Rate control or rhythm control?

Slow down the heart beat or restore the heart’s natural rhythm? This is the first question that has to be answered when treating atrial fibrillation. Generally both approaches reduce symptoms such as palpitations, dizziness and weakness, improving quality of life. Rate control only involves taking medication, whereas special procedures like catheter ablation are usually needed for rhythm control. The first step is often to try to slow the heart down, and this usually works. The heart may jump back to its normal rhythm by itself within 24 hours anyway. But if the symptoms don't get better after rate control, doctors recommend using rhythm control.

Doctors sometimes try to get the heart back into its normal sinus rhythm right away, especially if this is the first time someone has had atrial fibrillation or if it has only recently been diagnosed. More recent study data show that if the atrial fibrillation was diagnosed within the last twelve months, rhythm control can offer better protection from complications such as stroke and death than rate control.

Doctors also try rhythm control straight away if one or more of the following apply:

• If the atrial fibrillation has a treatable cause such as overactive thyroid, but has not disappeared after treatment of that cause,
• if the atrial fibrillation is causing acute, severe circulatory problems,
• if the high pulse is already damaging the heart muscle and weakening the heart,
• if there are no other medical conditions,
• in young people with atrial fibrillation,
• if people prefer rhythm control to treat their atrial fibrillation for personal reasons.

The main potential disadvantages of resetting the normal heart rhythm are the risks associated with the procedures and the generally limited chances of success: Although it is often possible to restore the normal heart rhythm through cardioversion, atrial fibrillation commonly returns in the long term.

What can help to make a decision?

Deciding which treatment is best depends on a number of factors. If you still have doubts after talking to your doctor and thinking things over, you can seek a second medical opinion.

Before doing so, it is important to be aware of the specific decision to be made, and then get detailed information about the advantages and disadvantages of the treatment options, that is to say rate control and the various rhythm control procedures.

Our decision aid “Atrial fibrillation: How can an irregular heart rhythm be treated?” briefly summarizes the key points. There you can make a note of what's especially important to you.

Atrial fibrillation: How can an irregular heart rhythm be treated?

(Six A4 pages)

Download file

83 kB

Sources

• Agasthi P, Lee JZ, Amin M et al. Catheter ablation for treatment of atrial fibrillation in patients with heart failure with reduced ejection fraction: A systematic review and meta-analysis. J Arrhythm 2019; 35(2): 171-181. [PMC free article: PMC6457370] [PubMed: 31007780]
• Briceño DF, Markman TM, Lupercio F et al. Catheter ablation versus conventional treatment of atrial fibrillation in patients with heart failure with reduced ejection fraction: a systematic review and meta-analysis of randomized controlled trials. J Interv Card Electrophysiol 2018; 53(1): 19-29. [PubMed: 30066291]
• Hindricks G, Eckardt L, Gramlich M et al. Kommentar zu den Leitlinien (2020) der ESC zur Diagnose und Behandlung von Vorhofflimmern. Kardiologe 2021; 15: 354-363.
• 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(5): 373-498. [PubMed: 32860505]
• Kasper DL, Fauci AS, Hauser SL et al. Harrison's Principles of Internal Medicine. New York: McGraw-Hill; 2015.
• Kirchhof P, Camm AJ, Goette A et al. Early Rhythm-Control Therapy in Patients with Atrial Fibrillation. N Engl J Med 2020; 383(14): 1305-1316. [PubMed: 32865375]
• Marrouche NF, Brachmann J, Andresen D et al. Catheter Ablation for Atrial Fibrillation with Heart Failure. N Engl J Med 2018; 378(5): 417-427. [PubMed: 29385358]
• National Institute for Health and Care Excellence (NICE). Atrial fibrillation: diagnosis and management. Evidence review I: Non-ablative rate control therapies. (NICE guidelines; No. NG196). 2021.
• Packer DL, Mark DB, Robb RA et al. Effect of Catheter Ablation vs Antiarrhythmic Drug Therapy on Mortality, Stroke, Bleeding, and Cardiac Arrest Among Patients With Atrial Fibrillation: The CABANA Randomized Clinical Trial. JAMA 2019; 321(13): 1261-1274. [PMC free article: PMC6450284] [PubMed: 30874766]
• Smer A, Salih M, Darrat YH et al. Meta-analysis of randomized controlled trials on atrial fibrillation ablation in patients with heart failure with reduced ejection fraction. Clin Cardiol 2018; 41(11): 1430-1438. [PMC free article: PMC6489934] [PubMed: 30178507]
• Turagam MK, Garg J, Whang W et al. Catheter Ablation of Atrial Fibrillation in Patients With Heart Failure: A Meta-analysis of Randomized Controlled Trials. Ann Intern Med 2019; 170(1): 41-50. [PubMed: 30583296]
• Valembois L, Audureau E, Takeda A et al. Antiarrhythmics for maintaining sinus rhythm after cardioversion of atrial fibrillation. Cochrane Database Syst Rev 2019; (9): CD005049. [PMC free article: PMC6738133] [PubMed: 31483500]
• Virk SA, Bennett RG, Chow C et al. Catheter Ablation Versus Medical Therapy for Atrial Fibrillation in Patients With Heart Failure: A Meta-Analysis of Randomised Controlled Trials. Heart Lung Circ 2019; 28(5): 707-718. [PubMed: 30509786]

• IQWiG health information is written with the aim of helping people understand the advantages and disadvantages of the main treatment options and health care services.

  Because IQWiG is a German institute, some of the information provided here is specific to the German health care system. The suitability of any of the described options in an individual case can be determined by talking to a doctor. informedhealth.org can provide support for talks with doctors and other medical professionals, but cannot replace them. We do not offer individual consultations.

  Our information is based on the results of good-quality studies. It is written by a team of health care professionals, scientists and editors, and reviewed by external experts. You can find a detailed description of how our health information is produced and updated in our methods.