and at high cardiovascular disease risk, we will continue with a rhythm-control strategy and add an antiarrhythmic medication or pursue a catheter ablation to maintain sinus rhythm. If they are >80 years of age and at low cardiovascular disease risk, we switch to rate control. (See 'Unsuccessful initial cardioversion or AF recurrence' above.) Preference for rate control https://www.uptodate.com/contents/management-of-atrial-fibrillation-rhythm-control-versus-rate-control/print 12/22 7/5/23, 9:15 AM Management of atrial fibrillation: Rhythm control versus rate control - UpToDate We generally prefer long-term rate control for asymptomatic patients age >80 years old who are asymptomatic and have a low cardiovascular disease risk ( algorithm 1). (See 'Rate control' above.) In selected patients who do not respond adequately and/or cannot tolerate pharmacologic rate control, we consider switching to a rhythm-control strategy. (See 'Unsuccessful pharmacologic rate control' above.) Changing management strategies If a patient has a strong preference to pursue another management strategy, or if there is a failure of the initial chosen strategy after a reasonable attempt, we often switch to another approach. (See 'Changing management strategies' above.) Use of UpToDate is subject to the Terms of Use. REFERENCES 1. Atwood JE, Myers JN, Tang XC, et al. Exercise capacity in atrial fibrillation: a substudy of the Sotalol-Amiodarone Atrial Fibrillation Efficacy Trial (SAFE-T). Am Heart J 2007; 153:566. 2. Spertus J, Dorian P, Bubien R, et al. Development and validation of the Atrial Fibrillation Effect on QualiTy-of-Life (AFEQT) Questionnaire in patients with atrial fibrillation. Circ Arrhythm Electrophysiol 2011; 4:15. 3. Wyse DG, Waldo AL, DiMarco JP, et al. A comparison of rate control and rhythm control in patients with atrial fibrillation. N Engl J Med 2002; 347:1825. 4. Van Gelder IC, Hagens VE, Bosker HA, et al. A comparison of rate control and rhythm control in patients with recurrent persistent atrial fibrillation. N Engl J Med 2002; 347:1834. 5. Zarembski DG, Nolan PE Jr, Slack MK, Caruso AC. Treatment of resistant atrial fibrillation. A meta-analysis comparing amiodarone and flecainide. Arch Intern Med 1995; 155:1885. 6. Antonielli E, Pizzuti A, P link s A, et al. Clinical value of left atrial appendage flow for prediction of long-term sinus rhythm maintenance in patients with nonvalvular atrial fibrillation. J Am Coll Cardiol 2002; 39:1443. 7. Israel CW, Gr nefeld G, Ehrlich JR, et al. Long-term risk of recurrent atrial fibrillation as documented by an implantable monitoring device: implications for optimal patient care. J Am Coll Cardiol 2004; 43:47. 8. Dorian P, Mangat I. Quality of life variables in the selection of rate versus rhythm control in patients with atrial fibrillation: observations from the Canadian Trial of Atrial Fibrillation. Card Electrophysiol Rev 2003; 7:276. https://www.uptodate.com/contents/management-of-atrial-fibrillation-rhythm-control-versus-rate-control/print 13/22 7/5/23, 9:15 AM Management of atrial fibrillation: Rhythm control versus rate control - UpToDate 9. Hagens VE, Ranchor AV, Van Sonderen E, et al. Effect of rate or rhythm control on quality of life in persistent atrial fibrillation. Results from the Rate Control Versus Electrical Cardioversion (RACE) Study. J Am Coll Cardiol 2004; 43:241. 10. Kirchhof P, Camm AJ, Goette A, et al. Early Rhythm-Control Therapy in Patients with Atrial Fibrillation. N Engl J Med 2020; 383:1305. 11. Willems S, Borof K, Brandes A, et al. Systematic, early rhythm control strategy for atrial fibrillation in patients with or without symptoms: the EAST-AFNET 4 trial. Eur Heart J 2022; 43:1219. 12. Snow V, Weiss KB, LeFevre M, et al. Management of newly detected atrial fibrillation: a clinical practice guideline from the American Academy of Family Physicians and the American College of Physicians. Ann Intern Med 2003; 139:1009. 13. Go AS, Hylek EM, Phillips KA, et al. Prevalence of diagnosed atrial fibrillation in adults: national implications for rhythm management and stroke prevention: the AnTicoagulation and Risk Factors in Atrial Fibrillation (ATRIA) Study. JAMA 2001; 285:2370. 14. Heijman J, Hohnloser SH, Camm AJ. Antiarrhythmic drugs for atrial fibrillation: lessons from the past and opportunities for the future. Europace 2021; 23:ii14. 15. Mankad P, Kalahasty G. Antiarrhythmic Drugs: Risks and Benefits. Med Clin North Am 2019; 103:821. 16. de Denus S, Sanoski CA, Carlsson J, et al. Rate vs rhythm control in patients with atrial fibrillation: a meta-analysis. Arch Intern Med 2005; 165:258. 17. Hohnloser SH, Kuck KH, Lilienthal J. Rhythm or rate control in atrial fibrillation Pharmacological Intervention in Atrial Fibrillation (PIAF): a randomised trial. Lancet 2000; 356:1789. 18. Carlsson J, Miketic S, Windeler J, et al. Randomized trial of rate-control versus rhythm- control in persistent atrial fibrillation: the Strategies of Treatment of Atrial Fibrillation (STAF) study. J Am Coll Cardiol 2003; 41:1690. 19. Opolski G, Torbicki A, Kosior DA, et al. Rate control vs rhythm control in patients with nonvalvular persistent atrial fibrillation: the results of the Polish How to Treat Chronic Atrial Fibrillation (HOT CAFE) Study. Chest 2004; 126:476. 20. Ogawa S, Yamashita T, Yamazaki T, et al. Optimal treatment strategy for patients with paroxysmal atrial fibrillation: J-RHYTHM Study. Circ J 2009; 73:242. 21. Roy D, Talajic M, Dorian P, et al. Amiodarone to prevent recurrence of atrial fibrillation. Canadian Trial of Atrial Fibrillation Investigators. N Engl J Med 2000; 342:913. https://www.uptodate.com/contents/management-of-atrial-fibrillation-rhythm-control-versus-rate-control/print 14/22 7/5/23, 9:15 AM Management of atrial fibrillation: Rhythm control versus rate control - UpToDate 22. Dittrich HC, Erickson JS, Schneiderman T, et al. Echocardiographic and clinical predictors for outcome of elective cardioversion of atrial fibrillation. Am J Cardiol 1989; 63:193. 23. January CT, Wann LS, Alpert JS, et al. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines and the Heart Rhythm Society. Circulation 2014; 130:e199. 24. January CT, Wann LS, Alpert JS, et al. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines and the Heart Rhythm Society. Circulation 2014; 130:2071. 25. Hindricks G, Potpara T, Dagres N, et al. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS): The Task Force for the diagnosis and management of atrial fibrillation of the European Society of Cardiology (ESC) Developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC. Eur Heart J 2021; 42:373. 26. January CT, Wann LS, Calkins H, et al. 2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society in Collaboration With the Society of Thoracic Surgeons. Circulation 2019; 140:e125. Topic 1045 Version 39.0 https://www.uptodate.com/contents/management-of-atrial-fibrillation-rhythm-control-versus-rate-control/print 15/22 7/5/23, 9:15 AM Management of atrial fibrillation: Rhythm control versus rate control - UpToDate GRAPHICS The rate of recurrent atrial fibrillation is lowest with amiodarone The Canadian Trial of Atrial Fibrillation randomized 403 patients with at least one episode of atrial fibrillation (AF) during the prior six months to low-dose amiodarone, propafenone, or sotalol. After a mean follow-up of 16 months, the likelihood of being free from recurrent AF was highest with amiodarone (65 versus 37 percent for sotalol and propafenone) and the median time to recurrence was longer (>468 versus 98 days). Data from: Roy D, Talajic M, Dorian P, et al. N Engl J Med 2000; 342:913. Graphic 69285 Version 3.0 https://www.uptodate.com/contents/management-of-atrial-fibrillation-rhythm-control-versus-rate-control/print 16/22 7/5/23, 9:15 AM Management of atrial fibrillation: Rhythm control versus rate control - UpToDate Long-term management of patients with atrial fibrillation: Selection of rhythm versus rate control In some patients who strongly prefer to be in SR, regardless of age or comorbidities, we pursue a rhythm control strategy. Regardless of strategy, it is important to assess need for anticoagulation based on patient's risk factors for thromboembolic events and bleeding risk (ie, CHADS2-VASCc score). Refer to related UpToDate content for further information. AF: atrial fibrillation; SR: sinus rhythm. High risk for cardiovascular disease includes >75 years of age, prior transient ischemic attack or stroke, or two of the following criteria: age >65 years, female sex, heart failure, hypertension, diabetes, severe coronary artery disease, chronic kidney disease, and left ventricular hypertrophy (diastolic septal wall width >15 mm). A patient at low risk for cardiovascular disease includes everyone else not at high risk. https://www.uptodate.com/contents/management-of-atrial-fibrillation-rhythm-control-versus-rate-control/print 17/22 7/5/23, 9:15 AM Management of atrial fibrillation: Rhythm control versus rate control - UpToDate An unsuccessful cardioversion will not result in conversion to SR or only short duration in SR. AF recurrence occurs later, not immediately after cardioversion Refer to related UpToDate content for further information. Graphic 141597 Version 1.0 https://www.uptodate.com/contents/management-of-atrial-fibrillation-rhythm-control-versus-rate-control/print 18/22 7/5/23, 9:15 AM Management of atrial fibrillation: Rhythm control versus rate control - UpToDate Prevalence of atrial fibrillation with age In a cross-sectional study of almost 1.9 million men and women, the prevalence of atrial fibrillation increases with age, ranging from 0.1 for those <55 years of age to over 9 percent in those 85 years of age. At all ages, the prevalence is higher in men than women. Data from Go AS, Hylek EM, Phillips K, et al. Prevalence of diagnosed atrial brillation in adults: National implications for rhythm management and stroke prevention: The AnTicoagulation and Risk Factors in Atrial Fibrillation (ATRIA) Study. JAMA 2001; 285:2370. Graphic 77268 Version 5.0 https://www.uptodate.com/contents/management-of-atrial-fibrillation-rhythm-control-versus-rate-control/print 19/22 7/5/23, 9:15 AM Management of atrial fibrillation: Rhythm control versus rate control - UpToDate Rate control versus rhythm control in AFFIRM Results of the AFFIRM trial in which 4060 patients with atrial fibrillation (AF) that was likely to be recurrent were randomly assigned to rhythm or rate control. The primary end point was overall mortality. There was an almost significant trend toward lower mortality with rate control (21.3 versus 23.8 percent, hazard ratio 0.87, 95 percent CI 0.75 to 1.01). Data from Wyse DG, Waldo AL, DiMarco JP, et al. N Engl J Med 2002; 347:1825. Graphic 61608 Version 3.0 https://www.uptodate.com/contents/management-of-atrial-fibrillation-rhythm-control-versus-rate-control/print 20/22 7/5/23, 9:15 AM Management of atrial fibrillation: Rhythm control versus rate control - UpToDate Rate control versus rhythm control in RACE Results of the RACE trial in which 522 patients with recurrent persistent atrial fibrillation (AF) were randomly assigned to rhythm or rate control. The primary end point was a composite of cardiovascular death, heart failure, thromboembolism, bleeding, pacemaker placement, and antiarrhythmic drug side effects. There was an almost significant trend toward a lower incidence of the primary end point with rate control (17.2 versus 22.6 percent with rhythm control, hazard ratio 0.73, 90 percent CI 0.53 to 1.01). Data from Van Gelder IC, Hagens VE, Bosker HA, et al. N Engl J Med 2002; 347:1834. Graphic 74434 Version 3.0 https://www.uptodate.com/contents/management-of-atrial-fibrillation-rhythm-control-versus-rate-control/print 21/22 7/5/23, 9:15 AM Management of atrial fibrillation: Rhythm control versus rate control - UpToDate Contributor Disclosures Kapil Kumar, MD No relevant financial relationship(s) with ineligible companies to disclose. Warren J Manning, MD Equity Ownership/Stock Options: Pfizer [Anticoagulants]. All of the relevant financial relationships listed have been mitigated. Peter J Zimetbaum, MD Consultant/Advisory Boards: Abbott Medical [Lead extraction]. All of the relevant financial relationships listed have been mitigated. Nisha Parikh, MD, MPH No relevant financial relationship(s) with ineligible companies to disclose. Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by vetting through a multi-level review process, and through requirements for references to be provided to support the content. Appropriately referenced content is required of all authors and must conform to UpToDate standards of evidence. Conflict of interest policy https://www.uptodate.com/contents/management-of-atrial-fibrillation-rhythm-control-versus-rate-control/print 22/22