly, rate control is, with current medications, safer and less likely to lead to drug-induced side effects. For example, to my knowledge, all current rhythm control medications, aside from amiodarone, can be "pro-arrhythmic", which can be risky in certain individuals. Also, the two most commonly used rhythm control drugs, flecainide and sotalol, can only be given to patients who enjoy a high cardiac output (EF). This means that any study that looks at patients taking these two drugs might well be skewed by the potentially healthier status of the participants being studied. You can see that the results of any meta-study needs to be viewed with caution.

My own assessment after reading dozens of studies over the years since I have had arrhythmias is that any difference is likely to be small and be hard to show. For instance, consider these complicating circumstances:

- the complex nature of individual heart conditions and the often unknown root cause of AF;

- the general prevalence of other cardiovascular diseases in any studied aging population; many with AF suffer with hypertension, diabetes, obesity or sleep apnoea, for example, all conditions that can bring complex heath issues on top of AF;

- the existence of other co-morbidities in any generally aging population under study, for example, relatively common inflammatory and auto-immune conditions;

- the very long term nature of such studies makes the close monitoring of individuals with AF who do become ill or die much less likely.

On balance, I suspect rate control will rightly remain the first-line treatment for most sufferers from health problems caused by atrial arrhythmias and with good reason. Also, rate control will often stop AF by different (yet largely unknown) mechanisms of action, as is the case with me.

Steve

[Tomred in reply to Ppiman]

thank you ppiman

[Tellingfibs]

I have Paroxysmal Afib which whilst it doesn’t bother me greatly, I feel my worst when my HR goes over 100, which it has a few times in the past, and that’s why I’m on 10 mgs of Bisoprolol daily. I have a couple of mild and moderately leaky valves. My cardiologist says it’s important to keep the HR reasonable, and mine in the low 60s at rest is ideal, apparently. My GP agrees. I have LOTS of ectopics these days and I wondered if I might be put on rate control, but my average HR remains ‘ideal’ so the medics are not concerned. I have only read articles where they state rate control is more important, but perhaps they are out of date now. And remember, what is sauce for the goose may not be the sauce for the gander !

Annie.

[Gumbie_Cat in reply to Tellingfibs]

I am in permanent AFib, and take 3.75mg daily, specifically for rate control. So it sounds as though that is what you are on?

When I was still in Paroxysmal AFib, I took Dronedarone which is for rhythm control. But that also brought my heart rate down - so it did both really. Then A Fib still broke through. Rhythm control through drugs or ablation is ideal, but sadly doesn’t work for everyone. Flecainide didn’t work on me either, nor an ablation.

If rhythm control isn’t achievable, then rate control can become essential. Though some people can have low rate permanent AFib and not need it. In some ways I feel more settled in constant AFib along with Bisoprolol. As the anti-arrhythmic medications were not working, and only giving a lower rate, it did feel more sensible to go on a ‘simpler’ medication - which for me has fewer side effects,

[Tellingfibs in reply to Gumbie_Cat]

Thanks for your reply. I am doing well on Bisoprolol and think maybe I could have a lower dose, just to see what happens, but GP said not to change anything. Also, all the ectopics might cause a faster rate. I’ve noticed a lot of people on this forum say the same as you - that they are more ‘settled’ in constant Afib, as they don’t have the anxiety of wondering when it is going to break through, and also, there is the idea that the heart adapts to the ‘craziness’, whereas it doesn’t cope so well with dropping in and out of Afib.

All the best to you.

Annie.

[JOY2THEWORLD49]

Hi

Rapid rate.

Taking CCB Calcium Channel Blockers reducers the rapid, mine went from 156 to 51. Lessened the dose to 120mg. I reduced weight by 6kg over the year and the controlled h/rate day from 88-96 to 60s.

In controlling the H/Rate also slows the rhythm and improves across the board.

Incidentally I cant take an anti-arrhymic med as my heart is not structurally normal.

The symptom comes from rapid h/rate such as uncontrollable sweating, exhausted, sleeping alot with no/little stamina.

Once h/rate at rest controlled below 100 I improved immensely.

Also we cant have an operation with a h/beat at rest over 100.

So quite clearly rate is most important. Damage can come from over 100 h/rate.

cheri JOY. 75 (NZ)

[bean_counter27]

Why do you ask? Do you have to choose?

[MWIC]

Way I see it is the key is Rhythm as it’s the Arrhythmia that is the cause of the problem so if the Arrhythmia is controlled or resolved I’d expect the unusual HR to go as all my high HR episodes relate to my Arrhythmia but that’s not discounting that heart rate should be ignored

[Angusdon]

I have had permanent AF for the past 4 years after 2 failed CVs and the only symptom I have is a little breathlessness if I over exert myself, but most days I don’t feel I’m in AF.

I don’t take any medication for my AF as my rate control is normal with a resting HR of about 65bpm sometimes as low as 60bpm So for me personally I would put rate control before rhythm control.