PGY3 Internal Medicine Northern Ontario School of Medicine Sudbury, Ontario, Canada
Background: Early rhythm control therapy for patients with new-onset atrial fibrillation (AF) and/or left ventricular (LV) dysfunction reduces major adverse cardiovascular events. However, bradycardia-related complications may be higher with rhythm control strategies, particularly when antiarrhythmic drugs (AADs) are used. The aim of this systematic review and meta-analysis was to compare the rate of syncope, falls or pacemaker implantation among AF patients treated with rate control as compared to rhythm control.
METHODS AND RESULTS: A systematic search was conducted for studies published from inception to January 14, 2025, in PubMed, Embase and CENTRAL. Included studies compared the rate of syncope, falls, or pacemaker implantation in AF patients treated with rate control versus rhythm control strategies. The primary outcome was a composite of syncope, falls or pacemaker implantation. Secondary outcomes were the individual components of the primary composite outcome as well as hospitalizations. Odds ratios (OR) were pooled with a random effects model. We identified three randomized controlled trials and six cohort studies, encompassing a total of 522,841 AF patients (348,831 treated with rate control and 174,010 with rhythm control). All nine studies included AADs, and four included catheter ablation, as part of their rhythm control strategies. The average age was 69.8 years in the rate control group, compared to 69.6 years in the rhythm control group (P = 0.31). Rhythm control was associated with a significantly higher risk of the primary composite outcome of syncope, falls or pacemaker implantation compared to rate control (OR 1.28; 95% confidence interval (CI) 1.14–1.44; P < 0.0001; I2 = 20%). Rhythm control was associated with a significantly higher risk of syncope compared to rate control (OR 1.64, 95% CI 1.16–2.32, P = 0.005, I² = 85%). There was a trend toward a higher rate of pacemaker implantation with rhythm control (OR 1.96, 95% CI 0.98–3.93, P = 0.06, I2 = 97%). Finally, rate of hospitalization was similar among patients treated with rhythm control compared to rate control (OR 1.16, 95% CI 0.72-1.87, P = 0.54, I2 = 98%).
Conclusion: In this meta-analysis, rhythm control was associated with an increased risk of syncope, falls, or pacemaker implantation compared to rate control among patients with AF. These risks should be carefully weighed when choosing between rate control and rhythm control strategies.
