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I read with interest the recent article by Lairikyengbam et al.1 The AFFIRM,2 RACE,3 and most recently the STAF pilot4 study have now all been published. These three studies in addition to the previously published PIAF5 study have all compared a rate with a rhythm control strategy for patients in atrial fibrillation. Data from these four studies would suggest that, for patients in persistent atrial fibrillation, rate control is associated with fewer drug side effects, reduced hospitalisation, with no reduction in quality of life compared with a rhythm control strategy. Early discontinuation of warfarin therapy is to be discouraged, even if sinus rhythm is initially achieved, as not only do most patients with atrial fibrillation have ⩾1 risk factor for stroke, the long term rate of sinus rhythm maintenance after is poor.
The AFFIRM study (4060 patients, and the largest of the studies) is the only study to have used mortality as its sole primary end point and noted a non-significant trend to improved mortality with rate control therapy. In this study there was also noted to be a significantly higher crossover rate from rhythm to rate control therapy than vice versa, suggesting the difficulty and poor tolerance of rhythm control therapy.
In conclusion, previously unavailable evidence has now emerged and would suggest that a rate control strategy is acceptable for a large proportion of patients in persistent atrial fibrillation.
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